SB 393
Page 1
Date of Hearing: July 3, 2012
ASSEMBLY COMMITTEE ON HEALTH
William W. Monning, Chair
SBPCA Bill Id: SB 393 (Ed Author: Ed Hernandez) – As Amended: Ver: June 15, 2012
SENATE VOTE: 30-7
SUBJECT: Medical homes.
SUMMARY: Establishes the Patient-Centered Medical Home (PCMH) Act of 2011 to define a PCMH as a health care delivery model that conforms to the definition contained in the federal Patient Protection and Affordable Care Act (ACA) and meets other specified criteria consistent with providing patient-centered, coordinated care. Specifically, this bill:
1) Defines PCMH, "medical home," "advanced practice primary care," "health home," "person-centered health care home," and "primary care home," all to mean a health care delivery model as defined in the ACA, and any subsequent federal rules or regulations, and that meets the following criteria:
a) Facilitates a relationship between a patient and his or her personal physician or other licensed primary care provider in a physician-directed practice team to provide comprehensive and culturally competent primary and preventive care; and,
b) Meets the criteria of, and participates in, a voluntary recognition process conducted by a nongovernmental entity to demonstrate that the practice has the capabilities to provide patient-centered services consistent with the medical home model.
2) Prohibits this bill from being construed to alter the scope of practice of any health care provider, or to authorize the delivery of health care services in a setting or manner otherwise authorized by law.
EXISTING LAW:
1) Defines PCMH under the ACA and authorizes tests of innovative Medicaid (Medi-Cal in California) and Medicare service delivery models in federal fiscal years 2010 to 2019, to reduce program expenditures while preserving or enhancing patient quality of care. Innovative models include PCMHs for high-need patients and medical homes that address women’s unique health care needs.
2) Makes grants under the ACA available to states to establish community-based interdisciplinary teams to support medical homes and help primary care providers implement them in federal fiscal years 2011 and 2012.
3) Authorizes the waiving of specified Medicaid requirements for demonstration projects, for care delivered through primary care case-management systems, or for the provision of home- or community-based services.
4) Establishes the Medi-Cal program, administered by the Department of Health Care Services (DHCS), under which qualified low-income persons receive health care benefits.
FISCAL EFFECT: None
COMMENTS:
1) PURPOSE OF THIS BILL. According to the author, this bill establishes a definition for the set of best health care practices known as PCMH to ensure uniform standards of quality and access. The author argues that out-of-control health care costs, diminishing state revenue, a growing shortage of primary care professionals, inadequate distribution of health care providers, and a sharp increase in the demand for services for those with chronic disease and mental health disorders drive the need for the PCMH model of health care delivery. The author maintains that establishing a definition for this model in state law makes it more likely that California will receive crucial federal health care dollars.
2) PCMH MODELS. According to the National Conference of State Legislatures (NCSL), PCMH is a way to provide comprehensive care that is designated and centered around the patient's needs. In the PCMH model, a health care team (i.e. doctors, nurses, physician assistants, medical assistants, mental health providers, community health workers, and social workers) works in partnership with one another, their patients, and their patients’ families to coordinate care and navigate the complex and often confusing health care system to ensure that patients receive the right care at the right time. The model aims to improve coordination of care, increase the value of health care received, expand administrative and quality innovations, promote active patient and family involvement, and help control the rising costs of health care for both individuals and payers, such as Medicaid and private insurers. NCSL reports that PCMHs are serving as key aspects in state health reform efforts. As of July 2010, at least 29 states had enacted medical home legislation and 22 had one or more public, private or public-private medical home pilot programs.
3) PCMH & ACA. The ACA includes provisions requiring the federal Secretary of Health and Human Services to establish a program to provide grants to, or enter into contracts with, eligible entities to establish community health teams to support the PCMH model. The ACA defines a PCMH as a mode of care that includes personal physicians; whole person orientation; coordinated and integrated care; safe and high-quality care through evidence-informed medicine, appropriate use of health information technology, and continuous quality improvements; expanded access to care; and, payment that recognizes added value from additional components of patient-centered care.
4) HEALTH HOME OPTION & ACA. The ACA authorizes a temporary, two-year 90% federal match rate for care coordination provided in conjunction with a health home. In November 2010, the Centers for Medicare & Medicaid Services (CMS) issued preliminary guidance describing the requirements, choices, funding opportunities, and expectations for successful implementation of the health home provision of the ACA. To be eligible for health home services, Medi-Cal beneficiaries must have at least two specified chronic conditions; one chronic condition and be at risk for another; or, one serious and persistent mental health condition. States are allowed to target health home services to those with particular chronic conditions or with higher numbers or severity of chronic or mental health conditions. Services must be provided by a designated health home provider arrangement.
CMS expects use of the health home service delivery model to result in lower rates of emergency room use, reductions in hospital admissions and re-admissions, reductions in health care costs, less reliance on long-term care facilities, and, improved experience of care and quality of care outcomes for the individual. CMS adds that states that opt to provide the health homes benefit, and the health home providers with which the states collaborate, are expected to operate under a "whole person" philosophy that cares not just for an individual's physical condition, but provides linkages to long-term community care services and supports, social services, and family services.
5) VOLUNTARY RECOGNITION STANDARDS. This bill requires a primary care practice to meet the criteria of, and participate in, a voluntary recognition process conducted by a nongovernmental entity to demonstrate that it provides patient-centered services consistent with a PCMH. Standards developed by the National Committee for Quality Assurance (NCQA) are most often used to identify which primary care practices have achieved designation as a medical home. The NCQA standards allow for recognition as a PCMH at three different levels and include 30 elements, of which 10 are considered mandatory or "must pass." The must pass elements include standards related to patient access and communication, patient tracking, care management, test and referral tracking, and performance reporting and improvement.
NCQA indicates on its Website that its PCMH 2011 standards offer guidance on developing better chronic care management programs, enhancing patient engagement and improving patient outreach. According to NCQA, clinicians, patients, health plans, employers, public entities, and other participants across the country are actively testing the model to learn how to transform and reward medical home practices. NCQA reports that the evidence shows promising results in improving care quality and lowering costs by increasing access to more efficient, coordinated, and responsive care. There are over 200 NCQA-recognized PCMHs in California.
The California Academy of Family Physicians, a cosponsor of this bill, notes that there are other organizations that also have PCMH recognition programs, including the Joint Commission, the Accreditation Association for Ambulatory Health Care, and the Utilization Review Accreditation Commission. This bill requires a practice to obtain PCMH recognition using any of these multiple program options.
6) RELATED LEGISLATION. AB 2266 (Mitchell) requires DHCS to design and administer a program to provide health homes to eligible individuals with high-health needs in order to take advantage of enhanced federal matching funds available under the ACA. AB 2266 is pending in the Senate Appropriations Committee.
7) PRIOR LEGISLATION:
a) AB 1542 (Jones) of 2010, substantially similar to this bill, would have established the Patient-Centered Medical Home Act of 2010 to encourage licensed health care providers and patients to partner in a patient-centered medical home, as defined, that promotes access to high-quality, comprehensive care, in accordance with prescribed requirements. AB 1542 included an urgency clause. AB 1542 failed passage on concurrence on the Assembly Floor.
b) SB 966 (Alquist) of 2010 would have directed DHCS to establish a definition of medical home consistent with specified guidelines and a timetable for Medi-Cal managed care (MCMC) plans to provide beneficiaries with a medical home. SB 966 died on the Senate Appropriations Committee Suspense File.
c) SB 771 (Alquist) of 2010 would have required a health plan or a health insurer, or a medical group that contracts with a plan that uses a pay-for-performance system for the payment of providers, to provide a differential payment to providers who provide patients with a PCMH. These provisions were amended out of SB 771.
d) AB 342 (John A. Pérez), Chapter 723, Statutes of 2010, revises and recasts provisions pertaining to the local Coverage Expansion and Enrollment Demonstration projects. Among other provisions, AB 342 defines a medical home and requires seniors and persons with disabilities enrolled in Medi-Cal and those enrolled in the health care coverage initiative to be provided with medical homes.
e) SB 208 (Steinberg), Chapter 714, Statutes of 2010, a companion bill to AB 342, enacts provisions that relate to hospital financing, mandatory enrollment of seniors and persons with disabilities into MCMC plans, and pilot projects to provide organized systems of care to California Children's Services and Medi-Cal eligible children and to Medicare and Medi-Cal dual eligible persons.
f) SB 1738 (Steinberg) of 2008 would have required DHCS to establish a three-year pilot program to provide intensive multidisciplinary services to 2,500 Medi-Cal beneficiaries identified as frequent users of health care. SB 1738 was vetoed by Governor Schwarzenegger who stated in his veto message that he could not support the bill because of the state's ongoing fiscal challenges and asked the author and stakeholders to work with his Administration to identify strategies to ensure these beneficiaries receive the right care, at the right time, in the right setting.
g) AB 1736 (Levine) of 2005 would have required the Department of Health Services (DHS now DHCS) to conduct a demonstration testing of the chronic care model of providing disease management services in community clinics and health center and public hospital settings. AB 1736 was vetoed by Governor Schwarzenegger who stated in his veto message that the bill was duplicative of current efforts and would impose significant costs.
8) SUPPORT. Supporters, representing various provider and consumer advocacy groups, agree that a medical home serves as a centralized hub to provide patients and their families with coordinated services, such as preventive and wellness care, referrals for specialty care, and help in coordinating care across specialties. They state that the PCMH model is particularly effective for children as it encourages a "whole child" approach that increases the ability to avoid or successfully manage chronic childhood conditions and, in doing so, it could produce potentially significant cost savings over a lifetime. Supporters write that, as the PCMH model continues to evolve and grow in popularity, this bill will ensure uniform application of the use of the PCMH in California and provide clarity on the appropriate standards of care for this model in the state. They add that this bill ensures that all licensed providers are included as partners in the medical home model and sends an important signal that California supports health care that is comprehensive, accessible, cost-effective, and evidence-based.
REGISTERED SUPPORT / OPPOSITION:
Support
American Academy of Pediatrics - California District (co-sponsor)
American College of Physicians, California Chapters (co-sponsor)
California Academy of Family Physicians (co-sponsor)
California Academy of Physician Assistants (co-sponsor)
California Association of Physician Groups (co-sponsor)
California Primary Care Association (co-sponsor)
California Psychiatric Association (co-sponsor)
Osteopathic Physicians and Surgeons of California (co-sponsor)
American Congress of Obstetricians and Gynecologists, District IX
California Black Health Network
California Department of Insurance
California Optometric Association
California Society of Health-System Pharmacists
Children Now
Planned Parenthood Affiliates of California
Opposition
None on file.
Analysis Prepared by: Cassie Royce / HEALTH / (916) 319-2097