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2019 LEGISLATIVE WRAP-UP
California Medical Association’s 2019 Legislative Wrap-Up
In January, California witnessed something completely new. The swearing in of Governor Gavin Newson marked the first time in state history that a Democratic governor was succeeded by another Democratic governor. Political history is flush with examples of challenges facing the incumbent party attempting to hold on to statewide power. Typically, voters seize the opportunity for change by electing a leader of a different party. But this time, voters chose to move from a moderate Democrat (Jerry Brown) to a progressive Democrat (Gavin Newsom).
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The transition from Brown, who retained tight control of the state’s budget and legislative process, to a first-time governor provided the legislature with an opportunity to reshape California’s policy landscape.
Discussion, debate, dialogue and compromise were the overwhelming themes of the 2019 session. Since Governor Newsom did not have a public veto or signing history, his policy perspective was not yet set in stone. Legislators saw this as an opportunity to bring nearly every recycled and newly minted policy idea to the proverbial table.
The tone of the 2019 legislative session was overall one of unbridled optimism. Such political environments pose many risks and opportunities, with many competing interest groups jockeying to raise their priorities.
The California Medical Association (CMA) successfully collaborated with the legislature on proactive efforts to expand public health initiatives, reduce administrative burdens, increase physician reimbursements and strengthen the physician workforce. However, over the course of the legislative year, additional reactive efforts emerged as various stakeholders launched unmerited attacks against the profession.
In January 2019, CMA was faced with an immediate crisis: flawed implementation of a new state law—intended to improve the security of physician prescription pads as a solution to the opioid crisis—left pharmacies unable to fill prescriptions and patients being refused necessary medications.
CMA quickly worked with the Newsom Administration, the California Department of Justice and the legislature to resolve the matter. The result was the swift approval and enactment of CMA-sponsored AB 149 (COOPER), which allowed patients to immediately start receiving their prescriptions and physicians to utilize their existing prescription pads until July 2021.
CMA also sponsored AB 744 (AGUIAR-CURRY) to revamp the rules regarding the payment of health care services provided via telehealth in order to increase access to care. Under existing law, physicians are incentivized to require patients to physically enter medical offices for services that could otherwise be delivered utilizing telehealth. Health plans sought to maintain existing law as a means of creating barriers to care. However, CMA worked with legislators from both rural and urban areas, showcasing the benefits of telehealth and the necessity for plans to pay for physician expertise regardless of the modality under which it is delivered. Despite the opposition of the health insurer lobby, the measure received only one “no” vote throughout the entire process.
During the last weeks of the legislative session, the United Healthcare Workers Union went after the physician community and sought to shame physicians for the compensation they receive. CMA successfully stopped the union’s sponsored bill, AB 1404 (SANTIAGO), which would have required targeted physician groups to disclose the total compensation of their physician partners as a means of creating leverage in union contract negotiations. Such attacks don’t belong in the health care legislative space; they increase the difficulty of recruiting the quantity of physicians needed to serve patients and negatively impact efforts to constrain health care costs.
In addition to the above, CMA took the following actions to either relieve existing administrative burdens or stop the creation of new burdens:
PASSED legislation to alleviate burdens associated with mandatory use of the CURES database DEFEATED legislation to change prescription labeling requirements DEFEATED legislation to require referral to alternative medicine practitioners prior to prescribing an opioid •
DEFEATED multiple attempts to publicly disclose physician reimbursement and contracted rates
This year’s budget contained $120 MILLION to support loan repayment programs for physicians and dentists (administered by Physicians for a Healthy California)
ACCESS TO CARE
In June, Governor Newsom signed his first state budget. The process for the 2019-2020 budget was dramatically different than prior years. Consistent with his campaign promises, Newsom prioritized health care. Not only did he expand health care insurance coverage, he was equally committed to funding access to care. This year’s budget contained:
$2.2 BILLION for provider rate increases funded by the Proposition 56 tobacco tax $120 MILLION to support loan repayment programs for physicians and dentists (administered by Physicians for a Healthy California) $250 MILLION for the creation of a Value-Based Payment Program within Medi-Cal
$150 MILLION for developmental and trauma screening supplemental payments
EXPANDED MEDI-CAL ELIGIBILITY, which now includes all young adults aged 19-25, regardless of their immigration status A STATE-LEVEL INDIVIDUAL MANDATE to obtain health coverage
The physician members of CMA hold sacred the trust patients and communities have in the medical profession. On countless occasions, the leaders of state, county and specialty societies wrestle with a variety of policy questions. And while there are many perspectives from which a policy can be debated, inevitably the question will be asked: how will this impact our patients and the trust the public places in physicians to look after their best interest and health? In 2015, CMA sponsored SENATOR RICHARD PAN, M.D.’S SB 277 to eliminate the personal belief exemption from the statutory requirements for childhood vaccinations.
The fight to enact SB 277 was fierce. Thousands of anti-vaxxers flooded the hallways of the Capitol. New security protocols were required for Senator Pan and CMA headquarters. The bill was heavily protested at the Capitol and in local districts; thousands of rabid anti-vaxxers spewed inflammatory rhetoric and threats of bodily harm. When Governor Jerry Brown signed that measure into law, Sacramento assumed the chapter on vaccines was closed.
The result of SB 277 was positive overall, and statewide vaccination rates improved. However, a number of geographic pockets of unvaccinated children emerged due to vaccine hesitancy and a few physicians willing to inappropriately monetize the moment by providing vaccine exemptions with questionable medical rationales. While some abuse was anticipated, the quantity of exemptions issued by a few physicians was alarming. On social media, parents openly discussed how to purchase exemptions, which physicians were open to such transactions and what medical symptoms to highlight in the visit. As such behavior persisted, Senator Pan and CMA faced a dilemma: how to respond to physicians whose actions threaten to erode public trust in the physician community?
Courage! CMA and Dr. Pan chose to once again brave the turbulence and introduced legislation (SB 276) to increase vaccination rates by cracking down on inappropriate physician behavior. The reaction of the opposition exceeded our expectations. We knew there would be threats and a high number of anti-vaxxers protesting at the State Capitol and in the districts. We did not expect blood to be thrown onto the Senate floor from the gallery or parents forming chains to block the entrance of the Capitol. CMA’s obligation to protect the integrity of the profession and the public trust in the physician community outweighed the fear of facing fierce, threatening opposition.
Similar courage was necessary on other fronts, including the legislature’s response to the sexual misconduct of gynecologist George Tyndall in student health centers at the University of Southern California. CMA ensured important due process protections for physicians remained, while not protecting the deplorable behavior of a specific physician. Navigating such troubling matters is complex, and CMA successfully preserved fundamental protections, while building our creditability with the legislature that CMA is an association that stands for quality physicians with the ability to self-police the profession.
Courage to fight for patients, courage to fight for the betterment of the profession and courage to fight for the public’s health is why CMA is the most effective advocacy organization in the Golden State!
In unity,
Janus L. Norman CMA Senior Vice President Centers for Government Relations and Political Operations
AB 149 is the clean-up to AB 1753 (Low) of 2018, which required new, uniquely serialized numbers to be printed on secure prescription pads. AB 149’s language is a collaboration of work of the medical board, pharmacy board, retail pharmacists, CMA and the Department of Justice (DOJ). It gives DOJ until January 1, 2020, to ensure that the serial numbers that are developed to be printed on security prescription pads are compliant with all state and federal laws as well as national industry standards. The bill also deems all prescription pads that were valid before January 1, 2019, as well as those printed since January 1, 2019, to be valid and allows prescribers to use up the supply of prescription pads they previously had as well as the ones recently purchased to be in compliance with the new law. These “older” prescription pads are valid until January 1, 2021, when the newest set, which is compliant with all national and industry standards, must begin to be used. Status: Signed by the Governor (Chapter 4, Statutes of 2019).
AB 744 strengthens existing laws around telehealth coverage to ensure that health plans do not treat services differently just because they are provided through telehealth technologies. If a health plan covers the service provided in-person, the bill states that the plans must also cover the service – if the exact same service – when provided through telehealth. Status: Signed by the Governor (Chapter 867, Statutes of 2019).
SB 276/SB 714 (PAN): IMMUNIZATIONS: MEDICAL EXEMPTIONS
The bill protects community immunity rates by ensuring that the implementation of SB 277 (CMA sponsored bill in 2015 to remove the personal and religious belief exemptions for vaccinations) effectively brings up the vaccination rates in all California neighborhoods. SB 276 develops a peer-review modeled process that ensures that only those who are truly immunocompromised, or who have a medical need, are granted a medical exemption. As a result of ongoing negotiations with the governor’s office, SB 276 was passed and moved to the governor’s desk. SB 714 was subsequently amended to address late concerns from the governor. The most notable change is limiting
California Department of Public Health review to medical exemptions written on or after Jan. 1, 2020, unless the physician has been disciplined by the medical board. This bill is the product of negotiations between the author, the governor’s office and CMA. Status: Signed by the Governor (Chapter 278, Statutes of 2019 / Chapter 281, Statutes of 2019).
SB 441 (GALGIANI): ELECTRONIC HEALTH RECORDS: VENDORS
SB 441 would have created a state regulatory structure for the enforcement of federal requirements related to interoperability and the provision of technical assistance with electronic health record vendors to increase efforts toward true interoperability and the benefits it could provide related to access, quality and affordability of health care. Status: Held in the Senate Health Committee.
This bill would have required health plans and insurers to report the approval, denial, modification and delay rates on the top 30 services most utilized by physicians that require a prior authorization. AB 1268 also encouraged insurers to take this information into account when updating their utilization review criteria. The bill also included a provision authorizing regulators to at least annually compare the information collected in the bill to the grievances they receive from enrollees for the same services. If, upon a finding that there is a trend of bad behavior by plans, they may assess a penalty on the plan or insurer. Status: Held in the Assembly Appropriations Committee.
CO-SPONSORED BILLS
AB 764 (BONTA): SUGAR-SWEETENED BEVERAGES: NONSALE DISTRIBUTION INCENTIVES
This bill would have prohibited beverage manufacturers from offering a coupon or other promotional incentive on any sugar-sweetened beverages to their partnering manufacturer, distributor or retailer as a way of subsidizing the lower retail cost of the beverage. Status: Held on the Assembly Floor.
This bill would have limited which beverages could be made available for purchase near the checkout counter at supermarkets, large grocery stores, supercenters and warehouse clubs, prohibiting sugar-sweetened beverages. Modeled after several local ordinances nationwide, this bill would have impacted the “impulse” purchasing of unhealthy beverage products. Status: Held in the Assembly Health Committee.
AB 766 (CHIU): UNSEALED BEVERAGE CONTAINER PORTION CAP
This bill would have limited the portion size of unsealed sugar-sweetened beverage sales to 16 ounces. Modeled after action taken in New York City, this bill would have impacted sales of fountain drinks at all restaurants, movie theaters, fast-food establishments, delis, sports stadiums, and corner stores or gas stations. Status: Held in the Assembly Health Committee.
PRIORITY SUPPORT BILLS
This bill provides critical fixes to the mandatory check requirement of the Controlled Substance Utilization Review and Evaluation System (CURES). It changes the requirement that a provider check the system every four months when a prescription remains part of a patient’s treatment plan to upon renewal if at least six months have passed; allows for delegate access to CURES; and relieves physicians of having to login to the CURES system when a patient’s record already contains a CURES report from within the last 24 hours. It also requires dispensers to report controlled substances dispensed to the CURES system within one working day of dispensing and includes Schedule V medications in the drugs that must be reported to the system by dispensers. Status: Signed by the Governor (Chapter 677, Statutes of 2019).
AB 138 (BLOOM): CALIFORNIA COMMUNITY HEALTH FUND
This bill would have imposed a fee on sodas and other sugary beverages, at a rate of $.02 per ounce, and used the new revenue to offset health and economic costs associated with overconsumptions of sugar. Status: Held in the Assembly Revenue and Taxation Committee.
The bill would have required health care service plans and health insurers notify their respective regulators if they, or their delegated entity, plan to terminate or let expire a current contract for the provision of anesthesia services. The regulator would then be required to ensure that the health care service plan/insurer/delegated entity has a contract with at least one anesthesiologist who is contracted with the health facility and that an enrollee requiring anesthesia services shall have access to a contracted anesthesiologist at all times and for all procedures at each of the health care service plan’s/insurer’s/delegated entity’s contracted health facilities. Status: Held in the Assembly Appropriations Committee.
AB 1264 (PETRIE-NORRIS): MEDICAL PRACTICE ACT: DANGEROUS DRUGS: APPROPRIATE PRIOR EXAM
This bill clarifies within existing prescribing laws that an appropriate prior examination does not require a real-time or synchronous face-to-face telehealth visit between the provider and patient. Planned Parenthood sponsored AB 1264 to clarify that birth control can be prescribed after an asynchronous patient interaction. CMA worked with the author and sponsor to ensure that AB 1264 ensured a broader application so that other prescriptions, if the physician feels appropriate, can be provided after an asynchronous visit as well. Status: Signed by the Governor (Chapter 741, Statutes of 2019).
AB 1639 (GRAY): TOBACCO PRODUCTS
This bill would have established tobacco control measures to reduce consumption of vapor products among youth. Specifically, it would have increased enforcement and penalties on underage sales of tobacco products and implemented prohibitions against advertisements of vaping products. Status: Held in the Senate Health Committee.
SB 347 (MONNING): SUGAR-SWEETENED BEVERAGES: SAFETY WARNINGS
This bill would have required a warning label on all sugarsweetened beverages. Specifically, it would have required labeling on any sealed beverage container and on any vending machine or beverage dispensing machine. Status: Held in the Assembly Health Committee.
AB 5 (GONZALEZ): WORKER STATUS: EMPLOYEES AND INDEPENDENT CONTRACTORS
This bill seeks to codify the California Supreme Court’s recently announced new test for determining whether a worker is an employee or an independent contractor in the landmark decision of Dynamex Operations West, Inc. v. Superior Court of Los Angeles, No. S222732 (Cal. Sup. Ct. Apr. 30, 2018). CMA secured an exemption for physicians to ensure they could maintain independent contractor status in the state. Status: Signed by the Governor (Chapter 296, Statutes of 2019).
AB 241 (KAMLAGER-DOVE): IMPLICIT BIAS: CONTINUING EDUCATION: REQUIREMENTS
This bill requires that all continuing medical education courses for physicians and surgeons contain curriculum that includes an understanding of positive and negative perceptions, feelings and stereotypes that impact decisionmaking in an unconscious way. The bill also requires the Physician Assistant Board and Board of Registered Nurses to implement similar implicit bias training into their licensees’ continuing medical education courses. Status: Signed by the Governor (Chapter 417, Statutes of 2019).
AB 288 (CUNNINGHAM): CONSUMER PRIVACY: SOCIAL MEDIA COMPANIES
This bill would have allowed social media users to have their information permanently deleted by social media companies at their request. The definition used in the bill for “social media company” was broadly defined to include any entity providing electronic services and accounts; therefore CMA successfully negotiated an exemption for physicians and medical services to ensure they weren’t inadvertently captured under the legislation. Status: Failed in the Assembly Privacy and Consumer Protection Committee.
AB 370 (VOEPEL): PHYSICIANS AND SURGEONS: FORMS: FEE LIMITATIONS
This bill would have capped at $25 the amount that a physician can charge for filling out a State Disability Insurance form, and also allowed the Medical Board of California to increase the fee annually by an amount equal to the Consumer Price Index increase. CMA successfully negotiated amendments that stated that the forms shall not cost more than a reasonable fee to the patient based on the time and effort necessary to complete the form. Status: Failed in the Assembly Health Committee.
AB 743 (GARCIA, EDUARDO): PUPIL HEALTH: SELF-ADMINISTRATION OF PRESCRIBED ASTHMA MEDICATION
CMA, in collaboration with teachers’ and school nurses’ associations, successfully negotiated AB 743 to allow for a physician contracted with a prepaid Mexican health plan, licensed in California, to write a note authorizing students to use their asthma rescue inhaler at school. The note must contain specific information including the medication, dose, duration and the physician’s contact information, in both Spanish and English. Status: Signed by the Governor (Chapter 101, Statutes of 2019).
AB 845 (MAIENSCHEIN): CONTINUING EDUCATION: PHYSICIANS AND SURGEONS: MATERNAL MENTAL HEALTH
This bill requires the Medical Board of California to consider adding a course in maternal mental health to the continuing medical education requirement. Status: Signed by the Governor (Chapter 220, Statutes of 2019).
AB 929 (RIVAS, LUZ): CALIFORNIA HEALTH BENEFIT EXCHANGE: DATA COLLECTION
This bill classifies Covered California as a health oversight authority, giving it more authority over products on the health insurance exchange and other parts of the health care market. In addition, AB 929 requires plans to report a host of information including contracted rates, disparity information, encounter data and cost detail directly to Covered California for review and inspection to help address shortfalls in coverage on the exchange. CMA obtained amendments that put the reporting requirements on the health plans, not the physicians, and ensured that any cost detail information would not be made public. CMA also secured amendments that prevent Covered California’s new oversight authority from applying to providers directly. Status: Signed by the Governor (Chapter 812, Statutes of 2019).
This bill would substantially limit the amount of time allowed for a business to report a known privacy breach to 45 days. CMA successfully negotiated an exemption for physicians, who are already subject to medical privacy laws that would now conflict with this broader state law. Status: Failed in the Senate Judiciary Committee.
AB 1131 (GLORIA): MEDI-CAL: COMPREHENSIVE MEDICATION MANAGEMENT
This bill would have established comprehensive medication management (CMM) services as a covered benefit under the Medi-Cal program, and would have required CMM services to include the development of a care plan in collaboration with the beneficiary and the beneficiary’s health care providers to address identified medication therapy problems. CMA collaborated with the author and sponsors to limit the instances when pharmacists can perform CMM, to if the physician refers the patient due to specific criteria outlined in the bill. Status: Failed in the Senate Appropriations Committee.
AB 1395 (CUNNINGHAM): INFORMATION PRIVACY: OTHER CONNECTED DEVICE WITH A VOICE RECOGNITION FEATURE
This bill builds upon existing law around “connected televisions” and requirements that their manufacturers must provide certain privacy notifications to consumers. The bill adds and defines other connected devices in the law as those with a voice recognition feature and a wireless speaker and voice command device sold in this state with an integrated virtual assistant that offers interactive actions and hands-free activation. CMA raised concerns initially that the bill could be broad enough to capture medical devices and other health care technologies; however, the bill was amended so it would no longer impact health care. Status: Failed in the Senate Judiciary Committee.
AB 1510 (REYES): SEXUAL ASSAULT AND OTHER SEXUAL MISCONDUCT: STATUTES OF LIMITATIONS ON CIVIL ACTIONS
This bill specifies that a civil action may be brought against any person or entity who owed a duty of care to the plaintiff for committing sexual assault or other criminal sexual conduct. The bill would also revive sexual misconduct claims, brought by or on behalf of a patient who suffered sexual misconduct at a student health center. The author took CMA’s amendments to significantly narrow the bill to apply to victims of George Tyndall. Amendments also limited the provisions to the dates at which George Tyndall worked at USC. Status: Signed by the Governor (Chapter 462, Statutes of 2019).
AB 1611 (CHIU): EMERGENCY HOSPITAL SERVICES: COSTS
AB 1611 would have required a health care service plan contract or an insurance policy to provide that if an enrollee or insured receives covered services from a non-contracted hospital, the enrollee or insured is prohibited from paying more than the same cost sharing that the enrollee or insured would pay for the same covered services received from a contracting hospital. The bill would have also required a health care service plan or insurer to pay a non-contracted hospital for emergency services (excluding poststabilization services) rendered to an enrollee or insured pursuant to the reasonable and customary value of the services provided. CMA secured amendments that would have ensured that the provisions of the bill did not apply to physicians and surgeons. Status: Failed in the Senate Health Committee.
SB 41 (HERTZBERG): CIVIL ACTIONS: DAMAGES
SB 41 prohibits the estimation, measure or calculation of civil damages from being based on, or considering, race, ethnicity, gender, religion or sexual orientation, except to determine life expectancy for calculating damages. The amendments limiting the prohibition in the bill to using race, ethnicity or gender in calculating lost earnings or impaired earning capacity ensure that these factors are used in their relevant context (i.e., life expectancy) and do not allow for the use of earnings tables to reduce earnings damages directly. Status: Signed by the Governor (Chapter 136, Statutes of 2019).
SB 58 (WIENER): ALCOHOLIC BEVERAGES: HOURS OF SALE
This bill established a pilot that would have allowed qualified cities to apply for an additional hours license to authorize the selling or purchasing of alcoholic beverages between the hours of 2 and 3 a.m. Status: Failed on the Assembly Floor.
This bill authorizes a pharmacist to furnish up to 60 days of preexposure prophylaxis (PrEP) and 30 days of postexposure prophylaxis (PEP) to patients who meet specific conditions consistent with federal guidelines. The bill sets a limitation on use that ensures physician oversight for the long-term use of PrEP medication while increasing access for patients. Status: Signed by the Governor (Chapter 532, Statutes of 2019).
SB 223 (HILL): PUPIL HEALTH: ADMINISTRATION OF MEDICINAL CANNABIS: SCHOOL SITES
This bill authorizes schools to adopt a policy that allows a parent or guardian of a pupil to possess and administer non-smokeable and non-vapeable medicinal cannabis to the authorized pupil at a school site. CMA successfully negotiated the removal of a requirement that the pupil’s primary care physician must also attest to knowing that the pupil uses medicinal cannabis. Status: Signed by the Governor (Chapter 699, Statutes of 2019).
SB 260 requires Covered California to enroll an individual who is no longer eligible for Medi-Cal in the lowest cost silver plan upon receiving the individual’s electronic account from a county or other entity. The bill would require enrollment to occur before Medi-Cal coverage is terminated, and would prohibit the premium due date from being sooner than the 30th day of the first month of enrollment. CMA secured amendments that provide protections for physicians to either receive payment from plans/insurers or to collect payment from a patient upfront. Status: Signed by the Governor (Chapter 845, Statutes of 2019).
SB 377 (MCGUIRE): JUVENILES: PSYCHOTROPIC MEDICATIONS: MEDICAL INFORMATION
This bill would require that, in order for the Medical Board of California to receive a juvenile ward of the court’s medical records for purposes of investigating overprescribing of psychotropic medication, there must be authorization by the child or child’s attorney to release the medical information. Also, the bill provides that the Judicial Council must develop the authorization form and specify that the medical information given must be relevant to the investigation of the prescription of psychotropic medication. Status: Signed by the Governor (Chapter 547, Statutes of 2019).
SB 425 (HILL): HEALTH CARE PRACTITIONERS: LICENSEE’S FILE: PROBATIONARY PHYSICIAN’S AND SURGEON’S CERTIFICATE: UNPROFESSIONAL CONDUCT
This bill requires that all patient complaints of sexual misconduct, made in writing, must be given to the appropriate licensing board by the entity that receives the complaint. The bill also ensures the same privacy protections are in place for these complaints as would apply to any complaint made to the medical board or appropriate licensing board. Status: Signed by the Governor (Chapter 849, Statutes of 2019).
SB 464 (MITCHELL): CALIFORNIA DIGNITY IN PREGNANCY AND CHILDBIRTH ACT
This bill requires hospitals that provide perinatal care, and alternative birth centers or primary clinics that provide services as an alternative birth center, to implement an implicit bias training program for all providers employed by the hospital. It also requires such facilities to make that training voluntarily available to physicians and surgeons not employed by the hospital. Additionally, the bill would require the department to track and publish data on pregnancy-related death and severe maternal morbidity. Status: Signed by the Governor (Chapter 533, Statutes of 2019).
SB 639 (MITCHELL): MEDICAL SERVICES: CREDIT OR LOAN
This bill strengthens consumer protections by prohibiting providers from offering medical credit cards or loans with deferred interest provisions; prohibiting providers from signing consumers up for these products in treatment areas; and simplifying the notice language. CMA negotiated amendments to limit the instances when providers are required to provide an alternate treatment plan. Status: Signed by the Governor (Chapter 856, Statutes of 2019).
SB 697 (CABALLERO): PHYSICIAN ASSISTANTS: PRACTICE AGREEMENT: SUPERVISION
SB 697 replaces the one physician to one physician assistant (PA) delegated services agreement with a flexible practice agreement that allows one agreement to bind a group of physicians who work in a setting to a PA who also works in that setting. It also removes specified chart review requirements and leaves that up to the practice agreement. Additionally, SB 697 repeals outdated provisions that relate to physician application and fees to supervise PAs and removes references to a PA board-maintained registry of physicians supervising PAs. These changes allow for more flexibility for physicians in their relationships with PAs and give PAs more parity with nurse practitioners. Status: Signed by the Governor (Chapter 707, Statutes of 2019).
SB 701 (JONES): FIREARMS: PROHIBITED PERSONS
This bill would make it a misdemeanor for a person with an outstanding warrant to own or possess a firearm or ammunition. Status: Vetoed by the Governor.
OPPOSED BILLS
AB 156 (VOEPEL): EYE CARE: REMOTE ASSESSMENT
This bill proposed limitations around the ability of ophthalmologists and optometrists to provide services via telehealth modalities. Specifically, it would have prohibited a person from operating an assessment mechanism to conduct an eye assessment or to generate a prescription for contact lenses or visual aid glasses unless numerous unnecessary requirements were met. The bill would have defined “assessment mechanism” to mean any type of telehealth modality and limited the locations where patients could seek such services. Status: Failed in Assembly Business and Professions Committee.
AB 290 (WOOD): HEALTH CARE SERVICE PLANS AND HEALTH INSURANCE: THIRD-PARTY PAYMENTS
This bill establishes requirements for any entity making third-party premium payments if that entity is a provider that receives a direct or indirect financial benefit from the third-party payments, or if that entity receives the majority of its funding from one or financially interested health care providers. AB 290 includes provisions that break an
existing plan/provider contract if a patient is receiving financial assistance, and instead puts in place the Medicare rate or an Independent Dispute Resolution Process that favors the health plans. Status: Signed by the Governor (Chapter 862, Statutes of 2019).
AB 503 (FLORA): GUN-FREE SCHOOL ZONE
This bill would have allowed an individual who holds a concealed carry license to carry their firearm in a church, synagogue or other place of worship, and on the grounds of a public or private school with permission from the school. Status: Failed in the Assembly Public Safety Committee.
AB 613 (LOW): PROFESSIONS AND VOCATIONS: REGULATORY FEES
This bill would have provided for an automatic licensing fee increase every four years on all licensing boards under the Department of Consumer Affairs (DCA), not to exceed the increase in the Consumer Price Index. This fee increase would have only needed to be approved by the director of DCA, with exemptions, and would not be need-based or in any way tied to enforcement or caseload. Status: Failed in Senate Business, Professions and Economic Development Committee.
AB 715 (NAZARIAN): RICHARD PAUL HEMANN PARKINSON’S DISEASE PROGRAM
Current law requires health care providers diagnosing or providing treatment to Parkinson’s disease patients to report each case to the California Department of Public Health. This bill extends the reporting requirement an additional year, beyond the current date of January 1, 2020. CMA defeated a budget request in this last budget cycle (2019-20) for $10 million over three years to continue the program, in the interest of reducing the administrative burden to physicians of data collection to support disease surveillance. Status: Signed by the Governor (Chapter 806, Statutes of 2019).
AB 780 (BROUGH): HEARING AID DISPENSERS: PRACTICE: CERUMEN MANAGEMENT: APPRENTICE LICENSE
AB 780 sought to expand the scope of practice for hearing aid dispensers to include tympanometry and cerumen management. AB 780 also would have removed continuing education requirements and an exam related to tympanometry, created an “advanced practice certificate,” and added in supervision by a mentor or trainer. Status: Failed in the Assembly Appropriations Committee.
AB 888 (LOW): OPIOID PRESCRIPTIONS: INFORMATION: NONPHARMACOLOGICAL TREATMENTS FOR PAIN
This bill would have required a prescriber to offer patients receiving opioids a referral to a non-pharmacological treatment provider such as a chiropractor or acupuncturist. AB 888 also sought to make prescribers obtain written, informed consent from patients receiving an opioid with specific informed consent language. Status: Failed in the Senate Business, Professions and Economic Development.
AB 890 (WOOD): NURSE PRACTITIONERS: SCOPE OF PRACTICE: UNSUPERVISED PRACTICE
This bill would have allowed nurse practitioners (NP) to practice without physician supervision, with additional education and training requirements for certain settings. The legislation contained a framework for the additional education, training and consumer protection requirements, but lacked significant details as to what specifically NPs would have to do to prove competency beyond the current educational requirements. Status: Failed in the Assembly Appropriations Committee.
AB 1030 (CALDERON): PELVIC EXAMINATIONS: INFORMATIONAL PAMPHLET
This bill would have required a physician to, prior to a patient’s first gynecological exam, provide the patient with a pamphlet that outlines what a patient may expect during the appointment. The bill required that certain information be included in the pamphlet and that the physician provide the pamphlet to the patient for review and signature immediately prior to the exam. Status: Failed on the Senate Inactive File.
AB 1038 (MURATSUCHI): HEALTH DATA: RATES FOR HEALTH CARE SERVICES: PHYSICIANS AND SURGEONS
This bill would have required every licensed provider in the state to report to the Office of Statewide Health Planning and Development the negotiated rate for each health care service for each contract a provider has with a plan or insurer, and to also report the amount patients are charged for each of those services. AB 1038 would have made the aggregated data public by geographic region and would have compared the negotiated rates to Medicare rates. Status: Failed in the Assembly Health Committee.
AB 1105 (GIPSON): SICKLE CELL DISEASE
This bill would have established a three-year pilot to develop regional sickle-cell disease centers to help patients access team-based medical, behavioral health, mental health, social support and surveillance services to adults with sickle cell. The bill did not require that the health services provided at the pilot centers be done through a licensed physician or allied health care professional under the supervision of a licensed physician. Status: Failed in the Assembly Appropriation Committee.
AB 1270 (STONE, MARK): FALSE CLAIMS ACT
AB 1270 would have based materiality of a false record or statement off of the potential effect, instead of the actual effect, of the false record or statement when the record or statement was made. The bill would also specify that amount of damages that may be awarded include consequential damages. Status: Failed in the Senate Appropriations Committee.
AB 1404 (SANTIAGO): NONPROFIT SPONSORS: REPORTING OBLIGATIONS
This bill would have required a health care entity to disclose a contracted physician’s complete compensation information, including base compensation, deferred compensation, and any bonuses and incentives that are part of their total compensation package, on its public website. Status: Failed on the Senate Inactive File.
AB 1670 would have authorized a provider that contracts with a health care service plan or health insurer to bill an enrollee or insured for a service that is not a covered benefit if the enrollee or insured provides initial written consent to the bill. The bill would have required a contracting physician to provide an enrollee or insured with a written estimate of the total cost, based on the standard rate the provider would charge for the service, if the service sought is not a covered benefit. Status: Failed in the Assembly Health Committee.
SB 201 (WIENER): MEDICAL PROCEDURES: TREATMENT OR INTERVENTION: SEX CHARACTERISTICS OF A MINOR
SB 201 would have prohibited a physician from performing any treatment or procedure on the sex characteristics of an intersex minor until the minor patient provides informed consent to the physician. The bill makes an exception for any procedure or treatment that is deemed medically necessary, which is defined in such a way that cannot properly address the complexity of such cases. Status: Failed in the Senate Business, Professions and Economic Development Committee.
SB 480 (ARCHULETA): RADIOLOGIST ASSISTANTS
This bill would have created a new class of licensees, called radiologist assistants, and defined their supervision and scope. The bill also limited supervision of these radiologist assistants to solely radiologists. Status: Failed in the Senate Business, Professions and Economic Development Committee.
SB 673 (MORRELL): COMPREHENSIVE SEXUAL HEALTH EDUCATION AND HIV PREVENTION EDUCATION
This bill would have required, for a student in a grade lower than 7th, an active parental “opt-in” for sexual health education and HIV prevention education in that year and in the upcoming year. Current law requires all students in 7th grade and above to participate in sexual health education and HIV prevention education unless a parent actively opts their child out of such education. Status: Failed in the Senate Education Committee.
SB 689 (MOORLACH): NEEDLE AND SYRINGE EXCHANGE PROGRAMS
This bill would have placed barriers on cities or other specified entities who seek to establish a needle exchange program. Status: Failed in the Senate Health Committee.
SB 746 (BATES): HEALTH CARE COVERAGE: ANTICANCER MEDICAL DEVICES
SB 746 would have required health care service plan contracts and health insurance policies that cover chemotherapy or radiation therapy for the treatment of cancer to also cover anticancer medical devices. Status: Failed in the Assembly Appropriations Committee.
Reception & Presentation
Lewis Atterbury Stimson Professor & Chairman Surgeon-in-Chief Weill Cornell Medicine Department of Surgery Fabrizio Michelassi, MD
Speaking on Cheese and Its Possible Link to Breast Cancer We will explore the history of cheese making, the classification of cheeses and the controversy about the effect of cheese on breast cancer mortality.
Please Join Us Thursday, March 12, 2019 • 5:30 pm to 7:00 pm Reception 5:30 pm • Presentation 6:00 pm Ridley-Tree Cancer Center at Sansum Clinic Lovelace Conference Hall, 540 West Pueblo Street. Free valet parking available. Please RSVP to Devin Scott by March 6 (805) 681-7762 or dscott@sansumclinic.org. Reservations required.
Title Sponsor
Practice Management: Tip of the Month Report unfair payment practices to the Department of Managed Health Care
A new Calfiornia law requires regulators to review physician complaints of unfair payment practices. Practices are urged to closely monitor their accounts receivables to ensure that they have been paid properly and to report any violations to the Department of Managed Health Care (DMHC) through its provider complaint portal or by calling the DMHC Help Center at (888) 466-2219.
For more information, visit cmadocs.org/tips.
Trouble Getting Paid? CMA Can Help!
RISK TIP
CULTURAL DIVERSITY CREATES LANGUAGE BARRIERS: REDUCING CLAIMS WITH MULTILINGUAL PATIENTS
RICH CAHILL, JD, VICE PRESIDENT AND ASSOCIATE GENERAL COUNSEL, AND SUSAN SHEPARD, MSN, RN, SENIOR DIRECTOR, PATIENT SAFETY EDUCATION, THE DOCTORS COMPANY
Ms. D., a naturalized U.S. citizen from Southeast Asia, presented to Dr. P. for a consultation regarding extensive acne scarring on her face and neck. The patient reported that she felt self-conscious about her appearance and sought advice on possible treatment options. According to the chart, Ms. D. spoke limited English. Her reading proficiency was not noted.
Following an examination of the affected area, Dr. P. offered CO2 laser resurfacing. The benefits and potential disadvantages of the procedure were discussed, including the possibility that her complexion type posed an increased risk of scarring and changes in pigmentation. Ms. D. subsequently agreed to undergo laser resurfacing and signed a written consent that specifically identified scarring and changes in skin color as possible postoperative outcomes.
The patient returned the following week. The treatment record ref lects that Dr. P. performed the procedure under local anesthesia and conscious sedation. The surgery was uneventful, and no intraoperative complications occurred. Ms. D. presented on numerous occasions over the next several months. Hyperpigmentation was noted, and
Solaquin Forte 4% and Pramosone lotion were prescribed. At one point, the patient complained of experiencing a burning sensation on her face. Approximately one year after the procedure, Ms. D. returned for further evaluation. The scarring was barely visible; the discoloration on her neck was noticeably improved. However, the patient expressed dissatisfaction with the result.
Ms. D. thereafter retained counsel and initiated suit alleging causes of action for medical malpractice and negligent inf liction of emotional distress. In substance, the patient claimed that because of her limited proficiency with English and the failure by the physician to utilize any translation services, including for any preoperative documentation, there was no informed consent. PROVIDING LANGUAGE SERVICES: OBLIGATIONS AND BENEFITS Clear and unambiguous communication constitutes the key component of the physician-patient relationship. Misunderstandings often create frustration and distrust, especially when an adverse event occurs, and can result in professional liability litigation or reports to state medical boards and third-party payers by disgruntled patients and family members. Proactively implementing office procedures for both physicians and staff to promote optimum communication reduces the risk of surprise and the potential for expensive, protracted, and unpleasant disputes.
With our culturally diverse national population, including many who speak a language other than English at home, language barriers raise the risk for an adverse event. The Department of Health and Human Services (HHS) Revised Guidance Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient (LEP) Persons outlines the requirements for recipients of federal financial assistance from HHS to take reasonable steps to ensure LEP persons have access to language services. (These recipients do not include providers who only receive Medicare Part B payments. However, providers that receive funding from any government program such as Medicaid or Medicare Advantage are subject to the requirements.)
To determine the extent of the obligation to provide language assistance, analyze the following four factors: • Number: The greater the number or proportion of LEP persons served or encountered by your clinic, the more likely language services will be needed. • Frequency: Even if unpredictable or infrequent, there must be a plan for providing language assistance for LEP persons. • Nature: Determine whether a delay in accessing your services could have serious or life-threatening implications. The more important the nature of the services you offer, or the greater the consequences of not accessing treatment, the more likely language services will be needed. • Resources: Consider the resources available and the cost to provide them. As a solo practitioner, you are not expected to provide the same level of service as a large, multispecialty group. Investigate technological services or sharing resources with other providers. It is not recommended to use a family member as an interpreter. Lay personnel are rarely familiar with medical terminology. Additionally, the patient may not want a family member to access their confidential health information.
An adult family member should serve as interpreter if a family member must be used—unless no adult is available, and care must be provided immediately to prevent harm. It is preferable to have a trained clinical staff member provide interpretation; alternately, your practice can use certified interpreter services. Consult your local hospital or the patient’s health plan for a list of qualified interpreters. Other resources include a local nationality society, the Registry of Interpreters for the Deaf, or the local center for the deaf. Also, keep consent forms—especially for invasive procedures—translated into the applicable non-English languages by a certified translator.
The Agency for Healthcare Research and Quality (AHRQ ) has prepared a guide, Improving Patient Safety Systems for Patients With Limited English Proficiency, which recommends that practices focus on the following: • Medication use: Understanding medication instructions is complicated for all patients, but even more difficult for LEP patients. Both patients and providers need to communicate accurately about mode of administration, allergies, and side effects. • Informed consent: Obtaining informed consent remains a hallmark of patient safety and a critical medical and legal responsibility. Achieving truly informed consent for LEP patients may require extra effort, but LEP patients should not be excluded from learning about choices that might affect their health and well-being. • Follow-up instructions: Understanding discharge instructions is especially challenging for LEP patients. Speaking Together: National Language Services Network, a project funded by the Robert Wood Johnson Foundation, which created the Speaking Together Toolkit, found the need for greater use of interpreters at key moments of information exchange, such as at assessment and discharge—not just during the acute phase of treatment. Relatively simple communication tools can provide some helpful solutions. These include: • AskMe3™: Rx for Patient Safety: Ask Me 3 • The teach-back method: AHRQ: Use the Teach-Back Method: Tool #5 • The SHARE approach: AHRQ: The SHARE Approach— Using the Teach-Back Technique: A Reference Guide for Health Care Providers • Patient experience surveys: The Doctors Company: Patient Experience Surveys To protect your patients from harm resulting from their LEP, develop and implement a plan for language access in your practice. For more information, see the Centers for Medicare and Medicaid Services’ Guide to Developing a Language Access Plan.
The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.
MEN’S HEALTH
IN PRAISE OF TESTOSTERONE
None that I’ve seen.
BY DAVID DODSON, MD
Let’s face it, testosterone is a Rodney Dangerfield hormone. It doesn’t get any respect. But I like testosterone. I’ve worn a full beard all my adult life and am grateful for the testosterone that allows me to do it. And inasmuch as testosterone promotes sex drive, in a real sense, we’re all here thanks to testosterone.
Testosterone tends to be conflated with maleness, but let’s not forget that women also have testosterone, and also that the more testosterone a man has, the more estrogen he also has thanks to aromatase converting a portion of circulating testosterone into estrogen. This sometimes becomes a problem when giving testosterone replacement to men deficient in testosterone as it occasionally leads to gynecomastia.
How about the notion that testosterone is toxic and leads to impulsivity and aggression? The tendency towards these traits is familiar to parents of little tots whose testosterone levels are very low. And while puberty brings with it soaring hormones including, but not limited to, testosterone and while some adolescents go wrong at that point never to be set right, this is true of some girls
also come off the rails at puberty sans high testosterone. I see a case of true, true, and unrelated as to cause and effect: true testosterone levels rise at puberty, and true some teenagers become aggressive and impulsive and irresponsible risk-takers, sometimes for the rest of their lives, but I am unconvinced that these phenomena have a cause and effect relation. Is there any data that computer nerds and shy wallflower-types have lower testosterone levels than rougher boys? None that I’ve seen. The key notion is that society interacts with biology, and such influences are often formative within families. For example, many physicians come from families of physicians, farmers from farmers, soldiers from soldiers, miners from miners, etc. I don’t think this reflects genetic influences any more than a Y chromosome and testosterone leads to aggression, criminality, and “toxic masculinity”. Testosterone deficiency on the other hand is unpleasant, depressing, and dangerous. Low testosterone has been linked to higher mortality, and it feels lousy. Men with low T complain not just of low libido but also of low energy and low mood. Low T is said to make a man grumpy. Dowd, so-called toxic masculinity: impulsive, aggressive, sexist, overbearing, etc. is a character flaw, not a hormonallydriven medical condition. Castrated lab animals are not motivated. They sit in a corner and display a lack of any kind of drive. They are fat and lethargic. So, it seems that testosterone does play a necessary if not sufficient role in drive and ambition. That ambition could be to create great art, build a cathedral, fly to the Moon, or to commit crimes. The difference between the artist, the engineer, or the criminal is not to be found in their hormones. The difference is in their souls. We should not conflate the two, and we should not denigrate testosterone. In addition to driving libido, testosterone helps drive ambition. This is where socialization comes in. You work hard for our health... let us work hard for you...
In addition to driving libido, testosterone helps drive ambition. This is where socialization comes in. If your ambition is to rob banks, you could become like Jesse James and die young in a blaze of gunfire. Is testosterone to blame? But if your ambition is to reach for the stars, you could become an astronaut or an aeronautical engineer. As the terrific movie “Hidden Figures” showed, this particular ambition is not the exclusive domain of white males. Did Kathleen Johnson, the brilliant African American mathematician depicted in “Hidden Figures” who calculated the trajectory of Mercury space flights in the pre-computer era at NASA and her colleagues have testosterone-fueled talents? Probably not. Again, socialization is the key. Behavior is complicated and reducing it to the influence of one hormone is simplistic and frankly patronizing and sexist. We are touching on the distinction to be made between biological sex and gender, a social construct. Unless one argues that the Y chromosome and testosterone are inherently bad, which has been done - see “Are Men Necessary” by Maureen
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Dr. Eric Levy of Santa Maria
On behalf of CenCal Health, Rachel Ponce (right) accepts the 2019 Innovation Award from the California Department of Health Care Services.
Dr. Douglas Jackson (left) and Dr. Douglas Cummings (right) of Jackson Medical Group, Santa Barbara and Goleta.
CenCal Health NEWS HUB: Awards Season
TOP PER FOR M ANCES BY PR IM ARY CAR E PROVIDERS AND LOCAL HEALTH PLAN
This month’s star-studded Academy Awards is the culmination of the annual awards season for the entertainment industry. Likewise, CenCal Health wraps up best performances in healthcare from the past year.
CenCal Health annually recognizes the work of local network physicians and healthcare centers through its Primary Care Providers (PCP) Incentive Top Performer Awards. The awards acknowledge PCPs across San Luis Obispo and Santa Barbara counties who provide high-quality healthcare and control utilization costs of their assigned health plan membership. (The awards are based on 2018 performance scores with the results announced throughout 2019.)
In internal medicine, Dr. Eric Levy of Santa Maria was named the top performer within his provider group. “I enjoy serving the CenCal Health population,” said Levy. “It’s a challenge that has to be met in our community. When the less fortunate are treated to quality healthcare, we all benefit.” The Jackson Medical Group, with multiple offices in Santa Barbara County, placed both second (Pacific Oaks, Goleta location) and third (Santa Barbara location).
To ensure that providers continue to offer quality services and in turn manage costs, CenCal Health monitors their performance via monthly reports. Within these reports, eight categories are measured: physician/ outpatient expenses, inpatient hospital expenses, pharmacy expenses, emergency room visits, doctor and patient encounters, after hours visits, preventive medicine evaluations, and increased access to care for Medi-Cal members. The data included is not only valuable to the health plan but is considered a key resource for practices looking to improve their quality of care.
“Our longtime mission at the Jackson Medical Group ( JMG) is to provide high-quality medical care in an efficient and cost-effective manner,” said JMG Medical Director Douglas R. Jackson, M.D. “CenCal Health is a wonderful partner and allows us to do our job without the roadblocks put up by so many other health plans.”
In pediatrics, Dr. Jeffery S. Kaplan of Santa Maria earned the top honor among his pediatrics peer group. Also recognized for their dedication to high quality care is Dr. Himat Tank of Santa Maria, and the Pediatric Medical Group of Santa Maria.
Valley Medical Group of Lompoc was named the best performing family practice within both counties. Central Coast Medical Group in Lompoc and Buellton Medical Center also stood out among their peer set.
Community Health Centers of the Central Coast, in both Santa Barbara and San Luis Obispo counties, earned the top spot for Federally Qualified Health Centers (FQHC). Other FQHCs awarded were Santa Barbara Neighborhood Clinic, and Santa Barbara County Public Health, located in Santa Barbara, Lompoc and Santa Maria.
*** Last October, California’s Department of Health Care Services (DHCS) presented its fifth annual Innovation Award to CenCal Health. The award is given to a Managed Care Plan (MCP) whose innovative interventions strive to improve the quality of health care for Medi-Cal beneficiaries. CenCal Health’s award-winning pilot program, titled K now More: HPV, is an in-office patient intervention that supports the public health mandate to increase HPV vaccination rates. A digital tablet that interactively provides health information on HPV and the need to vaccinate is handed out to targeted patients while in the waiting room. The K now More: HPV education pilot significantly increased HPV vaccination rates in just six months. “When we identify areas where our members aren’t utilizing available benefits, we look at why that is and how we can successfully address it,” said CenCal Health CEO Bob Freeman. “That was the case for this cancerprevention vaccine. An advantage of being a local plan is that we’re both motivated and able to get our arms around these types of problems and share solutions with the public at-large.”
The 2019 award was presented to CenCal Health’s Senior Quality Improvement Specialist Rachel Ponce at the DHCS Quality Conference in Sacramento. For more information, visit cencalhealth.org.
