Existing law requires that every patient who has blood drawn at a primary care clinic, as defined, and who has consented to the test, be offered an HIV test that is consistent with the United States Preventive Services Task Force recommendations for screening for HIV infection. Existing law specifies the manner in which the results of that test are provided.

This bill would, additionally, apply those provisions to a patient who has been admitted as an inpatient to a general acute care hospital through the emergency department and has blood drawn after being admitted to the hospital. The bill would specify that the emergency department is not responsible for offering the HIV test. The bill would authorize a hospital to offer the HIV test at any time during the patients admission. The bill would specify that these provisions do not prohibit a patients health plan from applying any patient cost share or other limitation that is authorized by law and included in the contract between the plan and the patient.

Existing law requires that every patient who has blood drawn at a primary care clinic, as defined, and who has consented to the test, be offered an HIV test that is consistent with the United States Preventive Services Task Force recommendations for screening for HIV infection. Existing law specifies the manner in which the results of that test are provided.

This bill would, additionally, apply those provisions to a patient who has been admitted as an inpatient to a general acute care hospital through the emergency department and has blood drawn after being admitted to the hospital. The bill would specify that the emergency department is not responsible for offering the HIV test. The bill would authorize a hospital to offer the HIV test at any time during the patients admission. The bill would specify that these provisions do not prohibit a patients health plan from applying any patient cost share or other limitation that is authorized by law and included in the contract between the plan and the patient.

Existing law requires that every patient who has blood drawn at a primary care clinic, as defined, and who has consented to the test, be offered an HIV test that is consistent with the United States Preventive Services Task Force recommendations for screening for HIV infection. Existing law specifies the manner in which the results of that test are provided.

This bill would, additionally, apply those provisions to a patient who has been admitted as an inpatient to a general acute care hospital through the emergency department and has blood drawn in a general acute care hospital after being admitted to the hospital through the hospital emergency department. hospital. The bill would specify that the emergency department is not responsible for offering the HIV test.

Existing law requires that every patient who has blood drawn at a primary care clinic, as defined, and who has consented to the test to test, be offered an HIV test that is consistent with the United States Preventive Services Task Force recommendations for screening for HIV infection. Existing law specifies the manner in which the results of that test are provided.

This bill would, additionally, apply those provisions to a patient who has been admitted to blood drawn in a general acute care hospital after having blood drawn at being admitted to the hospital through the hospital emergency department. The bill would exempt a hospital emergency department from the testing requirements if the personnel in the emergency department determine that the person is being treated for a life-threatening emergency or if the person lacks the capacity to consent to an HIV test.

Existing law requires that every patient who has blood drawn at a primary care clinic, as defined, and who has consented to the test to be offered an HIV test that is consistent with the United States Preventive Services Task Force recommendations for screening for HIV infection. Existing law specifies the manner in which the results of that test are provided.

This bill would, additionally, apply those provisions to a patient who has been admitted to a general acute care hospital. The bill would authorize a hospital emergency department to comply with certain requirements to provide information, counseling, and advice to a patient after the results of an HIV test have been received by providing the patient with printed material that includes that information and advice. hospital after having blood drawn at the hospital emergency department. The bill would exempt a hospital emergency department from the testing requirements if the personnel in the emergency department determine that the person is being treated for a life-threatening emergency or if the person lacks the capacity to consent to an HIV test.

Existing law requires that every patient who has blood drawn at a primary care clinic, as defined, and who has consented to the test to be offered an HIV test that is consistent with the United States Preventive Services Task Force recommendations for screening for HIV infection. Existing law specifies the manner in which the results of that test are provided.

This bill would, additionally, apply those provisions to a general acute care hospital. The bill would authorize a hospital emergency department to comply with certain requirements to provide information, counseling, and advice to a patient after the results of an HIV test have been received by providing the patient with printed material that includes that information and advice. The bill would exempt a hospital emergency department from the testing requirements if the personnel in the emergency department determine that the person is being treated for a life-threatening emergency or if the person lacks the capacity to consent to an HIV test.

Existing law requires that every patient who has blood drawn at a primary care clinic, as defined, and who has consented to the test to be offered an HIV test, test that is consistent with the United States Preventive Services Task Force recommendations for screening, specify screening for HIV infection. Existing law specifies the manner in which the results of that test are provided.

This bill would, additionally, apply those provisions to a general acute care hospital. The bill would authorize a hospital emergency department to comply with certain requirements to provide information, counseling, and advice to a patient after the results of an HIV test have been received by providing the patient with printed material that includes that information and advice.

Existing law requires that every patient who has blood drawn at a primary care clinic, as defined, and who has consented to the test to be offered an HIV test, consistent with the United States Preventive Services Task Force recommendations for screening, specify the manner in which the results of that test are provided.

This bill would, additionally, apply those provisions to a general acute care hospital.

GOVERNOR'S VETO

GV Bill Id:AB 521

Author:(Nazarian)

As Enrolled Ver:September 16, 2015

2/3 vote

Original Committee Reference: HEALTH

SUMMARY: Requires a patient who has been admitted as an inpatient to a hospital through the emergency department (ED) and has blood drawn after being admitted to the hospital, and who has consented, to be offered an human immunodeficiency virus (HIV) test.

The Senate amendments:

1. Specify the provisions of this bill only apply if the patient is admitted to the hospital through the ED.

2. Clarify that the HIV test can be offered at any time during admission.

3. Prohibit the ED from being held responsible for offering an HIV test.

4. Specify the provisions of this bill do not prohibit a patient’s health plan from applying any patient share of cost or other limitation that is allowed by law and included in the patient's health plan.

EXISTING LAW: Requires each patient who has blood drawn in a primary care clinic, and who has consented to an HIV test, to be offered an HIV test. Requires the test to conform with the United States Preventative Services (USPS) Task Force recommendation. Exempts from the requirement of testing, if the patient was tested, or offered testing and declined, within the last 12 months. Requires subsequent testing to be consistent with the most recent guidelines of the USPS Task Force.

FISCAL EFFECT: According to the Senate Appropriations Committee:

1. By requiring hospitals to offer additional HIV testing to patients, this bill will increase the number of tests provided and the number of previously undiagnosed individuals who will be diagnosed with HIV, typically leading to treatment. The number of additional tests provided and the number of previously undiagnosed cases of HIV discovered through those tests is subject to uncertainty. Based on information developed by the Office of Statewide Planning and Development, there are about 11.6 million ED patient encounters per year, of which about 160,000 lead to an inpatient admission at a hospital. If 50% of those admissions lead to an HIV test and the population accepting the test has roughly the same rate of undiagnosed HIV as the overall state population, there would be about 60 newly diagnosed cases of HIV identified under the bill per year. This would result in the following state costs:

   1. About $300,000 per year for additional HIV testing (including follow up testing for positive test results) by the Medi-Cal program (General Fund (GF) and federal funds).

   2. About $300,000 per year to provide medical care Medi-Cal enrollees newly diagnosed with HIV (GF and federal funds).

   3. About $200,000 per year to provide medical care to new Aids Drug Assistance Program enrollees (federal funds and drug rebate funds).

2. Unknown long-term cost savings to Medi-Cal due to earlier medical intervention for HIV-positive Medi-Cal enrollees. To the extent that HIV-positive Medi-Cal enrollees are diagnosed earlier and begin treatment earlier, it is likely that the long-term health status of those individuals will improve and some of the health effects of HIV will be delayed or avoided. There are indications that untreated HIV causes long-term health impacts such as elevated risk of diabetes and heart disease, even before the effects of compromised immune system function associated with HIV infection become evident. Earlier diagnosis and treatment for HIV-positive individuals may to reduce long-term Medi-Cal expenditures for those individuals. However, to some unknown extent the improvement in health status and reduction in health care needs will be offset by longer lifespans, potentially offsetting cost savings.

3. Unknown cost savings due to reduced HIV infections in the state, including amongst Medi-Cal beneficiaries. There are academic findings that diagnosis of HIV significantly reduces the likelihood that an HIV positive individual will infect others. This is due both to a reduction in risky behavior by those aware of their HIV positive status and reductions in viral loads in the blood due to antiretroviral treatments. To the extent that this bill results in new diagnoses of HIV and that newly diagnosed individuals are able to access appropriate medical care, this bill is likely to prevent future HIV infections.

COMMENTS: According to the author, California has led the way in identifying people living with HIV and linking them with care and treatment. For example, AB 446 (Mitchell), Chapter 589, Statues of 2013, requires public health clinics to offer an HIV test. Until the Patient Protection and Affordable Care Act has been fully implemented, EDs will continue to play a critical role in delivering primary care services to many new enrollees and the uninsured. Given that there are more than 5,000 new HIV infections in California every year, this bill will bridge the gap in lack of HIV testing by requiring EDs to uniformly provide HIV testing.

According to the sponsor, the acquired immune deficiency syndrome (AIDS) Healthcare Foundation (AHF), this bill simply requires the offer of an HIV test in an ED if blood is already being drawn for another purpose. AHF writes that they recognize that EDs are constantly under pressure to meet the immediate needs of their patients. AHF concludes, this bill seeks to balance the public health demands of controlling this epidemic with the operational needs of an ED. AHF points at the Emergency Room as the last remaining major source for the identification of new people with HIV.

In opposition, the California Chapter of the American College of Emergency Physicians (Cal/ACEP) argues that while this bill may appear to be an easy and efficient way to increase HIV diagnosis and treatment, it is unfortunately extremely problematic. Although fewer than 5% of doctors are emergency physicians, they handle a quarter of all acute care encounters and more than half of acute care visits by the uninsured. Diagnosing and treating HIV is an important public health endeavor, but EDs are not the proper venue for a diagnostic public health campaign. According to Cal/ACEP, this bill would place additional stress on California’s overcrowded and burdened EDs, while diverting precious time away from patients with critical conditions toward public health screening.

GOVERNOR'S VETO MESSAGE:

This bill would mandate hospitals to offer an HIV test to consenting patients who have blood drawn after being admitted through the emergency department.

This bill is not the best approach to identifying those who are undiagnosed with HIV. The demographics of patients targeted by this bill do not match the demographics of the population at risk for exposure to HIV infection. In addition, hospitals are not appropriately staffed nor are they the place to provide counseling, routine preventive screenings, or follow-up care for sensitive HIV testing. Limited resources would be better spent supporting outreach and education activities by existing providers which have the staff and training for HIV testing and follow-up care.

Analysis Prepared by: Patty Rodgers / HEALTH / (916) 319-2097 FN: 0002488

CONCURRENCE IN SENATE AMENDMENTS

CSA1 Bill Id:AB 521

Author:(Nazarian)

As Amended Ver:September 4, 2015

Majority vote

Original Committee Reference: HEALTH

SUMMARY: Requires a patient who has been admitted as an inpatient to a hospital through the emergency department (ED) and has blood drawn after being admitted to the hospital, and who has consented, to be offered an human immunodeficiency virus (HIV) test.

The Senate amendments:

1. Specify the provisions of this bill only apply if the patient is admitted to the hospital through the ED.

2. Clarify that the HIV test can be offered at any time during admission.

3. Prohibit the ED from being held responsible for offering an HIV test.

4. Specify the provisions of this bill do not prohibit a patient’s health plan from applying any patient share of cost or other limitation that is allowed by law and included in the patient's health plan.

EXISTING LAW: Requires each patient who has blood drawn in a primary care clinic, and who has consented to an HIV test, to be offered an HIV test. Requires the test to conform with the United States Preventative Services (USPS) Task Force recommendation. Exempts from the requirement of testing, if the patient was tested, or offered testing and declined, within the last 12 months. Requires subsequent testing to be consistent with the most recent guidelines of the USPS Task Force.

FISCAL EFFECT: According to the Senate Appropriations Committee:

1. By requiring hospitals to offer additional HIV testing to patients, this bill will increase the number of tests provided and the number of previously undiagnosed individuals who will be diagnosed with HIV, typically leading to treatment. The number of additional tests provided and the number of previously undiagnosed cases of HIV discovered through those tests is subject to uncertainty. Based on information developed by the Office of Statewide Planning and Development, there are about 11.6 million ED patient encounters per year, of which about 160,000 lead to an inpatient admission at a hospital. If 50% of those admissions lead to an HIV test and the population accepting the test has roughly the same rate of undiagnosed HIV as the overall state population, there would be about 60 newly diagnosed cases of HIV identified under the bill per year. This would result in the following state costs:

   1. About $300,000 per year for additional HIV testing (including follow up testing for positive test results) by the Medi-Cal program (General Fund (GF) and federal funds).

   2. About $300,000 per year to provide medical care Medi-Cal enrollees newly diagnosed with HIV (GF and federal funds).

   3. About $200,000 per year to provide medical care to new Aids Drug Assistance Program enrollees (federal funds and drug rebate funds).

2. Unknown long-term cost savings to Medi-Cal due to earlier medical intervention for HIV-positive Medi-Cal enrollees. To the extent that HIV-positive Medi-Cal enrollees are diagnosed earlier and begin treatment earlier, it is likely that the long-term health status of those individuals will improve and some of the health effects of HIV will be delayed or avoided. There are indications that untreated HIV causes long-term health impacts such as elevated risk of diabetes and heart disease, even before the effects of compromised immune system function associated with HIV infection become evident. Earlier diagnosis and treatment for HIV-positive individuals may to reduce long-term Medi-Cal expenditures for those individuals. However, to some unknown extent the improvement in health status and reduction in health care needs will be offset by longer lifespans, potentially offsetting cost savings.

3. Unknown cost savings due to reduced HIV infections in the state, including amongst Medi-Cal beneficiaries. There are academic findings that diagnosis of HIV significantly reduces the likelihood that an HIV positive individual will infect others. This is due both to a reduction in risky behavior by those aware of their HIV positive status and reductions in viral loads in the blood due to antiretroviral treatments. To the extent that this bill results in new diagnoses of HIV and that newly diagnosed individuals are able to access appropriate medical care, this bill is likely to prevent future HIV infections.

COMMENTS: According to the author, California has led the way in identifying people living with HIV and linking them with care and treatment. For example, AB 446 (Mitchell), Chapter 589, Statues of 2013, requires public health clinics to offer an HIV test. Until the Patient Protection and Affordable Care Act has been fully implemented, EDs will continue to play a critical role in delivering primary care services to many new enrollees and the uninsured. Given that there are more than 5,000 new HIV infections in California every year, this bill will bridge the gap in lack of HIV testing by requiring EDs to uniformly provide HIV testing.

According to the sponsor, the acquired immune deficiency syndrome (AIDS) Healthcare Foundation (AHF), this bill simply requires the offer of an HIV test in an ED if blood is already being drawn for another purpose. AHF writes that they recognize that EDs are constantly under pressure to meet the immediate needs of their patients. AHF concludes, this bill seeks to balance the public health demands of controlling this epidemic with the operational needs of an ED. AHF points at the Emergency Room as the last remaining major source for the identification of new people with HIV.

In opposition, the California Chapter of the American College of Emergency Physicians (Cal/ACEP) argues that while this bill may appear to be an easy and efficient way to increase HIV diagnosis and treatment, it is unfortunately extremely problematic. Although fewer than 5% of doctors are emergency physicians, they handle a quarter of all acute care encounters and more than half of acute care visits by the uninsured. Diagnosing and treating HIV is an important public health endeavor, but EDs are not the proper venue for a diagnostic public health campaign. According to Cal/ACEP, this bill would place additional stress on California’s overcrowded and burdened EDs, while diverting precious time away from patients with critical conditions toward public health screening.

Analysis Prepared by: Patty Rodgers / HEALTH / (916) 319-2097 FN: 0002260

 THIRD READING  

Bill No: AB 521

Author: Nazarian (D)

Amended: 9/4/15 in Senate

Vote: 21

SENATE HEALTH COMMITTEE: 6-2, 7/8/15

AYES: Hernandez, Hall, Monning, Pan, Roth, Wolk

NOES: Nguyen, Nielsen

NO VOTE RECORDED: Mitchell

SENATE APPROPRIATIONS COMMITTEE: 5-2, 8/27/15

AYES: Lara, Beall, Hill, Leyva, Mendoza

NOES: Bates, Nielsen

ASSEMBLY FLOOR: 51-21, 6/4/15 - See last page for vote

SUBJECT: HIV testing

SOURCE: AIDS Healthcare Foundation

DIGEST: This bill requires a patient who has been admitted as an inpatient to a hospital through the emergency department and has blood drawn after being admitted to the hospital, and who has consented, to be offered an HIV test.

Senate Floor Amendments of 9/4/15 permit a hospital to offer the HIV test at any time during the patient’s admission and specify that this bill does not prohibit a patient’s health plan from applying any patient cost share or other limitation that is allowed by law and included in the contract between the plan and the patient.

ANALYSIS: Existing law requires each patient who has blood drawn at a primary care clinic, and who has consented, to be offered an HIV test, consistent with the United States Preventive Services Task Force (USPSTF) recommendation for screening the HIV infection.

This bill:

1. Requires a patient who has been admitted as an inpatient to a hospital through the emergency department (ED) and has blood drawn after being admitted to the hospital, and who has consented, to be offered an HIV test. Permits a hospital to offer the HIV test at any time during the patient’s admission

2. Prohibits the ED from being responsible for offering an HIV test.

3. Requires the hospital clinician to offer an HIV test consistent with the USPSTF recommendation for screening HIV infection.

4. Makes related technical, conforming changes to existing law.

Comments

1. Author’s statement. According to the author, over the past decade, California has focused on the need to test, as early as possible, to reduce HIV infection rates and link people with HIV treatment. Given that there are more than 5,000 new HIV infections in California every year, AB 521 will bridge the gap in lack of HIV testing by requiring hospitals to offer an HIV test to patients that have been admitted via the ED. The ED trigger is key, as emergency rooms will continue to play a critical role in delivering primary care services to many new enrollees and to those who remain uninsured. AB 521 recognizes that emergency rooms continue to play a vital role in helping to identify individuals with HIV.

2. Background. According to a 2015 Centers for Disease Control and Prevention report, an estimated 1,148,200 persons aged 13 years and older are living with HIV infection. Over the past decade, the number of people living with HIV has increased, while the annual number of new HIV infections has remained relatively stable. Still, the pace of new infections continues at far too high a level, particularly among certain groups. The estimated incidence of HIV has remained stable overall in recent years, at about 50,000 new HIV infections per year. Within the overall estimates, however, some groups are affected more than others. Men who have sex with men continue to bear the greatest burden of HIV infection, and among races/ethnicities, African Americans continue to be disproportionately affected. In 2013, an estimated 47,352 people were diagnosed with HIV infection in the United States. In that same year, an estimated 26,688 people were diagnosed with AIDS. Overall, an estimated 1,194,039 people in the United States have been diagnosed with AIDS. An estimated 13,712 people with an AIDS diagnosis died in 2012, and approximately 658,507 people in the United States with an AIDS diagnosis have died overall. The deaths of persons with an AIDS diagnosis can be due to any cause—that is, the death may or may not be related to AIDS.

3. HIV positive but unaware. According to the CDC, of the nearly 1.2 million people estimated to be living with HIV in the United States, nearly one in seven (more than 168,000) do not know they are infected. According to the California Office of AIDS, as of the end of 2011, it is estimated that between 29,523 and 31,948 HIV-positive and unaware individuals reside in California. Because many new infections are transmitted by people who do not know they are infected, undiagnosed infection remains a significant factor fueling the HIV epidemic. According to the CDC, when HIV is diagnosed early, appropriately timed interventions, particularly highly active antiretroviral therapy, can lead to improved health outcomes, including slower clinical progression and reduced mortality. Additionally, HIV counseling with testing has been demonstrated to be an effective intervention for HIV-infected participants, who increased their safer behaviors and decreased risk behaviors.

Prior Legislation

AB 446 (Mitchell, Chapter 589, Statues of 2013), among other provisions related to consent for HIV testing, required community clinics to offer an HIV test.

FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: No

According to the Senate Appropriations Committee:

• By requiring hospitals to offer additional HIV testing to patients, this bill will increase the number of tests provided and the number of previously undiagnosed individuals who will be diagnosed with HIV, typically leading to treatment. The number of additional tests provided and the number of previously undiagnosed cases of HIV discovered through those tests is subject to uncertainty. Based on information developed by the Office of Statewide Planning and Development, there are about 11.6 million emergency department patient encounters per year, of which about 160,000 lead to an inpatient admission at a hospital. If 50% of those admissions lead to an HIV test and the population accepting the test has roughly the same rate of undiagnosed HIV as the overall state population, there would be about 60 newly diagnosed cases of HIV identified under the bill per year. This would result in the following state costs:

• About $300,000 per year for additional HIV testing (including follow up testing for positive test results) by the Medi-Cal program (General Fund and federal funds).

• About $300,000 per year to provide medical care Medi-Cal enrollees newly diagnosed with HIV (General Fund and federal funds).

• About $200,000 per year to provide medical care to new Aids Drug Assistance Program enrollees (federal funds and drug rebate funds).

• Unknown long-term cost savings to Medi-Cal due to earlier medical intervention for HIV-positive Medi-Cal enrollees. To the extent that HIV-positive Medi-Cal enrollees are diagnosed earlier and begin treatment earlier, it is likely that the long-term health status of those individuals will improve and some of the health effects of HIV will be delayed or avoided. There are indications that untreated HIV causes long-term health impacts such as elevated risk of diabetes and heart disease, even before the effects of compromised immune system function associated with HIV infection become evident. Earlier diagnosis and treatment for HIV-positive individuals may to reduce long-term Medi-Cal expenditures for those individuals. However, to some unknown extent the improvement in health status and reduction in health care needs will be offset by longer lifespans, potentially offsetting cost savings.

• Unknown cost savings due to reduced HIV infections in the state, including amongst Medi-Cal beneficiaries. There is academic findings that diagnosis of HIV significantly reduces the likelihood that an HIV positive individual will infect others. This is due both to a reduction in risky behavior by those aware of their HIV positive status and reductions in viral loads in the blood due to antiretroviral treatments. To the extent that this bill results in new diagnoses of HIV and that newly diagnosed individuals are able to access appropriate medical care, this bill is likely to prevent future HIV infections.

SUPPORT: (Verified 9/4/15)

AIDS Healthcare Foundation (source)

AIDS Project Los Angeles

Beyond AIDS

The Wall Las Memorias Project

OPPOSITION: (Verified 9/4/15)

California Hospital Association

Cedars-Sinai Medical Center

ASSEMBLY FLOOR: 51-21, 6/4/15

AYES: Achadjian, Alejo, Baker, Bloom, Bonilla, Bonta, Brown, Burke, Calderon, Campos, Chau, Chiu, Chu, Cooley, Dababneh, Daly, Dodd, Eggman, Cristina Garcia, Eduardo Garcia, Gatto, Gipson, Gomez, Gonzalez, Gordon, Hadley, Roger Hernández, Holden, Jones-Sawyer, Levine, Lopez, Low, Maienschein, McCarty, Mullin, Nazarian, O'Donnell, Quirk, Rendon, Ridley-Thomas, Rodriguez, Salas, Santiago, Mark Stone, Thurmond, Ting, Waldron, Weber, Williams, Wood, Atkins

NOES: Travis Allen, Bigelow, Brough, Chang, Chávez, Beth Gaines, Gray, Grove, Harper, Irwin, Jones, Kim, Lackey, Linder, Mathis, Melendez, Obernolte, Olsen, Patterson, Steinorth, Wagner

NO VOTE RECORDED: Cooper, Dahle, Frazier, Gallagher, Mayes, Medina, Perea, Wilk

Prepared by: Melanie Moreno / HEALTH /

9/8/15 16:19:43

**** END ****

 THIRD READING  

Bill No: AB 521

Author: Nazarian (D)

Amended: 6/29/15 in Senate

Vote: 21

SENATE HEALTH COMMITTEE: 6-2, 7/8/15

AYES: Hernandez, Hall, Monning, Pan, Roth, Wolk

NOES: Nguyen, Nielsen

NO VOTE RECORDED: Mitchell

SENATE APPROPRIATIONS COMMITTEE: 5-2, 8/27/15

AYES: Lara, Beall, Hill, Leyva, Mendoza

NOES: Bates, Nielsen

ASSEMBLY FLOOR: 51-21, 6/4/15 - See last page for vote

SUBJECT: HIV testing

SOURCE: AIDS Healthcare Foundation

DIGEST: This bill requires a patient who has been admitted as an inpatient to a hospital through the emergency department and has blood drawn after being admitted to the hospital, and who has consented, to be offered an HIV test.

ANALYSIS: Existing law requires each patient who has blood drawn at a primary care clinic, and who has consented, to be offered an HIV test, consistent with the United States Preventive Services Task Force (USPSTF) recommendation for screening the HIV infection.

This bill:

1. Requires a patient who has been admitted as an inpatient to a hospital through the emergency department (ED) and has blood drawn after being admitted to the hospital, and who has consented, to be offered an HIV test.

2. Prohibits the ED from being responsible for offering an HIV test.

3. Requires the hospital clinician to offer an HIV test consistent with the USPSTF recommendation for screening HIV infection.

4. Makes related technical, conforming changes to existing law.

Comments

1. Author’s statement. According to the author, over the past decade, California has focused on the need to test, as early as possible, to reduce HIV infection rates and link people with HIV treatment. Given that there are more than 5,000 new HIV infections in California every year, AB 521 will bridge the gap in lack of HIV testing by requiring hospitals to offer an HIV test to patients that have been admitted via the ED. The ED trigger is key, as emergency rooms will continue to play a critical role in delivering primary care services to many new enrollees and to those who remain uninsured. AB 521 recognizes that emergency rooms continue to play a vital role in helping to identify individuals with HIV.

2. Background. According to a 2015 Centers for Disease Control and Prevention report, an estimated 1,148,200 persons aged 13 years and older are living with HIV infection. Over the past decade, the number of people living with HIV has increased, while the annual number of new HIV infections has remained relatively stable. Still, the pace of new infections continues at far too high a level, particularly among certain groups. The estimated incidence of HIV has remained stable overall in recent years, at about 50,000 new HIV infections per year. Within the overall estimates, however, some groups are affected more than others. Men who have sex with men continue to bear the greatest burden of HIV infection, and among races/ethnicities, African Americans continue to be disproportionately affected. In 2013, an estimated 47,352 people were diagnosed with HIV infection in the United States. In that same year, an estimated 26,688 people were diagnosed with AIDS. Overall, an estimated 1,194,039 people in the United States have been diagnosed with AIDS. An estimated 13,712 people with an AIDS diagnosis died in 2012, and approximately 658,507 people in the United States with an AIDS diagnosis have died overall. The deaths of persons with an AIDS diagnosis can be due to any cause—that is, the death may or may not be related to AIDS.

3. HIV positive but unaware. According to the CDC, of the nearly 1.2 million people estimated to be living with HIV in the United States, nearly one in seven (more than 168,000) do not know they are infected. According to the California Office of AIDS, as of the end of 2011, it is estimated that between 29,523 and 31,948 HIV-positive and unaware individuals reside in California. Because many new infections are transmitted by people who do not know they are infected, undiagnosed infection remains a significant factor fueling the HIV epidemic. According to the CDC, when HIV is diagnosed early, appropriately timed interventions, particularly highly active antiretroviral therapy, can lead to improved health outcomes, including slower clinical progression and reduced mortality. Additionally, HIV counseling with testing has been demonstrated to be an effective intervention for HIV-infected participants, who increased their safer behaviors and decreased risk behaviors.

Prior Legislation

AB 446 (Mitchell, Chapter 589, Statues of 2013), among other provisions related to consent for HIV testing, required community clinics to offer an HIV test.

FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: No

According to the Senate Appropriations Committee:

• By requiring hospitals to offer additional HIV testing to patients, this bill will increase the number of tests provided and the number of previously undiagnosed individuals who will be diagnosed with HIV, typically leading to treatment. The number of additional tests provided and the number of previously undiagnosed cases of HIV discovered through those tests is subject to uncertainty. Based on information developed by the Office of Statewide Planning and Development, there are about 11.6 million emergency department patient encounters per year, of which about 160,000 lead to an inpatient admission at a hospital. If 50% of those admissions lead to an HIV test and the population accepting the test has roughly the same rate of undiagnosed HIV as the overall state population, there would be about 60 newly diagnosed cases of HIV identified under the bill per year. This would result in the following state costs:

• About $300,000 per year for additional HIV testing (including follow up testing for positive test results) by the Medi-Cal program (General Fund and federal funds).

• About $300,000 per year to provide medical care Medi-Cal enrollees newly diagnosed with HIV (General Fund and federal funds).

• About $200,000 per year to provide medical care to new Aids Drug Assistance Program enrollees (federal funds and drug rebate funds).

• Unknown long-term cost savings to Medi-Cal due to earlier medical intervention for HIV-positive Medi-Cal enrollees. To the extent that HIV-positive Medi-Cal enrollees are diagnosed earlier and begin treatment earlier, it is likely that the long-term health status of those individuals will improve and some of the health effects of HIV will be delayed or avoided. There are indications that untreated HIV causes long-term health impacts such as elevated risk of diabetes and heart disease, even before the effects of compromised immune system function associated with HIV infection become evident. Earlier diagnosis and treatment for HIV-positive individuals may to reduce long-term Medi-Cal expenditures for those individuals. However, to some unknown extent the improvement in health status and reduction in health care needs will be offset by longer lifespans, potentially offsetting cost savings.

• Unknown cost savings due to reduced HIV infections in the state, including amongst Medi-Cal beneficiaries. There is academic findings that diagnosis of HIV significantly reduces the likelihood that an HIV positive individual will infect others. This is due both to a reduction in risky behavior by those aware of their HIV positive status and reductions in viral loads in the blood due to antiretroviral treatments. To the extent that this bill results in new diagnoses of HIV and that newly diagnosed individuals are able to access appropriate medical care, this bill is likely to prevent future HIV infections.

SUPPORT: (Verified 8/28/15)

AIDS Healthcare Foundation (source)

AIDS Project Los Angeles

Beyond AIDS

The Wall Las Memorias Project

OPPOSITION: (Verified 8/28/15)

California Hospital Association

Cedars-Sinai Medical Center

ASSEMBLY FLOOR: 51-21, 6/4/15

AYES: Achadjian, Alejo, Baker, Bloom, Bonilla, Bonta, Brown, Burke, Calderon, Campos, Chau, Chiu, Chu, Cooley, Dababneh, Daly, Dodd, Eggman, Cristina Garcia, Eduardo Garcia, Gatto, Gipson, Gomez, Gonzalez, Gordon, Hadley, Roger Hernández, Holden, Jones-Sawyer, Levine, Lopez, Low, Maienschein, McCarty, Mullin, Nazarian, O'Donnell, Quirk, Rendon, Ridley-Thomas, Rodriguez, Salas, Santiago, Mark Stone, Thurmond, Ting, Waldron, Weber, Williams, Wood, Atkins

NOES: Travis Allen, Bigelow, Brough, Chang, Chávez, Beth Gaines, Gray, Grove, Harper, Irwin, Jones, Kim, Lackey, Linder, Mathis, Melendez, Obernolte, Olsen, Patterson, Steinorth, Wagner

NO VOTE RECORDED: Cooper, Dahle, Frazier, Gallagher, Mayes, Medina, Perea, Wilk

Prepared by: Melanie Moreno / HEALTH /

8/31/15 12:47:56

**** END ****

SENATE COMMITTEE ON APPROPRIATIONS

Senator Ricardo Lara, Chair

2015 - 2016 Regular Session

AB 521 (Nazarian) - HIV testing

This bill meets the criteria for referral to the Suspense File.

Bill Summary:

AB 521 would require a general acute care hospital to offer an HIV test to any individual who has been admitted to the hospital through the emergency department and who has blood drawn after admission to the hospital.

Fiscal Impact:

• By requiring hospitals to offer additional HIV testing to patients, the bill will increase the number of tests provided and the number of previously undiagnosed individuals who will be diagnosed with HIV, typically leading to treatment. The number of additional tests provided and the number of previously undiagnosed cases of HIV discovered through those tests is subject to uncertainty. Based on information developed by the Office of Statewide Planning and Development, there are about 11.6 million emergency department patient encounters per year, of which about 160,000 lead to an inpatient admission at a hospital. If 50% of those admissions lead to an HIV test and the population accepting the test has roughly the same rate of undiagnosed HIV as the overall state population, there would be about 60 newly diagnosed cases of HIV identified under the bill per year. This would result in the following state costs:

• About $300,000 per year for additional HIV testing (including follow up testing for positive test results) by the Medi-Cal program (General Fund and federal funds).

• About $300,000 per year to provide medical care Medi-Cal enrollees newly diagnosed with HIV (General Fund and federal funds).

• About $200,000 per year to provide medical care to new Aids Drug Assistance Program enrollees (federal funds and drug rebate funds).

• Unknown long-term cost savings to Medi-Cal due to earlier medical intervention for HIV-positive Medi-Cal enrollees. To the extent that HIV-positive Medi-Cal enrollees are diagnosed earlier and begin treatment earlier, it is likely that the long-term health status of those individuals will improve and some of the health effects of HIV will be delayed or avoided. There are indications that untreated HIV causes long-term health impacts such as elevated risk of diabetes and heart disease, even before the effects of compromised immune system function associated with HIV infection become evident. Earlier diagnosis and treatment for HIV-positive individuals may to reduce long-term Medi-Cal expenditures for those individuals. However, to some unknown extent the improvement in health status and reduction in health care needs will be offset by longer lifespans, potentially offsetting cost savings.

• Unknown cost savings due to reduced HIV infections in the state, including amongst Medi-Cal beneficiaries. There is academic findings that diagnosis of HIV significantly reduces the likelihood that an HIV positive individual will infect others. This is due both to a reduction in risky behavior by those aware of their HIV positive status and reductions in viral loads in the blood due to antiretroviral treatments. To the extent that the bill results in new diagnoses of HIV and that newly diagnosed individuals are able to access appropriate medical care, the bill is likely to prevent future HIV infections.

Background:

Under current law, patients who have blood drawn at primary care clinics must be offered an HIV test by the clinic.

Under state and federal law, the Department of Health Care Services operates the Medi-Cal program, which provides health care coverage to low income individuals, families, and children. Medi-Cal provides coverage to childless adults and parents with household incomes up to 138% of the federal poverty level and to children with household incomes up to 266% of the federal poverty level. The federal government provides matching funds that vary from 50% to 90% of expenditures depending on the category of beneficiary.

In addition, the Department of Public Health manages the Aids Drug Assistance Program which offers coverage for treatment of HIV to those who do not qualify for Medi-Cal.

Current law mandates that all individual and group health plans and insurance policies provide coverage for HIV testing.

Proposed Law:

AB 521 would require a general acute care hospital to offer an HIV test to any individual who has been admitted to the hospital through the emergency department and who has blood drawn after admission to the hospital.

The bill would specify that the emergency department of a hospital is not required to offer an HIV test.

Related Legislation:

AB 446 (Mitchell, Statutes of 2013) requires community clinics to offer HIV testing to patients.

Staff Comments:

Current law requires health plans and health insurers to cover HIV testing. However, the enrollee cost sharing for such testing will vary based on the individual’s plan and the network status of the hospital providing the HIV test. An individual with commercial health insurance may be required to pay a deductible or copay associated with the test required in the bill. In addition, if the hospital is not in the enrollee’s plan network, the enrollee may be required to cover a larger share of cost, potentially the entire cost of the test, depending on the terms of coverage.

The state’s Medi-Cal program covers HIV testing with no cost sharing for beneficiaries. However, because regular HIV screening has not been recommended for all individuals by the United States Preventative Services Taskforce, the Department of Health Care Services indicates that it is not clear whether federal matching funds would be available for HIV tests requested by individuals who do not meet the criteria for regular HIV screening. Under state law, hospitals would not be allowed to bill a Medi-Cal beneficiary for the costs of an HIV test.

-- END --

SENATE COMMITTEE ON HEALTH

Senator Ed Hernandez, O.D., Chair

BILL NO: AB 521

SUBJECT: HIV testing.

SUMMARY:

Requires a patient who has been admitted as an inpatient to a hospital through the emergency department and has blood drawn after being admitted to the hospital, and who has consented, to be offered an HIV test.

Existing law: Requires each patient who has blood drawn at a primary care clinic, and who has consented, to be offered an HIV test, consistent with the United States Preventive Services Task Force (USPSTF) recommendation for screening the HIV infection.

This bill:

1. Requires a patient who has been admitted as an inpatient to a hospital through the emergency department (ED) and has blood drawn after being admitted to the hospital, and who has consented, to be offered an HIV test.

2. Prohibits the ED from being responsible for offering an HIV test.

3. Requires the hospital clinician to offer an HIV test consistent with the USPSTF recommendation for screening HIV infection.

4. Makes related technical, conforming changes to existing law.

FISCAL EFFECT:

According to the Assembly Appropriations Committee:

1. Assuming this ED testing mandate identifies 150 individuals eligible for treatment through state programs, including Medi-Cal and the AIDS Drug Assistance Program (ADAP), and that 65% of those are linked to care, state costs as follows:

a) Potential Medi-Cal costs (in fee-for service Medi-Cal) or cost pressure (in managed care) of $450,000 (General Fund (GF)/federal) for increased testing.

b) $650,000 annually (GF/federal) to Medi-Cal for increased HIV/acquired immune deficiency syndrome (AIDS) treatment costs.

c) $250,000 annually (potential GF/federal) to the ADAP and the Office of AIDS Health Insurance Premium Program (OA/HIPP) for increased HIV/AIDS treatment costs, on a net basis.

Costs are potentially offset by unknown long-term state cost avoidance by identifying HIV infection and beginning treatment earlier before significant medical complications arise, and by potentially preventing additional transmission. Currently, about 5,000 people are newly diagnosed with HIV in California every year.

PRIOR VOTES:

COMMENTS:

1. Author’s statement. According to the author, over the past decade, California has focused on the need to test, as early as possible, to reduce HIV infection rates and link people with HIV treatment. Given that there are more than 5,000 new HIV infections in California every year, AB 521 will bridge the gap in lack of HIV testing by requiring hospitals to offer an HIV test to patients that have been admitted via the emergency department. The ED trigger is key, as emergency rooms will continue to play a critical role in delivering primary care services to many new enrollees and to those who remain uninsured. AB 521 recognizes that emergency rooms continue to play a vital role in helping to identify individuals with HIV.

2. Background. According to a 2015 CDC report, an estimated 1,148,200 persons aged 13 years and older are living with HIV infection. Over the past decade, the number of people living with HIV has increased, while the annual number of new HIV infections has remained relatively stable. Still, the pace of new infections continues at far too high a level, particularly among certain groups. The estimated incidence of HIV has remained stable overall in recent years, at about 50,000 new HIV infections per year. Within the overall estimates, however, some groups are affected more than others. Men who have sex with men (MSM) continue to bear the greatest burden of HIV infection, and among races/ethnicities, African Americans continue to be disproportionately affected. In 2013, an estimated 47,352 people were diagnosed with HIV infection in the United States. In that same year, an estimated 26,688 people were diagnosed with AIDS. Overall, an estimated 1,194,039 people in the United States have been diagnosed with AIDS. An estimated 13,712 people with an AIDS diagnosis died in 2012, and approximately 658,507 people in the United States with an AIDS diagnosis have died overall. The deaths of persons with an AIDS diagnosis can be due to any cause—that is, the death may or may not be related to AIDS.

3. HIV positive but unaware. According to the CDC, of the nearly 1.2 million people estimated to be living with HIV in the US, nearly one in seven (more than 168,000) do not know they are infected. According to the California Office of AIDS, as of the end of 2011, it is estimated that between 29,523 and 31,948 HIV-positive and unaware individuals reside in California. Because many new infections are transmitted by people who do not know they are infected, undiagnosed infection remains a significant factor fueling the HIV epidemic. According to the CDC, when HIV is diagnosed early, appropriately timed interventions, particularly highly active antiretroviral therapy, can lead to improved health outcomes, including slower clinical progression and reduced mortality. Additionally, HIV counseling with testing has been demonstrated to be an effective intervention for HIV-infected participants, who increased their safer behaviors and decreased risk behaviors.

4. Double referral. This bill has been double referred. Should this bill pass out of this committee, it will be referred to the Senate Judiciary Committee.

5. Prior legislation. AB 446 (Mitchell, Chapter 589, Statues of 2013), among other provisions related to consent for HIV testing, requires community clinics to offer an HIV test.

6. Support. According to the sponsor, the AIDS Healthcare Foundation (AHF), Californians who are HIV-positive but do not know they are HIV-positive are not getting treatment and unwittingly expose uninfected people to HIV, and the more than 20,000 Californians who do not know they are HIV-positive are causing 70% of the new infections, while the 84% of Californians who are aware they are HIV-positive only cause 30% of new infections. AHF states that this bill’s provisions are triggered by a person’s admission to the hospital through an ED because many people who are served in an ED reflect the demographics that are often missed in other HIV screening programs. AHF contends that if the state is to ever get full control of the HIV epidemic, it must reach the people it is not reaching now, and a focal point for engaging those people is through ER-admissions to the hospital. AIDS Project Los Angeles writes that a recent CDC analysis showed that 90% of new HIV infections could be prevented by diagnosing people living with HIV and linking them with ongoing care and treatment and this bill will help identify Californians living with HIV, link them to care, and help prevent the spread of the disease.

7. Opposition. The California Hospital Association (CHA) states that this bill presents operational and capacity challenges for acute care hospitals as hospitals would be required to comply with Health and Safety Code Section 120990, which details the informed consent process for HIV testing. Staff time will be required to explain the test and why it is being offered, and to obtain the patient’s consent or refusal. CHA states that this bill is another unfunded mandate potentially increasing costs to hospitals and creates a time-consuming process that will divert staff time and resources away from in-patient care.

SUPPORT AND OPPOSITION:

Support: AIDS Healthcare Foundation (sponsor)

AIDS Project Los Angeles

Beyond AIDS

The Wall Las Memorias Project

Numerous individuals

Oppose: California Hospital Association

-- END --

ASSEMBLY THIRD READING

ATR Bill Id:AB 521

Author:(Nazarian)

As Amended Ver:June 2, 2015

Majority vote

SUMMARY: Applies existing human immunodeficiency virus (HIV) testing requirements for primary care clinics to patients admitted by hospital emergency departments (EDs), as specified. Specifically, this bill:

1. Requires each patient who has blood drawn in a hospital ED, and who is subsequently admitted to the hospital, and who has consented to an HIV test, to be offered an HIV test. Requires the test to conform with the United States Preventative Services Task Force (USPS Task Force) recommendation. Exempts from testing if the patient was tested, or offered testing and declined, within the last 12 months. Requires subsequent testing to be consistent with the most recent guidelines of the USPS Task Force.

2. Allows a hospital ED to charge a patient to cover the cost of HIV testing.

3. Indicates that a hospital ED has complied with these requirements if an HIV test is offered.

4. Requires a hospital ED to attempt to provide test results to the patient prior to departure from the hospital. Allows the hospital to inform the patient of a negative result by letter or telephone if the patient leaves the hospital before test result is available. Requires the hospital to inform a patient with a positive test result in a manner consistent with state law.

EXISTING LAW: Requires each patient who has blood drawn in a primary care clinic, and who has consented to an HIV test, to be offered an HIV test. Requires the test to conform with the USPS Task Force recommendation. Exempts from testing if the patient was tested, or offered testing and declined, within the last 12 months. Requires subsequent testing to be consistent with the most recent guidelines of the USPS Task Force.

FISCAL EFFECT: According to the Assembly Appropriations Committee:

1. Assuming this ED testing mandate identifies 150 individuals eligible for treatment through state programs, including Medi-Cal and AIDS Drug Assistance Program (ADAP), and that 65% of those are linked to care, state costs as follows:

2. Potential Medi-Cal costs (in fee-for service Medi-Cal) or cost pressure (in managed care) of $450,000 (General Fund (GF)/federal) for increased testing.

3. $650,000 annually (GF/federal) to Medi-Cal for increased HIV/acquired immune deficiency syndrome (AIDS) treatment costs.

4. $250,000 annually (potential GF/federal) to the ADAP and the Office of AIDS Health Insurance Premium Program (OA/HIPP) for increased HIV/AIDS treatment costs, on a net basis.

5. Costs are potentially offset by unknown long-term state cost avoidance by identifying HIV infection and beginning treatment earlier before significant medical complications arise, and by potentially preventing additional transmission. Currently, about 5,000 people are newly diagnosed with HIV in California every year.

COMMENTS: According to the author, California has led the way in identifying people living with HIV and linking them with care and treatment. For example, AB 446 (Mitchell), Chapter 589, Statues of 2013, requires public health clinics to offer an HIV test. Until the Patient Protection and Affordable Care Act has been fully implemented, EDs will continue to play a critical role in delivering primary care services to many new enrollees and the uninsured. Given that there are more than 5,000 new HIV infections in California every year, this bill will bridge the gap in lack of HIV testing by requiring EDs to uniformly provide HIV testing.

According to the sponsor, the AIDS Healthcare Foundation (AHF), this bill simply requires the offer of an HIV test in an ED if blood is already being drawn for another purpose. AHF writes that they recognize that EDs are constantly under pressure to meet the immediate needs of their patients. AHF concludes, this bill seeks to balance the public health demands of controlling this epidemic with the operational needs of an ED. AHF points at the Emergency Room as the last remaining major source for the identification of new people with HIV.

In opposition, the California Chapter of the American College of Emergency Physicians (Cal/ACEP) argues that while this bill may appear to be an easy and efficient way to increase HIV diagnosis and treatment, it is unfortunately extremely problematic. Although fewer than 5% of doctors are emergency physicians, they handle a quarter of all acute care encounters and more than half of acute care visits by the uninsured. Diagnosing and treating HIV is an important public health endeavor, but EDs are not the proper venue for a diagnostic public health campaign. According to Cal/ACEP, this bill would place additional stress on California’s overcrowded and burdened EDs, while diverting precious time away from patients with critical conditions toward public health screening.

Analysis Prepared by: Max Mikalonis / HEALTH (916) 319-2097 FN: 0000854

Date of Hearing: May 6, 2015

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Jimmy Gomez, Chair

ABPCA Bill Id:AB 521

Author:(Nazarian) – As Amended Ver:April 23, 2015

Urgency: No State Mandated Local Program: No Reimbursable: No

SUMMARY:

This bill applies existing human immunodeficiency virus (HIV) testing requirements for primary care clinics to hospital emergency departments (EDs), requiring most patients seeking emergency care in an ED to be offered an HIV test any time blood is drawn.

FISCAL EFFECT:

The California Department of Public Health reports nearly 20,000 individuals in California are infected with HIV and don't know it. It is unknown how many HIV-positive individuals would be identified through these new testing requirements. Assuming this ED testing mandate identifies1,500 individuals eligible for treatment through state programs, including Medi-Cal and ADAP, and that 65% of those are linked to care, state costs as follows:

1. Potential Medi-Cal costs (in fee-for service Medi-Cal) or cost pressure (in managed care) of $4.5 million (GF/federal) for increased testing.

2. $6.5 million annually (GF/federal) to Medi-Cal for increased HIV/AIDS treatment costs.

3. $2.5 million annually (potential GF/federal) to the AIDS Drug Assistance Program (ADAP) and the Office of AIDS Health Insurance Premium Program (OA/HIPP) for increased HIV/AIDS treatment costs, on a net basis.  Actual expenditures would be higher, but approximately 70% of ADAP expenditures return to the state in the form of rebate revenues.  This estimate is net of rebate revenue funds.  As the availability of additional federal funds made available to the state through the state's current Medi-Cal Section 1115 waiver, and because the amount of federal funds for these purposes are capped, it is likely that at least a portion of any additional increased ADAP costs would be borne by the GF.

4. Costs are potentially offset by unknown long-term state cost avoidance by identifying HIV infection and beginning treatment earlier before significant medical complications arise, and by potentially preventing additional transmission.  Currently, about 5,000 people are newly diagnosed with HIV in California every year. 

COMMENTS:

1. Purpose. According to the author, California has led the way in identifying people living with HIV and linking them with care and treatment. For example, AB 446 (Mitchell), Chapter 589, Statues of 2013, requires public health clinics to offer an HIV test. The author states EDs continue to play a critical role in delivering primary care services to many individuals, and this bill will bridge the gap in lack of HIV testing by requiring EDs to uniformly provide HIV testing.

2. Background. HIV destroys cells that are crucial to the normal function of the human immune system. Although a person infected with HIV may not show symptoms until several years later, the virus is active in the body and, if untreated, the HIV disease will progress to AIDS. An AIDS diagnosis is made when the count of CD4+, or T cells, falls below a certain level or when the person has a history of infections commonly associated with AIDS. HIV/AIDS can be treated with a complex regimen of antiretroviral medications. Although fewer people are dying from AIDS, the total number of HIV cases in California is still increasing every year because of new diagnoses, and because the mortality rate from AIDS has declined dramatically.

3. HIV Testing. Identifying those with HIV and linking them to treatment can allow them to live a normal life span, and also prevent the spread of the virus by suppressing their viral load. However, many HIV-positive people have not achieved viral suppression because many people do not know their status, and because some who do are not in care. Despite recommendations for universal testing, identifying those who are HIV-positive and do not know it has proven challenging. The challenges and opportunities of providing HIV testing in emergency departments have been well-documented in the public health literature. On one hand, testing is fairly efficient with high prevalence rates. Models for such testing appear to be public health department-driven, such as local collaborations with EDs where public health departments provide either direct funding or staffing to provide testing services within EDs, or provide technical assistance, training, free test kits, or other related services.

4. Opposition. The California Hospital Association, California Medical Association, and emergency department doctors oppose this bill as an unfunded mandate on EDs and doctors, whose primary mission is to stabilize patients with emergent conditions, to conduct a widespread and ongoing public health diagnostic screening campaign.

5. Related Legislation. AB 383 (Gipson), pending in this committee, requires primary care clinics to screen for Hepatitis C.

6. Previous Legislation.

1. AB 446 required primary care clinics to offer an HIV test when taking a blood draw.
   
   

2. AB 1894 (Krekorian), Chapter 631, Statutes of 2008, requires health care service plans and disability insurers selling health insurance to offer testing for HIV antibodies and AIDS, regardless of whether the testing is related to a primary diagnosis.

Analysis Prepared by: Lisa Murawski / APPR. / (916) 319-2081

Date of Hearing: April 21, 2015

ASSEMBLY COMMITTEE ON HEALTH

Rob Bonta, Chair

ABPCA Bill Id:AB 521

Author:(Nazarian) – As Amended Ver:April 14, 2015

SUBJECT: HIV testing.

SUMMARY: Applies existing human immunodeficiency virus (HIV) testing requirements for primary care clinics to hospital emergency departments (EDs), as specified. Specifically, this bill:

1. Requires each patient who has blood drawn in a hospital ED, and who has consented to an HIV test, to be offered an HIV test. Requires the test to conform with the U.S. Preventative Services Task Force (USPS Task Force) recommendation. Exempts from testing if the patient was tested, or offered testing and declined, within the last 12 months. Requires subsequent testing to be consistent with the most recent guidelines of the USPS Task Force.

2. Allows a hospital ED to charge a patient to cover the cost of HIV testing.

3. Indicates that a hospital ED has complied with these requirements if an HIV test is offered.

4. Requires a hospital ED to attempt to provide test results to the patient prior to departure from the hospital. Allows the hospital to inform the patient of a negative result by letter or telephone if the patient leaves the hospital before test result is available. Requires the hospital to inform a patient with a positive test result in a manner consistent with state law.

5. Deems a hospital ED to be in compliance with existing HIV testing notification and counseling requirements if they provide printed material to the patient that includes the following information and advice:

   1. Timely information and counseling, as appropriate, to explain the results and the implications for the patient’s health;

   2. If the patient tests positive for HIV infection, information that there are numerous treatment options available and identify followup testing and care that may be recommended, including contact information for medical and psychological services; and,

   3. If the patient tests negative for HIV infection and is known to be at high risk for HIV infection, information advising the patient of the need for periodic retesting, explaining the limitations of current testing technology and the current window period for verification of results, and may offer prevention counseling or a referral to prevention counseling.

EXISTING LAW:

1. Requires each patient who has blood drawn in a primary care clinic, and who has consented to an HIV test, to be offered an HIV test. Requires the test to conform with the USPS Task Force recommendation. Exempts from testing if the patient was tested, or offered testing and declined, within the last 12 months. Requires subsequent testing to be consistent with the most recent guidelines of the USPS Task Force.

2. Allows a primary care clinic to charge a patient to cover the cost of HIV testing.

3. Indicates that a primary care clinic has complied with these requirements if an HIV test is offered.

4. A primary care clinic shall attempt to provide test results to the patient prior to departure from the facility. Allows the clinic to inform the patient of a negative result by letter or telephone if the patient leaves the hospital before test result is available. Requires the hospital to inform a patient with a positive test result in a manner consistent with state law.

5. Requires a medical care provider, after the results of an HIV test have been received, to:

   1. Ensure that the patient receives timely information and counseling, as appropriate, to explain the results and the implications for the patient’s health;

   2. If the patient tests positive for HIV infection, the medical provider or the person who administers the test shall inform the patient that there are numerous treatment options available and identify followup testing and care that may be recommended, including contact information for medical and psychological services; and,

   3. If the patient tests negative for HIV infection and is known to be at high risk for HIV infection, the medical provider or the person who administers the test shall advise the patient of the need for periodic retesting, explain the limitations of current testing technology and the current window period for verification of results, and may offer prevention counseling or a referral to prevention counseling.

6. Requires a medical care provider, except in the event that the test is independently requested and prior to ordering an HIV test, that a medical care provider inform the patient that the test is planned, provide information about the test, inform the patient that there are numerous treatment options available for a patient who tests positive for HIV and that a person who tests negative for HIV should continue to be routinely tested, and advise the patient that he or she has the right to decline the test. If a patient declines the test, the medical care provider shall note that fact in the patient’s medical file.

7. Requires informed consent by the patient or their parent, guardian, conservator, or other individual specified by law, before administering an HIV test, except in the event that the test is independently requested from an HIV counseling and testing site employing a trained HIV counselor. Informed consent may be provided orally or in writing, but consent shall be documented, whether obtained orally or in writing, in the client’s medical record.

FISCAL EFFECT: This bill has not been analyzed by a fiscal committee.

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, California has led the way in identifying people living with HIV and linking them with care and treatment. For example, AB 446 (Mitchell), Chapter 589, Statues of 2013, requires public health clinics to offer an HIV test. Until the Patient Protection and Affordable Care Act has been fully implemented, EDs will continue to play a critical role in delivering primary care services to many new enrollees and the uninsured. Given that there are more than 5,000 new HIV infections in California every year, this bill will bridge the gap in lack of HIV testing by requiring EDs to uniformly provide HIV testing.

2. BACKGROUND. HIV is the virus that can lead to acquired immunodeficiency syndrome, or AIDS. Unlike some other viruses, the human body cannot get rid of HIV. That means that once you have HIV, you have it for life. No safe and effective cure currently exists, but scientists are working hard to find one, and remain hopeful. Meanwhile, with proper medical care, HIV can be controlled. Treatment for HIV is often called antiretroviral therapy or ART. It can dramatically prolong the lives of many people infected with HIV and lower their chance of infecting others. Before the introduction of ART in the mid-1990s, people with HIV could progress to AIDS in just a few years. Today, someone diagnosed with HIV and treated before the disease is too far advanced can have a nearly normal life expectancy. HIV affects specific cells of the immune system, called CD4 cells, or T cells. Over time, HIV can destroy so many of these cells that the body can’t fight off infections and disease. When this happens, HIV infection leads to AIDS. According to the California Department of Public Health (DPH), Office of AIDS, in California there were 119,878 living cases of HIV (AIDS and non-AIDS) as of December 31, 2013.

3. SUPPORT. According to the sponsor, the AIDS Healthcare Foundation (AHF), despite dramatic advances in treatment options, this epidemic is far from over. There are more than 5,000 new infections in California every year. According to DPH, 16% of Californians who are HIV-positive do not know they are HIV-positive and thus are not getting treatment and unwittingly expose uninfected people to HIV; that number jumps to 58% for young people, up to age 24. The more than 20,000 Californians who do not know they are HIV-positive are causing 70% of the new infections, while the 84% of Californians who are aware they are HIV-positive only cause 30% of new infections.
   
   AHF continues, this bill simply requires the offer of an HIV test in an ED if blood is already being drawn for another purpose. AHF writes that they recognize that EDs are constantly under pressure to meet the immediate needs of their patients. AHF concludes, this bill seeks to balance the public health demands of controlling this epidemic with the operational needs of an ED. AHF points at the Emergency Room as the last remaining major source for the identification of new people with HIV.

4. OPPOSITION. In opposition, the California Chapter of the American College of Emergency Physicians (Cal/ACEP) argues that while this bill may appear to be an easy and efficient way to increase HIV diagnosis and treatment, it is unfortunately extremely problematic. Although fewer than 5% of doctors are emergency physicians, they handle a quarter of all acute care encounters and more than half of acute care visits by the uninsured. Diagnosing and treating HIV is an important public health endeavor, but EDs are not the proper venue for a diagnostic public health campaign. According to Cal/ACEP, this bill would place additional stress on California’s overcrowded and burdened EDs, while diverting precious time away from patients with critical conditions toward public health screening. Emergency physicians estimate they draw blood from 50%of their 12 million patients per year. If adding an HIV test only took an additional five minutes that would result in an additional 30 million minutes, or 57 years, of care each year. Additionally, this bill provides no funding for the test itself thereby placing another unfunded mandate on EDs.

5. COMMITTEE COMMENT. The opposition has raised concerns about the difficulty obtaining consent from those unable to provide it, such as from a patient with a severe injury, illness, mental disturbance, or some other factor. The Committee may recommend that this bill be amended to waive the requirement that an HIV test be offered when the patient is unresponsive, unconscious, incapacitated, or otherwise unable to consent to the test.

6. PREVIOUS LEGISLATION

   1. AB 446 changes state HIV testing law requiring primary care clinics to offer an HIV test when taking a blood draw, upon the informed consent of the patient.
      
      

   2. AB 1894 (Krekorian), Chapter 631, Statutes of 2008, requires health care service plans and disability insurers selling health insurance to offer testing for HIV antibodies and AIDS, regardless of whether the testing is related to a primary diagnosis.

REGISTERED SUPPORT / OPPOSITION:

Support

AIDS Healthcare Foundation (sponsor)

Opposition

California Chapter of the American College of Emergency Physicians (Cal/ACEP)
California Hospital Association
California Medical Association

Analysis Prepared by: Max Mikalonis / HEALTH / (916) 319-2097