Date of Hearing: May 8, 2019

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Lorena Gonzalez, Chair

ABPCA Bill Id:AB 1676

Author:(Maienschein) – As Amended Ver:April 22, 2019

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

SUMMARY:

This bill requires health plans and insurers, by January 1, 2021, to establish a telehealth consultation program that allows providers who treat children and pregnant and postpartum persons access to a psychiatrist during standard provider hours, which may include evenings and weekends.

FISCAL EFFECT:

1. Uncertain, potentially significant costs to Medi-Cal managed care plans to develop or contract for e-consultation models (GF/federal). Increased administrative costs to provide the service, as well as increased reimbursement for higher utilization of psychiatric services, would be reflected in Medi-Cal managed care rates. A statewide program in Massachusetts that primary care providers can access by phone costs the state about $850,000 per year (the total population of the state or in Massachusetts is roughly comparable to the population served under this bill). As the program is required to be implemented among multiple Medi-Cal managed care plans, costs would likely be significantly higher. According to the Department of Health Care Services, providing access to a psychiatrist on evenings and during weekends is expected to be administratively burdensome and costly to plans.
2. Costs to Department of Managed Health Care of $50,000 in 2019-20, $550,000 in 2020-21, and $450,000 thereafter annually and ongoing to issue regulations, review compliance and handle enforcement cases (Managed Care Fund).
3. Costs to the California Department of Insurance are expected to be minor and absorbable (Insurance Fund).

COMMENTS:

1. Purpose. According to the author, this bill will increase the capacity of primary care providers (PCP) to treat mental health disorders by requiring e-consultation with a psychiatrist.
2. Background. Maternal mental health conditions, including post-partum depression, anxiety and psychosis, affect about one in five mothers in California. Research shows these conditions are often undiagnosed and untreated.

According to the California Health Benefits Review Program (CHBRP), electronic consultations between two health care providers (e.g., a psychiatrist and a PCP) are referred to as “eConsults.” The goal of psychiatric eConsults is for PCPs to be able to more quickly diagnose and treat mental health conditions. CHBRP estimates this bill would increase providers’ access to specialists proportionally more for Medi-Cal beneficiaries compared to commercial plan enrollees, as 74% of commercial and California Public Employees' Retirement System (CalPERS) enrollees and 38% of MCMC enrollees are covered by plans and insurers that already have a psychiatric eConsult program in place.

CHBRP notes the literature also indicates that after consultation with psychiatrists, a large proportion of mental health diagnoses and treatment plans may be corrected, which has the potential to impact patient mental health outcomes immediately and over time.

1. Support. 2020 Mom and Maternal Mental Health NOW, the co-sponsors of this bill, state it will help providers and patients address positive screens by allowing quick and easy access to a psychiatrist, via a telehealth consultation line, who is specially trained to advise on evidence-based treatment options. This bill would ameliorate unnecessary treatment delays and increase access to timely and appropriate care, thus giving mothers the best chances of recovery.
2. Opposition. The California Chamber of Commerce and health plans and insurers oppose this bill, contending plans and insurers are not in the position to practice medicine and that this bill raises costs.
3. Related Legislation. AB 798 (Cervantes), pending in this committee, creates a pilot program, in counties that elect to participate, to increase the capacity of health care providers that serve pregnant and postpartum women up to one year after delivery to effectively prevent, identify and manage postpartum depression and other mental health conditions.

AB 577 (Eggman), pending in this committee, extends Medi-Cal eligibility for postpartum mothers from 60 days post-birth to one year post-birth.

AB 744 (Aguiar-Curry), pending in this committee, requires plans and insurers to reimburse for services provided via telehealth at an equivalent rate to services provided via methods other than telehealth.

1. Prior Legislation. AB 1893 (Maienschein), Chapter 140, Statutes of 2018, requires the California Department of Public Health to apply for federal funding opportunities regarding maternal mental health.

AB 2193 (Maienschein), Chapter 755, Statutes of 2018, requires health plans and health insurers, by July 1, 2019, to ensure a mother is offered screening or is appropriately screened for maternal mental health conditions.

AB 244 (Cervantes), of the 2017-18 Legislative Session, was similar to AB 798 and was referred to but never heard in the Assembly Health Committee.

ACR 148 (Lowenthal), Chapter 96, Statutes of 2014, requests the California Maternal Mental Health Collaborative, a nonprofit organization, to establish a task force on the status of maternal mental health care.

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

Date of Hearing: April 23, 2019

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

ABPCA Bill Id:AB 1676

Author:(Maienschein) – As Amended Ver:April 22, 2019

SUBJECT: Health care: mental health.

SUMMARY: Requires health care service plans (health plans) and health insurers, by January 1, 2021, to establish a telehealth consultation program, as specified. Requires health plans and insurers to communicate information relating to the telehealth program at least twice a year in writing. Requires health plans and health insurers to maintain records and data, as necessary. Exempts certain specialized health plans and health insurers from these provisions. Specifically, this bill:

1. Requires, by January 1, 2021, a health plan or insurer to establish a telehealth consultation program that provides providers who treat children and pregnant and postpartum persons with access to a psychiatrist during standard provider hours, which may include evenings and weekends, in order to more quickly diagnose and treat children and pregnant and postpartum persons suffering from mental illness.
2. Requires the telehealth consultation program to provide consultation by telephone or telehealth video and may include guidance on providing triage services and referrals to evidence-based treatment options, including psychotherapy.
3. Requires a health plan or insurer to communicate information relating to the telehealth program and its availability to contracting medical providers who treat children and pregnant and postpartum persons, including pediatricians, obstetricians, and primary care providers, at least twice a year in writing.
4. Requires a health plan or insurer to maintain records and data pertaining to the utilization of its telehealth consultation program and the availability of psychiatrists in order to facilitate ongoing changes and improvements to the program, as necessary.
5. Exempts specialized health plans or insurers, except specialized behavioral health-only plans offering professional mental health services.

EXISTING LAW:

1. Provides for the licensure and regulation of various healing arts professions, including, but not limited to, physicians and surgeons, by various boards within the Department of Consumer Affairs. Imposes certain fines and other penalties for, and authorizes these boards to take disciplinary action against licensees for, violations of the provisions governing those professions.
2. Establishes the Department of Managed Health Care (DMHC) to regulate health plans and the California Department of Insurance (CDI) to regulate health insurers.
   
3. Establishes the federal Patient Protection and Affordable Care Act (ACA), which enacts various health care coverage market reforms including the availability of health insurance exchanges (exchanges) and new individual and small group products offered on and off the exchanges beginning 2014.
4. Requires health plans and health insurers providing health coverage in the individual and small group markets to cover, at a minimum, essential health benefits (EHBs), including the ten EHB benefit categories in the ACA, as specified in state law, which include the following 10 categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and, pediatric services, including oral and vision care.
5. Requires health plans to provide basic health care services, including: physician services; hospital inpatient and ambulatory care services; diagnostic laboratory and diagnostic and therapeutic radiologic services; home health services; preventive health services; emergency health care services; and, hospice care.
6. Requires health plans to make all services readily available at reasonable times to each enrollee consistent with good professional practice and in a manner providing continuity of care and ready referral of patients to other providers at times as may be appropriate consistent with good professional practice.
7. Requires DMHC to develop and adopt regulations to ensure that enrollees have access to health care services in a timely manner and consider the following as indicators of timeliness of access to care:
   1. Waiting times for appointments with physicians, including primary care and specialty physicians;
   2. Timeliness of care in an episode of illness, including the timeliness of referrals and obtaining other services, if needed; and,
   3. Waiting time to speak to a physician, registered nurse, or other qualified health professional acting within his or her scope of practice who is trained to screen or triage an enrollee who may need care.
      
8. Requires DMHC, in developing these timely access standards, to consider clinical appropriateness, the nature of the specialty, the urgency of care, and the requirements of other provisions of law, including provisions governing utilization review that may affect timeliness of access.
9. Requires CDI to promulgate regulations to ensure that insureds have the opportunity to access needed health care services in a timely manner and ensure adequacy of the number and locations of facilities and providers and consider the regulations adopted by DMHC.
10. Requires health plans and health insurers, by July 1, 2019, to develop, consistent with sound clinical principles and processes, a maternal mental health program, as specified.
11. States legislative intent to recognize the practice of telehealth as a legitimate means by which an individual may receive health care services from a health care provider without in-person contact with the provider. Prohibits a health plan or health insurer from requiring in-person contact between a health care provider and a patient before payment is made for the covered services appropriately provided through telehealth, subject to the terms and conditions of the contract entered into between the enrollee and the health plan or the insured and health insurer, and between the health plan or health insurer and its participating providers or provider groups.
12. Prohibits a health plan or health insurer from limiting the type of setting where services are provided for the patient or by the health care provider before payment is made for the covered services appropriately provided through telehealth, subject to the terms and conditions of the contract entered into between the enrollee and the health plan or the insured and the health insurer, and between the health plan or health insurer and its participating providers or provider groups.
13. Prohibits existing telehealth law from being interpreted to authorize a health plan or health insurer to require the use of telehealth when the health care provider has determined that it is not appropriate.

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

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, by increasing the capacity of screening primary care providers (PCP) to treat mental health disorders, this bill would open access to treatment for the 100,000 new California mothers and close to 500,000 children who suffer from a mental health disorder each year who would otherwise find it difficult to locate timely and much-needed mental health services in their communities.
2. BACKGROUND. According to the California Health Benefits Review Program (CHBRP), electronic consultations between two health care providers (e.g., a psychiatrist and a PCP) are referred to as “eConsults.” A patient may or may not be present during an eConsult. A telehealth consultation solely between a provider and a patient is not included in this definition. The goal of psychiatric eConsults is for PCPs to be able to more quickly diagnose and treat mental health conditions. In health care research, these outcomes may be measured using access to care and time to service indicators. Access to care refers to having use of health care services when they are needed. This may include having resources (e.g., health insurance), having the ability to enter the health care system and having an appropriate provider available, or having physical access (e.g., transportation). Timeliness of care refers to a health care system's capacity to provide care quickly after a need is recognized. This may include wait times, time to referral to a specialist, or time to initial appointment. With respect to appropriate care, eConsults can address a significant obstacle to access and service delivery in terms of alignment of patient needs and provider skills related to culture and language. eConsults can leverage expertise between interdisciplinary teams and between different models of care, and they can provide PCPs with consulting clinicians whose expertise they can tap. Like patients, PCPs need consultants with broad perspectives, cultural expertise, and experience with a variety of populations to adapt practice.
   1. CHBRP analysis. AB 1996 (Thomson), Chapter 795, Statutes of 2002, requests the University of California to assess legislation proposing a mandated benefit or service and prepare a written analysis with relevant data on the medical, economic, and public health impacts of proposed health plan and health insurance benefit mandate legislation. CHBRP was created in response to AB 1996. SB 125 (Hernandez), Chapter 9, Statutes of 2015, added an impact assessment on EHBs, and legislation that impacts health insurance benefit designs, cost sharing, premiums, and other health insurance topics. CHBRP states in its analysis of this bill the following:
      
      1. Enrollees covered. CHBRP estimates that, in 2021, all 24.5 million Californians enrolled in state-regulated health insurance, including enrollees in Medi-Cal managed care (MCMC) plans, will have insurance subject to this bill.
         
      2. Impact on expenditures. CHBRP estimates this bill would result in increases in administrative costs. For example, Massachusetts’s psychiatry consultation program allows PCPs to access by phone costs the state about $850,000 per year. The implementation of this bill could create a shift in utilization from in-person patient consultations or provider to-patient telehealth consultation to eConsults. It could also increase the referrals of patients to psychiatrists, which will increase overall utilization of psychiatric services. If that happens, it may impact overall cost; however, the magnitude of the effect is unknown. CHBRP estimates that this bill would increase providers’ access to specialists proportionally more for Medi-Cal beneficiaries compared to commercial plan enrollees, as 74% of commercial and California Public Employees' Retirement System (CalPERS) enrollees and 38% of MCMC enrollees are covered by plans and insurers that already have a psychiatric eConsult program in place. Mandates such as this bill that impact Medi-Cal more significantly may lead to differences in the coverage and utilization of certain services for these beneficiaries; therefore, it may disproportionately affect the Latino, African-American, or other racial/ethnic population if the mandate-relevant service is found to be medically effective.
         1. CalPERS. CHBRP does not expect impact for CalPERS enrollees to be different from the impacts to enrollees in other commercial plans or policies.
         2. Number of Uninsured in California. As described above, CHBRP did not estimate impacts on premiums and is therefore unable to determine whether there would be an impact on the number of uninsured.
      3. EHBs. According to CHBRP, this bill would not require coverage for a new state benefit mandate that appears to exceed the definition of EHBs in California because it requires plans to establish a telepsychiatry consultation program for providers and is not a benefit for enrollees.
      4. Medical effectiveness. CHBRP identified no rigorous studies that addressed the use of psychiatric eConsult programs to treat the specific populations specified in this bill. An analysis of studies of psychiatric eConsult programs for adults in general is provided, in order to provide some context on effectiveness. CHBRP found limited evidence on the effectiveness of psychiatric eConsults generally and insufficient evidence on the effectiveness of psychiatric eConsults specifically for children and pregnant and postpartum persons. Specifically, there is limited evidence that psychiatric eConsults are effective at improving appropriate treatment of mental health conditions as measured by improvement in the receipt of more appropriate care, mental health outcomes in patients, provider knowledge and skill development for mental health treatment, provider satisfaction, and timeliness of services.
      5. Benefit coverage. CHBRP did not model benefit changes because this bill does not require coverage of a benefit available to enrollees but rather requires insurers to make a psychiatric eConsult program available to PCPs. Similarly, CHBRP did not model an effect in terms of utilization or expenditures. Currently, 74% of enrollees with health insurance that can be subject to state mandates and 38% of enrollees with MCMC coverage subject to this bill are already enrolled in health plans or policies with a psychiatric eConsult program. Postmandate, CHBRP assumes that health plans and insurers without psychiatry eConsult programs will need to establish one. Health plans and insurers could provide a telepsychiatry consultation program for PCPs through a third party vendor, in-network psychiatrists, or some other approach.
      6. Utilization. Estimates of current utilization of psychiatric eConsults are not available given limitations in coding and data sources. As a result of this bill, more enrollees with mental health care needs may have increased access to psychiatric services including medications and psychotherapy through their PCPs as a result of a psychiatric eConsult program, but CHBRP is not able to quantify these impacts.
      7. Public health. In the first year postmandate, the impacts of this bill on public health and disparities in health outcomes are unknown due to insufficient evidence regarding the effectiveness of psychiatric eConsults for mental health treatment for children and pregnant and postpartum persons. According to CHBRP, there is limited evidence suggesting that psychiatric eConsults for the adult population overall are effective. CHBRP states that the populations specified in this bill would experience the same effectiveness of psychiatric eConsults as the general population does. Incorporating telepsychiatry consultations for PCPs who treat children and pregnant and postpartum persons could potentially increase access and timeliness to appropriate mental health care. It is estimated that this change in access would be greatest for rural beneficiaries who may, directly or through their PCP, otherwise not have had their mental health concerns addressed by a psychiatrist due to shortages of licensed psychiatrists in rural areas.
      8. Long-term impacts. According to CHBRP, the potential long-term impacts of this bill on cost, utilization, and mental health are unknown. Mental health conditions in the population overall contribute to general economic loss, although it is difficult to estimate losses for these specific populations and conditions. The literature reviewed for this analysis suggests that there is the potential for PCPs to increase knowledge and skills over time with regard to diagnosis and treatment of mental health conditions. Therefore, it is plausible that over time these providers may be better prepared to advise their patients after obtaining regular access to psychiatrists for consultation, resulting in the potential for more prompt diagnosis and treatment, and improved patient and provider satisfaction. Further, the literature also indicates that after consultation with psychiatrists, a large proportion of mental health diagnoses and treatment plans may be corrected. This has the potential to impact patient mental health outcomes immediately and overtime.
3. SUPPORT. 2020 Mom, the sponsor of this bill, writes that this bill will provide support to screening providers to initiate much-needed treatment for mothers and children with mental illnesses, so that California families can thrive. According to Maternal Mental Health NOW, this bill helps providers and patients address positive screens by allowing quick and easy access to a psychiatrist, via a telehealth consultation line, who is specially trained to advise on evidence-based treatment options. This bill would ameliorate unnecessary treatment delays, and increase access to timely and appropriate care, thus giving mothers the best chances of recovery.
4. OPPOSITION. The California Chamber of Commerce states that normally, physicians determine whether they are able to handle care and provide treatment such as prescribing medication. It also falls within the physician’s purview, and not the health plans, to determine if the patient should be referred out or whether the physician should consult with another provider such as a psychologist, psychiatrist or a therapist who would take over care. By mandating the establishment of a health plan and insurer psychiatric consultation program, this bill puts health plans and insurers in a position of dictating medical practice.

The California Association of Health Plans (CAHP), the Association of California Life and Health Insurance Companies (ACLHIC), and America’s Health Insurance Plans (AHIP) oppose state mandates as it would increase costs of coverage, especially for families who buy coverage without subsidies, small business owners who cannot or do not wish to self-insure, and California taxpayers who foot the bill for the state’s share of those mandates. According to CAHP, ACLHIC, and AHIP, with the elimination of the federal individual mandate, Covered California reported that new enrollment growth dropped by 24% and the average benchmark premium rose by 7.7% from 2018 to 2019. The repeal of the individual mandate has already caused increased premiums and coverage losses, and these mandates would further exacerbate the situation. Additionally, CAHP contends that its members do not directly engage in the practice of medicine by facilitating advice for physicians or educating them on how to assess and diagnose their patients.

1. RELATED LEGISLATION.
   1. AB 798 (Cervantes) creates a privately funded pilot program, in counties that elect to participate, designed to increase the capacity of health care providers that serve pregnant and postpartum women up to one year after delivery to effectively prevent, identify, and manage postpartum depression and other mental health conditions. Requires the California Health and Human Services Agency to submit a report to the Legislature regarding the pilot program six months after the results of the pilot program are reported, as specified. Sunsets AB 798 on January 1, 2025. AB 798 is pending in Assembly Appropriations Committee.
   2. AB 577 (Eggman) extends Medi-Cal eligibility for a pregnant individual who is receiving health care coverage under the Medi-Cal program, or another specified program, and who has been diagnosed with a maternal mental health condition, for a period of one year following the last day of the individual’s pregnancy if the individual complies with certain requirements. AB 577 is pending in Assembly Appropriations Committee.
   3. AB 744 (Aguiar-Curry) requires a contract issued, amended, or renewed on or after January 1, 2020, between a health plan and a healthcare provider for the provision of healthcare services to an enrollee or subscriber, or a contract issued, amended, or renewed on or after January 1, 2020, between a health insurer and a healthcare provider for an alternative rate of payment to specify that the health care service plan or health insurer reimburse a healthcare provider for the diagnosis, consultation, or treatment of an enrollee, subscriber, insured, or policyholder delivered through telehealth services on the same basis and to the same extent that the health care service plan or health insurer is responsible for reimbursement for the same service through in-person diagnosis, consultation, or treatment. AB 744 is pending a hearing in Assembly Health Committee.
2. PREVIOUS LEGISLATION.
   1. AB 1893 (Maienschein), Chapter 140, Statutes of 2018, requires DPH to investigate and apply for federal funding opportunities regarding maternal mental health, as specified. Requires DPH to notify the Legislature on or before January 1, 2020, on DPH’s efforts to secure and utilize the federal funding it receives.
   2. AB 2193 (Maienschein), Chapter 755, Statutes of 2018, requires health plans and health insurers, by July 1, 2019, to develop, consistent with sound clinical principles and processes, a maternal mental health program, as specified.
   3. AB 244 (Cervantes) of 2017 would have created a pilot program in counties that elect to participate, including Riverside County, to increase the capacity of health providers that serve pregnant and postpartum women to prevent, identify, and manage postpartum depression and other mental health conditions. AB 244 was never heard in the Assembly Health Committee.
   4. ACR 148 (Waldron), Chapter 96, Statutes of 2014, requests the California Maternal Mental Health Collaborative, a nonprofit organization, to establish a task force on the status of MMH care.
3. POLICY COMMENTS.
   1. Maternal mental health program. As stated above, AB 2193 requires health plans to develop a maternal mental health program, designed to promote quality and cost-effective outcomes, and to be developed consistent with sound clinical principles and processes. This bill may be premature in light of these requirements.
   2. Lack of effective outcomes. This bill may be premature given the lack of outcomes identified by CHBRP. According to CHBRP, there is limited evidence that psychiatric eConsults are effective at improving appropriate treatment of mental health conditions as measured by improvement in the receipt of more appropriate care, mental health outcomes in patients, provider knowledge and skill development for mental health treatment, provider satisfaction, and timeliness of services. Additionally, the impacts of this bill on public health and disparities in health outcomes are unknown due to insufficient evidence regarding the effectiveness of psychiatric eConsults for mental health treatment for children and pregnant and postpartum persons and, there is limited evidence suggesting that psychiatric eConsults for the adult population overall are effective. Finally, CHBRP notes that the potential long-term impacts of this bill on cost, utilization, and mental health are unknown.

REGISTERED SUPPORT / OPPOSITION:

Support

2020 Mom (sponsor)
Association of Women's Health And Neonatal Nursing
California Association for Health Services at Home
Children Now
DBSA California
March for Moms
Maternal Mental Health Now
Mothers Strong
National Health Law Program
Return To Zero: H.O.P.E.
Society for Maternal-Fetal Medicine
Solid Start Initiative
Steinberg Institute

Opposition

America's Health Insurance Plans
Association of California Life & Health Insurance Companies
California Association of Health Plans
California Chamber of Commerce

Analysis Prepared by: Kristene Mapile / HEALTH / (916) 319-2097