GOVERNOR'S VETO

GV Bill Id:AB 2360

Author:(Maienschein)

As Enrolled Ver:September 1, 2020

2/3 vote

SUMMARY:

Requires health care service plans (health plans) and health insurers, by July 1, 2021, to provide access to a telehealth consultation program for children, pregnant individuals, and individuals up to one year postpartum 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 monitor data pertaining to the utilization of its telehealth consultation program to facilitate ongoing quality improvements to the program, as necessary. Exempts certain specialized health plans and health insurers from these provisions.

The Senate Amendments:

1. Delay implementation to July 1, 2021.
2. Require, by July 1, 2021, a health plan or health insurer to provide access to a telehealth consultation program that provides contracting providers who treat children and persons who are pregnant or up to one year postpartum with access to a mental health consultation program during the treating provider's standard provider hours, which may include evenings and weekends. Require the telehealth consultation program to include a triage service and consultation by a mental health clinician with expertise appropriate for pregnant, postpartum, and pediatric patients, including a psychiatrist when appropriate or requested by the treating provider, by telephone or telehealth video, and to include guidance on the range of evidence-based treatment options, including psychotherapy, as determined to be appropriate, screening tools, and referrals.
3. Require a health plan or health insurer to monitor data pertaining to the utilization of its telehealth consultation program to facilitate ongoing quality improvements to the program, as necessary.
4. Require a health plan or health insurer to provide a description of the telehealth consultation program to the Department of Managed Health Care (DMHC) or California Department of Insurance in a manner and format, as prescribed.
5. Provide that this bill not be construed to alter a health insurer's obligations pursuant to existing law.

Governor's Veto Message:

This bill would require health plans, including Knox-Keene licensed Medi-Cal managed care health plans, to provide access to a provider-to­ provider telehealth consultation program for providers who treat children and pregnant and postpartum persons.

While I appreciate the author's intent to expand mental health services for children and pregnant and postpartum persons, the bill would create costs that would be more appropriately addressed through the annual budget process

COMMENTS:

According to the Department of Public Health (DPH), one in five California women who recently gave birth experience symptoms of depression during or after pregnancy. That translates to about 100,000 women a year. All women are at risk for symptoms of perinatal depression; however, Black or Latina women, women who have low incomes or those who have experienced hardships in their childhood or during pregnancy are at heightened risk of having symptoms of depression. Depression during pregnancy is likely to lead to depression after the baby is born and is associated with serious risks to the mother and infant. Though not all women with symptoms of depression will be diagnosed with clinical depression, screening and appropriate care should be provided during prenatal care.

Often in rural or remote areas, primary care providers (PCP) assume full responsibility for treating their patients' mental health conditions due to a lack of available resources. Telehealth consultations have been introduced as one way to address this lack of resources by enabling consultations between specialists at a distance and PCPs.

In 2010, California designated May as Perinatal Depression Awareness Month. ACR 105 (Nava), Resolution Chapter 9, Statutes of 2010, also requested that several stakeholders including the DHCS, DPH, First 5 California, the American College of Obstetricians and Gynecologists, and Postpartum Support International work together on several issues. ACR 105 encouraged these stakeholders to explore ways to improve women's access to mental health care, increase awareness and education about perinatal depression, encourage the use of screening tools, and improve the availability of effective treatment options and community support services. In 2014, the California Legislative Women's Caucus introduced ACR 148 (Waldron), Chapter 96, Statutes of 2014, to explore untreated maternal mental health disorders and their impacts. The resolution passed and initiated a multidisciplinary Task Force representing stakeholders in mental health, medicine, public health, nursing, research, insurance, and hospitals. From 2015 to 2016, the California Task Force on the Status of Maternal Mental Health Care examined existing barriers to screening and diagnosis, current treatment options, evidence-based treatments, and emerging treatments.

Funded by a legislative appropriation in the Department of Mental Health budget, the Massachusetts Child Psychiatry Access Project (MCPAP) was established in 2004. MCPAP is a system of regional children's psychiatric consultation teams designed to improve access to treatment for children with behavioral health problems. MCPAP seeks to strengthen pediatric PCPs ability to screen, diagnose, and treat children with mild to moderate behavioral health problems (e.g., anxiety, depression, attention deficit hyperactivity disorder) in primary care. It also supports PCPs in referring children with more serious behavioral health problems to appropriate psychiatric specialty care.

AB 1676 (Maienschein) of 2019 CHBRP analysis. According to the California Health Benefits Review Program (CHBRP), provider-to-provider telehealth consultations are referred to as electronic consultations or "eConsults", and include both synchronous (e.g., phone, videoconference) and asynchronous (e.g., email, electronic health record) modalities. 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. Since this bill is substantially similar to AB 1676, it is appropriate to use CHBRP's analysis of that bill, which indicates the following:

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. As a result of this bill, more enrollees with mental health care needs may have increased access to psychiatrist services including medications and psychotherapy through their PCPs as a result of a psychiatric eConsult program, but CHBRP is not able to quantify these indirect effects. 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 enrollees and 38% of Medi-Cal Managed Care enrollees are covered by plans and insurers that already have a psychiatric eConsult program in place.

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.

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.

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.

According to the Author:

Now more than ever we need to invest in expanding telehealth services, especially in fields where there are significant provider shortages. By increasing the capacity of screening PCPs to treat mental health disorders, this bill lays the groundwork to 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.

Arguments in Support:

2020 Mom, co-sponsors of this bill, writes that this bill will provide support to frontline screening providers to initiate much-needed treatment for mothers and children with mental illnesses, so that California families can thrive. Maternal Mental Health Now, co-sponsors of this bill, states that this bill is critical during the pandemic, as children and mothers has become even more vulnerable to experiencing mental health issues. The California Hospital Association writes that currently, one in five women who are pregnant or have recently given birth suffer from depression, making it more common than diabetes during pregnancy. Depression is also the leading cause of disability worldwide among women of reproductive age, and maternal suicide accounts for 20% of postpartum deaths among depressed women. Raising awareness of behavioral health and promoting good health before pregnancy, as well as better screening for and treatment of postpartum depression, would strengthen hospitals' efforts to ensure all moms and babies can receive the care they need, when they need it. The American Academy of Pediatrics, California states that according to the World Health Organization, approximately 10% of pregnant women and 13% of women who have just given birth experience a mental disorder. When left untreated, depression can cause suffering and reduced responses to the needs of newborns. Shame, stigma, lack of time, lack of childcare, and lack of social supports can all be barriers to accessing care for Maternal Mental Health disorders. Telehealth can help lessen or in some cases completely remove these barriers. Telepsychiatry can provide easier access to care at less cost, reach people living in rural areas who might not otherwise have access to a clinic, and make it easier for patients with mobility issues to access care.

Arguments in Support if Amended.

The California Board of Psychology and the California Academy of PAs are in support if amended to include respective providers to the telehealth consultation program.

Arguments in Opposition:

The California Chamber of Commerce (CCC) contends that this bill requires a psychiatric consultation program to be made available to providers and also mandates that the health plan and insurer psychiatrists be made accessible to providers during standard hours, including evenings and weekends. CCC writes that physicians determine whether a patient's condition exceeds the scope of their practice and that it also falls within a physician's clinical judgment (not the health plans) to determine if the patient's condition requires the intervention of a specialist or separate provider, such as a psychiatrist or psychologist. 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. According to the California Association of Health Plans and Association of Life and Health Insurance Companies, the COVID-19 pandemic has only elevated how critical it is to maintain affordable premiums and not unnecessarily drive of that cost of care. DHCS writes that this bill would create significant administrative burdens for managed care plans (MCPs) to develop and implement this type of consultation program, especially for those MCPs that may not already have similar programs or frameworks in place that model the program proposed in the bill. Further, the consultation program would only be available to providers serving children and pregnant and postpartum persons, which would exclude providers who serve other MCP members who may also benefit from this type of consultation program. Lastly, because DHCS anticipates the bill would increase utilization of mental health services, it would impact managed care rates; given these increased costs, DHCS believes this would be more appropriately addressed in state budget process.

FISCAL COMMENTS:

According to the Senate Appropriations Committee:

The DMHC indicates the following workload across various units, specifically (*Managed Care Fund):

1. Office of Plan Monitoring (OPM): $13,000 and 0.1 personnel years (PY) in fiscal year (FY) 2020-21, $209,000 and 1.2 PYs in FY 2021-22, $248,000 and 1.3 PYs in FY 2022-23, $247,000 and 1.3 PYs in FY 2023-24, and the same amount annually thereafter, for workload to update Technical Assistance Guides, develop survey tools and methodologies guidance, and conduct ongoing assessments of health plan surveys for compliance.
2. Office of Enforcement: $86,000 and 0.5 PY in FY 2021-22, $88,000 and 0.5 PY in FY 2022-23, and the same amount annually thereafter, for workload to address an assumed six referrals annually from OPM, starting in FY 2021-22.
3. Office of Legal Services: $90,000 and 0.6 PY in FY 2020-21 only for short-term workload to conduct legal research, prepare legal memorandums, AND promulgate a rulemaking package.
4. Office of Plan Licensing: $222,000 and 1.1 PYs in FY 2020-21 only FOR short-term workload to review provider contracts and plan documents for compliance.

CHBRP assesses proposed legislation that seeks to mandate a specific benefit or analysis (AB 1996 (Thomson), Chapter 795, Statutes of 2002). CHBRP analyzed a similar bill, AB 1676 (Maienschein, 2019). CHBRP referred to provider-to-provider telehealth consultations as electronic consultations, or "eConsults," and according to its analysis:

…Found limited evidence on the effectiveness of psychiatric eConsults generally and insufficient evidence on the effectiveness of psychiatric eConsults 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, 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.

…Incorporating telepsychiatry consultations for primary care providers who treat children and pregnant and postpartum persons could potentially increase access and timeliness to appropriate mental health care. This change in access would be greatest for rural beneficiaries who may, directly or through their primary care provider, otherwise not have had their mental health concerns addressed by a psychiatrist due to shortages of licensed psychiatrists in rural areas. AB 1676 would increase providers' access to specialists proportionally more for Medi-Cal beneficiaries compared to commercial plan enrollees, as 74% of commercial and CalPERS enrollees and 38% of Medi-Cal Managed Care enrollees are covered by plans and insurers that already have a psychiatric eConsult program in place.

As the COVID-19 pandemic continues, DPH regularly issues guidance and resources on maternal, family caregiver, and children supports. In addition, the California Surgeon General, in recognition of stress and anxiety levels across caregivers and children, released its playbook, which included recommendations for mental and behavioral health care.

VOTES:

ASM HEALTH: 11-2-2

YES: Wood, Aguiar-Curry, Bonta, Burke, Carrillo, Limón, McCarty, Nazarian, Ramos, Rodriguez, Santiago

NO: Bigelow, Flora

ABS, ABST OR NV: Mayes, Waldron

ASM APPROPRIATIONS: 13-5-0

YES: Gonzalez, Bauer-Kahan, Bloom, Bonta, Calderon, Carrillo, Chau, Eggman, Gabriel, Eduardo Garcia, Petrie-Norris, McCarty, Robert Rivas

NO: Bigelow, Megan Dahle, Diep, Fong, Voepel

ASSEMBLY FLOOR: 64-12-3

YES: Aguiar-Curry, Arambula, Bauer-Kahan, Berman, Bloom, Boerner Horvath, Bonta, Burke, Calderon, Carrillo, Cervantes, Chau, Chiu, Chu, Cooley, Cooper, Cunningham, Daly, Diep, Eggman, Frazier, Friedman, Gabriel, Gallagher, Cristina Garcia, Eduardo Garcia, Gipson, Gloria, Gonzalez, Gray, Grayson, Holden, Irwin, Jones-Sawyer, Kalra, Kamlager, Levine, Limón, Low, Maienschein, McCarty, Medina, Mullin, Muratsuchi, Nazarian, O'Donnell, Petrie‑Norris, Quirk-Silva, Ramos, Reyes, Luz Rivas, Robert Rivas, Rodriguez, Blanca Rubio, Salas, Santiago, Smith, Mark Stone, Ting, Waldron, Weber, Wicks, Wood, Rendon

NO: Bigelow, Brough, Chen, Choi, Megan Dahle, Fong, Kiley, Lackey, Mathis, Obernolte, Patterson, Voepel

ABS, ABST OR NV: Flora, Mayes, Quirk

SENATE FLOOR: 31-6-3

YES: Allen, Archuleta, Atkins, Beall, Bradford, Caballero, Chang, Dodd, Durazo, Galgiani, Glazer, Lena Gonzalez, Hertzberg, Hill, Hueso, Hurtado, Jackson, Leyva, McGuire, Mitchell, Monning, Pan, Portantino, Roth, Rubio, Skinner, Stern, Umberg, Wieckowski, Wiener, Wilk

NO: Bates, Borgeas, Grove, Melendez, Morrell, Nielsen

ABS, ABST OR NV: Dahle, Jones, Moorlach

ASSEMBLY FLOOR: 62-0-17

YES: Aguiar-Curry, Arambula, Bauer-Kahan, Berman, Bloom, Boerner Horvath, Bonta, Burke, Calderon, Carrillo, Cervantes, Chau, Chiu, Chu, Cooley, Cunningham, Daly, Diep, Friedman, Gabriel, Gallagher, Cristina Garcia, Eduardo Garcia, Gipson, Gloria, Gonzalez, Gray, Grayson, Holden, Irwin, Jones-Sawyer, Kalra, Kamlager, Lackey, Levine, Limón, Low, Maienschein, McCarty, Medina, Mullin, Muratsuchi, Nazarian, O'Donnell, Petrie-Norris, Quirk, Quirk-Silva, Ramos, Reyes, Luz Rivas, Robert Rivas, Rodriguez, Blanca Rubio, Salas, Santiago, Smith, Mark Stone, Ting, Waldron, Weber, Wood, Rendon

ABS, ABST OR NV: Bigelow, Brough, Chen, Choi, Cooper, Megan Dahle, Eggman, Flora, Fong, Frazier, Kiley, Mathis, Mayes, Obernolte, Patterson, Voepel, Wicks

UPDATED:

VERSION: September 1, 2020

CONSULTANT: Kristene Mapile / HEALTH / (916) 319-2097 FN: 0003700

CONCURRENCE IN SENATE AMENDMENTS

CSA1 Bill Id:AB 2360

Author:(Maienschein)

As Amended Ver:August 5, 2020

Majority vote

SUMMARY:

Requires health care service plans (health plans) and health insurers, by July 1, 2021, to provide access to a telehealth consultation program for children, pregnant individuals, and individuals up to one year postpartum 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 monitor data pertaining to the utilization of its telehealth consultation program to facilitate ongoing quality improvements to the program, as necessary. Exempts certain specialized health plans and health insurers from these provisions.

The Senate Amendments:

1. Delay implementation to July 1, 2021.
2. Require, by July 1, 2021, a health plan or health insurer to provide access to a telehealth consultation program that provides contracting providers who treat children and persons who are pregnant or up to one year postpartum with access to a mental health consultation program during the treating provider's standard provider hours, which may include evenings and weekends. Require the telehealth consultation program to include a triage service and consultation by a mental health clinician with expertise appropriate for pregnant, postpartum, and pediatric patients, including a psychiatrist when appropriate or requested by the treating provider, by telephone or telehealth video, and to include guidance on the range of evidence-based treatment options, including psychotherapy, as determined to be appropriate, screening tools, and referrals.
3. Require a health plan or health insurer to monitor data pertaining to the utilization of its telehealth consultation program to facilitate ongoing quality improvements to the program, as necessary.
4. Require a health plan or health insurer to provide a description of the telehealth consultation program to the Department of Managed Health Care (DMHC) or California Department of Insurance in a manner and format, as prescribed.
5. Provide that this bill not be construed to alter a health insurer's obligations pursuant to existing law.

COMMENTS:

According to the Department of Public Health (DPH), one in five California women who recently gave birth experience symptoms of depression during or after pregnancy. That translates to about 100,000 women a year. All women are at risk for symptoms of perinatal depression; however, Black or Latina women, women who have low incomes or those who have experienced hardships in their childhood or during pregnancy are at heightened risk of having symptoms of depression. Depression during pregnancy is likely to lead to depression after the baby is born and is associated with serious risks to the mother and infant. Though not all women with symptoms of depression will be diagnosed with clinical depression, screening and appropriate care should be provided during prenatal care.

Often in rural or remote areas, primary care providers (PCP) assume full responsibility for treating their patients' mental health conditions due to a lack of available resources. Telehealth consultations have been introduced as one way to address this lack of resources by enabling consultations between specialists at a distance and PCPs.

In 2010, California designated May as Perinatal Depression Awareness Month. ACR 105 (Nava), Resolution Chapter 9, Statutes of 2010, also requested that several stakeholders including the DHCS, DPH, First 5 California, the American College of Obstetricians and Gynecologists, and Postpartum Support International work together on several issues. ACR 105 encouraged these stakeholders to explore ways to improve women's access to mental health care, increase awareness and education about perinatal depression, encourage the use of screening tools, and improve the availability of effective treatment options and community support services. In 2014, the California Legislative Women's Caucus introduced ACR 148 (Waldron), Chapter 96, Statutes of 2014, to explore untreated maternal mental health disorders and their impacts. The resolution passed and initiated a multidisciplinary Task Force representing stakeholders in mental health, medicine, public health, nursing, research, insurance, and hospitals. From 2015 to 2016, the California Task Force on the Status of Maternal Mental Health Care examined existing barriers to screening and diagnosis, current treatment options, evidence-based treatments, and emerging treatments.

Funded by a legislative appropriation in the Department of Mental Health budget, the Massachusetts Child Psychiatry Access Project (MCPAP) was established in 2004. MCPAP is a system of regional children's psychiatric consultation teams designed to improve access to treatment for children with behavioral health problems. MCPAP seeks to strengthen pediatric PCPs ability to screen, diagnose, and treat children with mild to moderate behavioral health problems (e.g., anxiety, depression, attention deficit hyperactivity disorder) in primary care. It also supports PCPs in referring children with more serious behavioral health problems to appropriate psychiatric specialty care.

AB 1676 (Maienschein) of 2019 CHBRP analysis. According to the California Health Benefits Review Program (CHBRP), provider-to-provider telehealth consultations are referred to as electronic consultations or "eConsults", and include both synchronous (e.g., phone, videoconference) and asynchronous (e.g., email, electronic health record) modalities. 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. Since this bill is substantially similar to AB 1676, it is appropriate to use CHBRP's analysis of that bill, which indicates the following:

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. As a result of this bill, more enrollees with mental health care needs may have increased access to psychiatrist services including medications and psychotherapy through their PCPs as a result of a psychiatric eConsult program, but CHBRP is not able to quantify these indirect effects. 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 enrollees and 38% of Medi-Cal Managed Care enrollees are covered by plans and insurers that already have a psychiatric eConsult program in place.

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.

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.

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.

According to the Author:

According to the author, now more than ever we need to invest in expanding telehealth services, especially in fields where there are significant provider shortages. By increasing the capacity of screening PCPs to treat mental health disorders, this bill lays the groundwork to 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.

Arguments in Support:

2020 Mom, co-sponsors of this bill, writes that this bill will provide support to frontline screening providers to initiate much-needed treatment for mothers and children with mental illnesses, so that California families can thrive. Maternal Mental Health Now, co-sponsors of this bill, states that this bill is critical during the pandemic, as children and mothers has become even more vulnerable to experiencing mental health issues. The California Hospital Association writes that currently, one in five women who are pregnant or have recently given birth suffer from depression, making it more common than diabetes during pregnancy. Depression is also the leading cause of disability worldwide among women of reproductive age, and maternal suicide accounts for 20% of postpartum deaths among depressed women. Raising awareness of behavioral health and promoting good health before pregnancy, as well as better screening for and treatment of postpartum depression, would strengthen hospitals' efforts to ensure all moms and babies can receive the care they need, when they need it. The American Academy of Pediatrics, California states that according to the World Health Organization, approximately 10% of pregnant women and 13% of women who have just given birth experience a mental disorder. When left untreated, depression can cause suffering and reduced responses to the needs of newborns. Shame, stigma, lack of time, lack of childcare, and lack of social supports can all be barriers to accessing care for Maternal Mental Health disorders. Telehealth can help lessen or in some cases completely remove these barriers. Telepsychiatry can provide easier access to care at less cost, reach people living in rural areas who might not otherwise have access to a clinic, and make it easier for patients with mobility issues to access care.

Arguments in Support if Amended.

The California Board of Psychology and the California Academy of PAs are in support if amended to include respective providers to the telehealth consultation program.

Arguments in Opposition:

The California Chamber of Commerce (CCC) contends that this bill requires a psychiatric consultation program to be made available to providers and also mandates that the health plan and insurer psychiatrists be made accessible to providers during standard hours, including evenings and weekends. CCC writes that physicians determine whether a patient's condition exceeds the scope of their practice and that it also falls within a physician's clinical judgment (not the health plans) to determine if the patient's condition requires the intervention of a specialist or separate provider, such as a psychiatrist or psychologist. 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. According to the California Association of Health Plans and Association of Life and Health Insurance Companies, the COVID-19 pandemic has only elevated how critical it is to maintain affordable premiums and not unnecessarily drive of that cost of care. DHCS writes that this bill would create significant administrative burdens for managed care plans (MCPs) to develop and implement this type of consultation program, especially for those MCPs that may not already have similar programs or frameworks in place that model the program proposed in the bill. Further, the consultation program would only be available to providers serving children and pregnant and postpartum persons, which would exclude providers who serve other MCP members who may also benefit from this type of consultation program. Lastly, because DHCS anticipates the bill would increase utilization of mental health services, it would impact managed care rates; given these increased costs, DHCS believes this would be more appropriately addressed in state budget process.

FISCAL COMMENTS:

According to the Senate Appropriations Committee:

The DMHC indicates the following workload across various units, specifically (*Managed Care Fund):

1. Office of Plan Monitoring (OPM): $13,000 and 0.1 personnel years (PY) in fiscal year (FY) 2020-21, $209,000 and 1.2 PYs in FY 2021-22, $248,000 and 1.3 PYs in FY 2022-23, $247,000 and 1.3 PYs in FY 2023-24, and the same amount annually thereafter, for workload to update Technical Assistance Guides, develop survey tools and methodologies guidance, and conduct ongoing assessments of health plan surveys for compliance.
2. Office of Enforcement: $86,000 and 0.5 PY in FY 2021-22, $88,000 and 0.5 PY in FY 2022-23, and the same amount annually thereafter, for workload to address an assumed six referrals annually from OPM, starting in FY 2021-22.
3. Office of Legal Services: $90,000 and 0.6 PY in FY 2020-21 only for short-term workload to conduct legal research, prepare legal memorandums, AND promulgate a rulemaking package.
4. Office of Plan Licensing: $222,000 and 1.1 PYs in FY 2020-21 only FOR short-term workload to review provider contracts and plan documents for compliance.

CHBRP assesses proposed legislation that seeks to mandate a specific benefit or analysis (AB 1996 (Thomson), Chapter 795, Statutes of 2002). CHBRP analyzed a similar bill, AB 1676 (Maienschein, 2019). CHBRP referred to provider-to-provider telehealth consultations as electronic consultations, or "eConsults," and according to its analysis:

…Found limited evidence on the effectiveness of psychiatric eConsults generally and insufficient evidence on the effectiveness of psychiatric eConsults 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, 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.

…Incorporating telepsychiatry consultations for primary care providers who treat children and pregnant and postpartum persons could potentially increase access and timeliness to appropriate mental health care. This change in access would be greatest for rural beneficiaries who may, directly or through their primary care provider, otherwise not have had their mental health concerns addressed by a psychiatrist due to shortages of licensed psychiatrists in rural areas. AB 1676 would increase providers' access to specialists proportionally more for Medi-Cal beneficiaries compared to commercial plan enrollees, as 74% of commercial and CalPERS enrollees and 38% of Medi-Cal Managed Care enrollees are covered by plans and insurers that already have a psychiatric eConsult program in place.

As the COVID-19 pandemic continues, DPH regularly issues guidance and resources on maternal, family caregiver, and children supports. In addition, the California Surgeon General, in recognition of stress and anxiety levels across caregivers and children, released its playbook, which included recommendations for mental and behavioral health care.

VOTES:

ASM HEALTH: 11-2-2

YES: Wood, Aguiar-Curry, Bonta, Burke, Carrillo, Limón, McCarty, Nazarian, Ramos, Rodriguez, Santiago

NO: Bigelow, Flora

ABS, ABST OR NV: Mayes, Waldron

ASM APPROPRIATIONS: 13-5-0

YES: Gonzalez, Bauer-Kahan, Bloom, Bonta, Calderon, Carrillo, Chau, Eggman, Gabriel, Eduardo Garcia, Petrie-Norris, McCarty, Robert Rivas

NO: Bigelow, Megan Dahle, Diep, Fong, Voepel

ASSEMBLY FLOOR: 64-12-3

YES: Aguiar-Curry, Arambula, Bauer-Kahan, Berman, Bloom, Boerner Horvath, Bonta, Burke, Calderon, Carrillo, Cervantes, Chau, Chiu, Chu, Cooley, Cooper, Cunningham, Daly, Diep, Eggman, Frazier, Friedman, Gabriel, Gallagher, Cristina Garcia, Eduardo Garcia, Gipson, Gloria, Gonzalez, Gray, Grayson, Holden, Irwin, Jones-Sawyer, Kalra, Kamlager, Levine, Limón, Low, Maienschein, McCarty, Medina, Mullin, Muratsuchi, Nazarian, O'Donnell, Petrie‑Norris, Quirk-Silva, Ramos, Reyes, Luz Rivas, Robert Rivas, Rodriguez, Blanca Rubio, Salas, Santiago, Smith, Mark Stone, Ting, Waldron, Weber, Wicks, Wood, Rendon

NO: Bigelow, Brough, Chen, Choi, Megan Dahle, Fong, Kiley, Lackey, Mathis, Obernolte, Patterson, Voepel

ABS, ABST OR NV: Flora, Mayes, Quirk

SENATE FLOOR: 31-6-3

YES: Allen, Archuleta, Atkins, Beall, Bradford, Caballero, Chang, Dodd, Durazo, Galgiani, Glazer, Lena Gonzalez, Hertzberg, Hill, Hueso, Hurtado, Jackson, Leyva, McGuire, Mitchell, Monning, Pan, Portantino, Roth, Rubio, Skinner, Stern, Umberg, Wieckowski, Wiener, Wilk

NO: Bates, Borgeas, Grove, Melendez, Morrell, Nielsen

ABS, ABST OR NV: Dahle, Jones, Moorlach

UPDATED:

VERSION: August 5, 2020

CONSULTANT: Kristene Mapile / HEALTH / (916) 319-2097 FN: 0003272

 THIRD READING  

Bill No: AB 2360

Author: Maienschein (D)

Amended: 8/5/20 in Senate

Vote: 21

SENATE HEALTH COMMITTEE: 7-1, 8/1/20

AYES: Pan, Lena Gonzalez, Hurtado, Leyva, Mitchell, Monning, Rubio

NOES: Grove

NO VOTE RECORDED: Melendez

SENATE APPROPRIATIONS COMMITTEE: 5-2, 8/20/20

AYES: Portantino, Bradford, Hill, Leyva, Wieckowski

NOES: Bates, Jones

ASSEMBLY FLOOR: 64-12, 6/10/20 - See last page for vote

SUBJECT: Telehealth: mental health

SOURCE: 2020 Mom
Maternal Mental Health Now

DIGEST:

This bill requires a health plan or health insurer to provide access to a telehealth consultation program by July 1, 2021 that provides providers who treat children and pregnant and postpartum persons with access to a mental health consultation during standard provider hours, which may include evenings and weekends.

ANALYSIS:

Existing law:

1. Establishes the Department of Managed Health Care (DMHC) to regulate health plans under the Knox-Keene Health Care Service Plan Act of 1975 (Knox-Keene Act) and the California Department of Insurance (CDI) to regulate health insurance. [HSC §1340, et seq. and INS §106, et seq.]
   
2. Requires a health plan or insurer to develop a maternal mental health (MMH) program to address mental and behavioral issues by July 1, 2019, and requires a licensed health care practitioner who provides prenatal or postpartum care for a patient to ensure the mother is offered screening or is appropriately screened for MMH conditions. [HSC §1367.625, HSC §123640 and INS §10123.867]
   

This bill:

1. Requires a health plan or health insurer to provide access to a telehealth consultation program by July 1, 2021 that provides providers who treat children and persons who are pregnant and up to one year postpartum with access to a mental health consultation during standard provider hours, which may include evenings and weekends. Requires the program to include a triage service and consultation by a clinician with expertise with pregnant, postpartum and pediatric patients, including a psychiatrist when appropriate or requested by a provider by telephone or telehealth video, and requires it to include guidance on the range of evidence-based treatment options, including psychotherapy as determined to be appropriate, screening tools, and referrals.
2. Requires a health plan or health 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.
3. Requires a health plan or health 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.
4. Requires the plan or insurer to provide a description of the program to DMHC or CDI in a form and manner determined by DMHC or CDI.
5. Exempts a specialized health plan or health insurer, except a specialized behavioral health-only plan offering professional mental health services from this bill.

Comments

According to the author, the prevalence of MMH and Children’s Mental Health issues was already increasing. The COVID-19 crisis will only exacerbate these issues through anxiety, isolation, fear and uncertainty. Now more than ever we need to invest in expanding telehealth services, especially in fields where there are significant provider shortages. By increasing the capacity of screening primary care providers to treat mental health disorders, this bill has the capacity to 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.

California Health Benefits Review Program (CHBRP) analysis. AB 1996 (Thomson, Chapter 795, Statutes of 2002) requested 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, and reviewed a similar bill, AB 1676 from 2019 that was held in the Assembly Appropriations Committee. In the report, CHBRP refers to provider-to-provider telehealth consultations as electronic consultations or “eConsults”, and include both synchronous (e.g., phone, videoconference) and asynchronous (e.g., email, electronic health record) modalities. 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. Key findings of the analysis include:

1. Coverage impacts and enrollees covered. Currently, 74% of enrollees with health insurance that can be subject to state mandates and 38% of enrollees with Medi-Cal managed care coverage subject to the bill are already enrolled in health plans or policies with a psychiatric eConsult program. Postmandate, CHBRP assumes that health plans and insurers without psychiatric eConsult programs will need to establish one. Health plans and insurers could provide a telepsychiatry consultation program for primary care providers through a third-party vendor, in-network psychiatrists, or some other approach.
2. Medical effectiveness. CHBRP identified no rigorous studies that addressed the use of psychiatric eConsult programs to treat the specific populations specified in the 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.
3. Utilization. Estimates of current utilization of psychiatric eConsults are not available given limitations in coding and data sources. As a result of the bill, more enrollees with mental health care needs may have increased access to psychiatric services including medications and psychotherapy through their primary care provider as a result of a psychiatric eConsult program, but CHBRP is not able to quantify these impacts.
4. Medi-Cal. CHBRP estimates that the bill would increase providers’ access to specialists proportionally more for Medi-Cal beneficiaries compared to commercial plan enrollees, as 74% of commercial and CalPERS enrollees and 38% of Medi-Cal Managed Care enrollees are covered by plans and insurers that already have a psychiatric eConsult program in place. Mandates such as in the 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.
5. Impact on expenditures. CHBRP estimates the bill would result in increases in administrative costs. As an example, a psychiatry consultation program in Massachusetts that primary care providers can access by phone costs the state about $850,000 per year. The implementation of the 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.
6. Public health. In the first year postmandate, the impacts of the 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. As noted above, there is limited evidence suggesting that psychiatric eConsults for the adult population overall are effective. It stands to reason that the populations specified in the bill would experience the same effectiveness of psychiatric eConsults as the general population. Incorporating telepsychiatry consultations for primary care providers 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 primary care provider, otherwise not have had their mental health concerns addressed by a psychiatrist due to shortages of licensed psychiatrists in rural areas.
7. Essential health benefits. The bill would not require coverage for a new state benefit mandate that appears to exceed the definition of essential health benefits in California because it requires plans to establish a telepsychiatry consultation program for providers and is not a benefit for enrollees.

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

According to the Senate Appropriations Committee, staff received the following estimates for the departments, respectively:

• DMHC. $325,000 (Managed Care Fund) and 1.8 PYs in FY 2020-21; $295,000 (Managed Care Fund) and 1.7 PYs in FY 2021-22; $336,000 (Managed Care Fund) and 1.8 PYs in FY 2022-23; $335,000 (Managed Care Fund) and 1.8 PYs in FY 2023-24, and ongoing annually thereafter, for workload to issue regulations, review compliance and handle enforcement cases. The Managed Care Fund is covered through fees assessed on health plans.
• CDI. One-time costs of $180,000 (Insurance Fund) in FY 2021-22 for limited-term 0.89 PY to promulgate regulations.

SUPPORT: (Verified 8/20/20)

2020 Mom (co-source)
Maternal Mental Health Now (co-source)

Advocacy Outreach Lead Mom Congress

Alameda Health Consortium

American Academy of Lactation Policy and Practice

American Academy of Pediatrics, California
American Association of Birth Centers, California Chapter
American Association of Birth Centers, National Office

American College of Nurse-Midwives
American Congress of Obstetricians & Gynecologists - District IX

Association of Women’s Health, Obstetric and Neonatal Nurses, California Section

Black Wellness and Prosperity Center

California Academy of Child and Adolescent Psychiatry

California Academy of Family Physicians

California Association of Marriage and Family Therapists

California Chronic Care Coalition

California Council of Community Behavioral Health Agencies

California Hospital Association
California Nurse-Midwives Association

California Pan - Ethnic Health Network
California Psychiatric Association
California Psychological Association

California State PTA

California Telehealth Network
California Telehealth Policy Coalition

Center for Youth Wellness

Children Now

Children’s Specialty Care Coalition

Didi Hirsch Mental Health Services

Disability Rights California

Every Mother Counts

First 5 Association of California

First 5 California

First 5 Monterey County
First Five Butte County Children & Families Commission

Health Policy Pacific Business Group on Health

Jewish Public Affairs Committee

LA Best Babies Network

Lucile Packard Children’s Hospital/Stanford Children’s Health

March of Dimes

Maternal and Child Health Access

Maternal Justice Campaign
Mental Health Association of San Francisco

Mom Congress

Moms Rising

NAMI- Santa Clara County

National Association of Social Workers-CA

National Birth Equity Collaborative
Nurse - Family Partnership

National Health Law Program

Pacific Business Group on Health

Postpartum Health Alliance

Postpartum Support International

Postpartum Support International, California Chapter

Return to Zero

Sisterweb

Society for Maternal-Fetal Medicine
Steinberg Institute

St. Joseph Hospital

Supporting Mamas

The California Children’s Trust

The Children’s Partnership

United Parents

Zero to Three

OPPOSITION: (Verified 08/20/20)

Association of California Life & Health Insurance Companies
California Association of Health Plans
California Chamber of Commerce

California Department of Health Care Services

Local Health Plans of California

ARGUMENTS IN SUPPORT: 2020 Mom, a co-sponsor of this bill, and many other proponents, write that mental health disorders such as depression and anxiety are highly prevalent - affecting 100,000 new mothers and nearly 500,000 children in California each year. The COVID-19 pandemic may present the most stressful time in modern history for women facing pregnancy, childbirth, and the life change of caring for a new baby with little support - putting these mothers at risk for MMH conditions in the prenatal and postpartum periods. Children are also facing disruptions in their daily lives, which may trigger mental health issues as they adjust to extended remote schooling, friendships, and activities. It is more important than ever during a period of social distancing to provide access to mental health treatment via telehealth for moms and children. Due to the severe shortage of mental health professionals in CA, mothers often turn to their primary care physicians - including OBs and pediatricians - for help for themselves and their children, but these providers don’t feel adequately trained on how to treat them for mental illnesses. By providing a psychiatric telehealth consultation line, this bill will support frontline healthcare professionals who see mothers and children in diagnosing and developing a treatment plan in line with patient preferences and needs, including psychiatric medications if necessary. This bill will ensure that doctors have the support needed to initiate treatment for mothers and children with mental illnesses, so that California families can thrive. Maternal Mental Health Now, another cosponsor of this bill, writes that in Los Angeles County alone, 130,000 women give birth annually and the Department of Public Health estimates that 20% of these women experience depression, with a higher percentage affecting low-income communities. Maternal depression directly impacts the healthy brain development of young children. In addition, untreated perinatal depression and anxiety can result in developmental delays, child abuse and neglect. For these reasons, establishing a tele-psychiatry consultation line will ensure children and mothers receive immediate care and doctors are empowered with the ability to consult a psychiatrist to provide better care for their patients.

ARGUMENTS IN OPPOSITION: The California Chamber of Commerce writes there is already a psychiatrist shortage in California. To take these much-needed professionals away from seeing patients and instead have them on call morning, nights and weekends, in case someone calls, may not be the best use of such valuable skills. CHBRP was unable to conduct a cost analysis; however, it is likely that this program will increase health care costs. This bill cannot be viewed in isolation when it comes to its cost impact. As the COVID-19 pandemic rages, the unexpected and dramatic cost to insurers and insureds is expected to cause health insurance premiums to rise in 2021. According to the Association of California Life and Health Insurance Companies (ACLHIC) and California Association of Health Plans (CAHP), health plans and insurers are currently required to have a program in place when a woman wishes to contact their plan with MMH concerns. While CAHP and ACLHIC members strive to incorporate evidence-based care, they 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. Furthermore, CAHP and ACLHIC note that the CHBRP analysis of AB 1676 (Maienschein), an almost identical bill, noted that CHBRP found limited effectiveness of psychiatric eConsults generally and insufficient evidence on the effectiveness of psychiatric eConsults specifically for children and postpartum persons. Considering these findings, along with the significant cost of implementing these provisions, ACLHIC and CAHP believe that this bill is not necessary. The pandemic has forced us all to re-evaluate our priorities this year, focusing on the critical issues necessary to address this pandemic, and in this vein, CAHP and ACLHIC’s members remain acutely concerned about the cumulative impact of benefit mandates on premiums, particularly as they face the inherent pressures of an evolving and unstable market. The COVID-19 pandemic has only elevated how critical it is to maintain affordable premiums and not unnecessarily drive up that cost of care. The Local Health Plans of California (LHPC) indicate that recent amendments provide some flexibility but (LHPC) must remain opposed unless the provision to require access to a psychiatrist “when appropriate or requested by a treating physician” is removed because of the workforce shortages in this field. LHPC indicates there are significant cost implications with implementing this program, as described.

ASSEMBLY FLOOR: 64-12, 6/10/20

AYES: Aguiar-Curry, Arambula, Bauer-Kahan, Berman, Bloom, Boerner Horvath, Bonta, Burke, Calderon, Carrillo, Cervantes, Chau, Chiu, Chu, Cooley, Cooper, Cunningham, Daly, Diep, Eggman, Frazier, Friedman, Gabriel, Gallagher, Cristina Garcia, Eduardo Garcia, Gipson, Gloria, Gonzalez, Gray, Grayson, Holden, Irwin, Jones-Sawyer, Kalra, Kamlager, Levine, Limón, Low, Maienschein, McCarty, Medina, Mullin, Muratsuchi, Nazarian, O'Donnell, Petrie-Norris, Quirk-Silva, Ramos, Reyes, Luz Rivas, Robert Rivas, Rodriguez, Blanca Rubio, Salas, Santiago, Smith, Mark Stone, Ting, Waldron, Weber, Wicks, Wood, Rendon

NOES: Bigelow, Brough, Chen, Choi, Megan Dahle, Fong, Kiley, Lackey, Mathis, Obernolte, Patterson, Voepel

NO VOTE RECORDED: Flora, Mayes, Quirk

Prepared by: Teri Boughton / HEALTH / (916) 651-4111

8/23/20 7:38:30

**** END ****

SENATE COMMITTEE ON APPROPRIATIONS

Senator Anthony Portantino, Chair

2019 - 2020 Regular Session

AB 2360 (Maienschein) - Telehealth: mental health

Bill Summary:

Assembly Bill 2360 would enact the Mothers and Children Mental Health Support Act of 2020, which would require, by July 1, 2021, a health plan and health insurer to provide access to a telehealth consultation program for children, pregnant individuals, and individuals up to one year postpartum.

Fiscal Impact:

Staff received the following estimates for the departments, respectively:

• Department of Managed Health Care. $325,000 (Managed Care Fund) and 1.8 PYs in FY 2020-21; $295,000 (Managed Care Fund) and 1.7 PYs in FY 2021-22; $336,000 (Managed Care Fund) and 1.8 PYs in FY 2022-23; $335,000 (Managed Care Fund) and 1.8 PYs in FY 2023-24, and ongoing annually thereafter, for workload to issue regulations, review compliance and handle enforcement cases. The Managed Care Fund is covered through fees assessed on health plans.
• Department of Insurance. One-time costs of $180,000 (Insurance Fund) in FY 2021-22 for limited-term 0.89 PY to promulgate regulations.

Background:

1. ACR 148 (Lowenthal, Chapter 96, Statutes of 2014) requested the California Maternal Mental Health Collaborative to form a task force to study, review, and identify the following: current barriers to screening and diagnosis; current treatment options for individuals with private and publicly-insured; evidence-based and emerging treatment options that are scalable in public and private health settings; and, the needs of both providers and patients in order to improve diagnosis and treatment. According an April 2017 California Task Force on the Status of Maternal Mental Health (MMH) Care report, up to one in five (20 percent) of new or expectant mothers will experience a mental health disorder during pregnancy or the first year following childbirth, including depression, anxiety, and postpartum psychosis. Depression affects more than 16 million adults each year, and maternal depression is the most common complication of pregnancy in the U.S. All women are at risk of maternal stress and MMH disorders, and prevalence can increase to 50 percent among those in poverty, compared to 15 percent to 20 percent among the general population.

Proposed Law:

The bill includes the following provisions for health plans and health insurers:

Mental health telehealth consultation program. By July, 1, 2021, a health plan and health insurer must provide access to a telehealth consultation program that provides contracting providers who treat children and persons who are pregnant or up to one year postpartum with access to a mental health consultation program during the treating provider’s standard provider hours, which may include evenings and weekends. The telehealth consultation program must include a triage service and consultation by a mental health clinician with expertise appropriate for pregnant, postpartum, and pediatric patients, including a psychiatrist when appropriate or requested by the treating provider, by telephone or telehealth video, and must include guidance on the range of evidence-based treatment options, including psychotherapy, as determined to be appropriate, screening tools, and referrals.

Communication. A health plan and health insurer must, at least twice a year in writing, communicate the telehealth program’s availability to specified contracting providers, including pediatricians, obstetricians, and primary care providers.

Data monitoring and quality improvements. A health plan and insurer must monitor utilization data to facilitate ongoing program quality improvements.

Exemptions. This bill does not apply to a specialized health plan, except a specialized behavioral health-only plan offering professional mental health services. This bill also does not apply to a specialized health insurer, except a specialized behavioral health-only insurer offering professional mental health services.

Other. A health plan and health insurer must provide a description of the telehealth consultation program to the DMHC and CDI, respectively, in a manner and format prescribed by the department.

The bill’s provisions must not be construed to alter a health insurer’s obligations pursuant to federal Patient Protection and Affordable Care Act (ACA) Section 10112.2 or 10144.4 and all covered mental health and substance use disorder benefits in compliance with federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 and specified rules, regulations, and federal statute.

The bill provides no state reimbursement is necessary, as specified.

Related Legislation:

• AB 1676 (Maienschein, 2019) was substantively similar to this bill. AB 1676 was held in the Assembly Appropriations Committee.
• AB 2193 (Maienschein, Chapter 755, Statutes of 2018) requires, by July 1, 2019, a licensed health care practitioner who provides prenatal or postpartum care to ensure screening or the mother is screened for maternal mental health conditions, and requires a health plan or insurer to develop a MMH program.
• AB 1893 (Maienschein, Chapter 140, Statutes of 2018) requires CDPH to investigate and apply for federal funding opportunities to support maternal mental health, and requires CDPH to notify the Legislature of its efforts to secure and utilize federal funds it receives. AB 1893 sunsets on January 1, 2023.

Staff Comments:

1. The DMHC indicates the following workload across various units, specifically (*Managed Care Fund):

• Office of Plan Monitoring (OPM). $13,000 and 0.1 PY in FY 2020-21, $209,000 and 1.2 PYs in FY 2021-22, $248,000 and 1.3 PYs in FY 2022-23, $247,000 and 1.3 PYs in FY 2023-24, and the same amount annually thereafter, for workload to update Technical Assistance Guides (TAGs), develop survey tools and methodologies guidance, and conduct ongoing assessments of health plan surveys for compliance.
• Office of Enforcement (OE). $86,000 and 0.5 PY in FY 2021-22, $88,000 and 0.5 PY in FY 2022-23, and the same amount annually thereafter, for workload to address an assumed six referrals annually from OPM, starting in FY 2021-22.
• Office of Legal Services (OLS). $90,000 and 0.6 PY in FY 2020-21 only FOR short-term workload to conduct legal research, prepare legal memorandums, AND promulgate a rulemaking package.
• Office of Plan Licensing (OPL). $222,000 and 1.1 PYs in FY 2020-21 only FOR short-term workload to review provider contracts and plan documents for compliance.

2. The California Health Benefits Review Program (CHBRP) assesses proposed legislation that seeks to mandate a specific benefit or analysis (AB 1996, Thomson, Chapter 795, Statutes of 2002). CHBRP analyzed a similar bill, AB 1676 (Maienschein, 2019). CHBRP referred to provider-to-provider telehealth consultations as electronic consultations, or “eConsults,” and according to its analysis:

…Found limited evidence on the effectiveness of psychiatric eConsults generally and insufficient evidence on the effectiveness of psychiatric eConsults 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, 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.

…Incorporating telepsychiatry consultations for primary care providers who treat children and pregnant and postpartum persons could potentially increase access and timeliness to appropriate mental health care. This change in access would be greatest for rural beneficiaries who may, directly or through their primary care provider, otherwise not have had their mental health concerns addressed by a psychiatrist due to shortages of licensed psychiatrists in rural areas. AB 1676 would increase providers’ access to specialists proportionally more for Medi-Cal beneficiaries compared to commercial plan enrollees, as 74% of commercial and CalPERS enrollees and 38% of Medi-Cal Managed Care enrollees are covered by plans and insurers that already have a psychiatric eConsult program in place.

As the COVID-19 pandemic continues, the Department of Public Health regularly issues guidance and resources on maternal, family caregiver, and children supports. In addition, the California Surgeon General, in recognition of stress and anxiety levels across caregivers and children, released its playbook, which included recommendations for mental and behavioral health care.

-- END --

SENATE COMMITTEE ON HEALTH

Senator Dr. Richard Pan, Chair

BILL NO: AB 2360

SUBJECT: Telehealth: mental health.

SUMMARY:

Requires a health plan or health insurer to establish or provide access to a telehealth consultation program by July 1, 2021 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. Includes minimum requirements regarding training and certification of consulting providers, as specified.

Existing law:

1. Establishes the Department of Managed Health Care (DMHC) to regulate health plans under the Knox-Keene Health Care Service Plan Act of 1975 (Knox-Keene Act) and the California Department of Insurance (CDI) to regulate health insurance. [HSC §1340, et seq. and INS §106, et seq.]
   
2. Requires a health plan or insurer to develop a maternal mental health (MMH) program to address mental and behavioral issues by July 1, 2019, and requires a licensed health care practitioner who provides prenatal or postpartum care for a patient to ensure the mother is offered screening or is appropriately screened for MMH conditions. [HSC §1367.625, HSC §123640 and INS §10123.867]
   

This bill:

1. Requires a health plan or health insurer to establish or provide access to a telehealth consultation program by July 1, 2021 that provides providers who treat children and persons who are pregnant and up to one year postpartum with access to a psychiatric consultation program during standard provider hours, which may include evenings and weekends. Requires the program to include a triage service and psychiatric consultation by telephone or telehealth video, and requires it to include guidance on the range of evidence-based treatment options, including psychotherapy.
2. Requires the program to be implemented, at a minimum, pursuant to the following:
   
   1. Allow the treating provider to utilize a telephone line or video consultation service;
   2. Include triage by a clinician trained in the appropriate specialty of mental health care, including a registered nurse, psychologist, licensed clinical social worker, licensed clinical counselor, or licensed marriage and family therapist. Requires for pediatric patients, clinicians to have appropriate training in child and adolescent mental health. Requires for perinatal patients, clinicians to have appropriate training in maternal mental health, and include a clinician certified in perinatal mental health;
   3. Requires the triage clinician to provide guidance on appropriate additional screening tools and evidence-based treatment options to assist with the development of a plan for further assessment, if needed, and development of a treatment plan;
   4. Provide the names and contact information for behavioral health clinicians within the enrollees’ network, if deemed appropriate; and,
   5. Connection to a consulting psychiatrist trained in child psychiatry or maternal mental health, or both, if deemed appropriate and requested by the treating provider.
      
3. States a health plan or health insurer that currently has or develops an asynchronous e-consult program for consultation with psychiatrists is encouraged to provide that service as part of the program, but requires the plan or insurer to provide live telephonic or video consult access, or both.
   
4. Requires a health plan or health 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.
5. Requires a health plan or health 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.
6. Exempts a specialized health plan or health insurer, except a specialized behavioral health-only plan offering professional mental health services from this bill.

FISCAL EFFECT:

According to the Assembly Appropriations Committee, uncertain, potentially significant costs to Medi-Cal managed care plans to develop or contract for "e-consultation" models (General Fund/federal funds).

Costs to DMHC of $50,000 in 2020-21, $550,000 in 2021-22 and $450,000 thereafter annually to issue regulations, review compliance and handle enforcement cases (Managed Care Fund). Costs to the California Department of Insurance are expected to be minor and absorbable (Insurance Fund).

PRIOR VOTES:

COMMENTS:

1. Author’s statement. According to the author, the prevalence of MMH and Children’s Mental Health issues was already increasing. The COVID-19 crisis will only exacerbate these issues through anxiety, isolation, fear and uncertainty. Now more than ever we need to invest in expanding telehealth services, especially in fields where there are significant provider shortages. By increasing the capacity of screening primary care providers to treat mental health disorders, this bill has the capacity to 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. California Health Benefits Review Program (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, and reviewed a similar bill, AB 1676 from 2019 that was held in the Assembly Appropriations Committee. In the report, CHBRP refers to provider-to-provider telehealth consultations as electronic consultations or “eConsults”, and include both synchronous (e.g., phone, videoconference) and asynchronous (e.g., email, electronic health record) modalities. 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. Key findings of the analysis include:
   
   1. Coverage impacts and enrollees covered. Currently, 74% of enrollees with health insurance that can be subject to state mandates and 38% of enrollees with Medi-Cal managed care coverage subject to the bill are already enrolled in health plans or policies with a psychiatric eConsult program. Postmandate, CHBRP assumes that health plans and insurers without psychiatric eConsult programs will need to establish one. Health plans and insurers could provide a telepsychiatry consultation program for primary care providers through a third-party vendor, in-network psychiatrists, or some other approach.
   2. Medical effectiveness. CHBRP identified no rigorous studies that addressed the use of psychiatric eConsult programs to treat the specific populations specified in the 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.
   3. Utilization. Estimates of current utilization of psychiatric eConsults are not available given limitations in coding and data sources. As a result of the bill, more enrollees with mental health care needs may have increased access to psychiatric services including medications and psychotherapy through their primary care provider as a result of a psychiatric eConsult program, but CHBRP is not able to quantify these impacts.
   4. Medi-Cal. CHBRP estimates that the bill would increase providers’ access to specialists proportionally more for Medi-Cal beneficiaries compared to commercial plan enrollees, as 74% of commercial and CalPERS enrollees and 38% of Medi-Cal Managed Care enrollees are covered by plans and insurers that already have a psychiatric eConsult program in place. Mandates such as in the 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.
   5. Impact on expenditures. CHBRP estimates the bill would result in increases in administrative costs. As an example, a psychiatry consultation program in Massachusetts that primary care providers can access by phone costs the state about $850,000 per year. The implementation of the 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.
   6. Public health. In the first year postmandate, the impacts of the 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. As noted above, there is limited evidence suggesting that psychiatric eConsults for the adult population overall are effective. It stands to reason that the populations specified in the bill would experience the same effectiveness of psychiatric eConsults as the general population. Incorporating telepsychiatry consultations for primary care providers 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 primary care provider, otherwise not have had their mental health concerns addressed by a psychiatrist due to shortages of licensed psychiatrists in rural areas.

• 1. Essential health benefits. The bill would not require coverage for a new state benefit mandate that appears to exceed the definition of essential health benefits in California because it requires plans to establish a telepsychiatry consultation program for providers and is not a benefit for enrollees.
     

1. Health Resources and Services Administration (HRSA) grants. In 2018, the HRSA awarded $12.4 million through two programs designed to support the mental health of women and children across the United States. Approximately $7.9 million of the funding was awarded to support 18 states to integrate behavioral health into pediatric primary care using telehealth through the Pediatric Mental Health Care Access Program. The funding was provided for state or regional networks of pediatric mental health teams to provide tele-consultation, training, technical assistance and care coordination for pediatric primary care providers to diagnose, treat and refer children with behavioral health conditions. An additional $4.5 million was awarded to support seven states to implement the Screening and Treatment for Maternal Depression and Related Behavioral Disorders Program. The funding was provided for real-time psychiatric consultation, care coordination, and training to help front-line providers screen, assess, refer and treat pregnant and postpartum women for depression and other behavioral health conditions such as anxiety and substance misuse – including in rural and medically underserved areas. While the California Department of Public Health (CDPH) submitted an application for funding, California’s proposal was not funded.
   
2. Prior legislation. AB 1676 (Maienschein of 2019) similar to this bill would have required health plans and health insurers, by January 1, 2021, to establish a telehealth consultation program. Would have required health plans and insurers to communicate information relating to the telehealth program at least twice a year in writing, and maintain records and data, as necessary. Exempts certain specialized health plans and health insurers from these provisions. AB 1676 was held in the Assembly Appropriations Committee.
   

AB 2197 (Maienschein, Chapter 755, Statutes of 2018) mandates that a health plan or insurer develop a MMH program to address mental and behavioral issues by July 1, 2019, and requires a licensed health care practitioner who provides prenatal or postpartum care for a patient to ensure the mother is offered screening or is appropriately screened for MMH conditions.

AB 1893 (Maienschein, Chapter 140, Statutes of 2018) requires CDPH to investigate and apply for federal funding opportunities to support MMH, and requires CDPH to notify the Legislature of its efforts to secure and utilize federal funds it receives. AB 1893 sunsets on January 1, 2023.

1. Support. 2020 Mom, a co-sponsor of this bill, and many other proponents, write that mental health disorders such as depression and anxiety are highly prevalent - affecting 100,000 new mothers and nearly 500,000 children in California each year. The COVID-19 pandemic may present the most stressful time in modern history for women facing pregnancy, childbirth, and the life change of caring for a new baby with little support - putting these mothers at risk for MMH conditions in the prenatal and postpartum periods. Children are also facing disruptions in their daily lives, which may trigger mental health issues as they adjust to extended remote schooling, friendships, and activities. It is more important than ever during a period of social distancing to provide access to mental health treatment via telehealth for moms and children. Due to the severe shortage of mental health professionals in CA, mothers often turn to their primary care physicians - including OBs and pediatricians - for help for themselves and their children, but these providers don’t feel adequately trained on how to treat them for mental illnesses. By providing a psychiatric telehealth consultation line, this bill will support frontline healthcare professionals who see mothers and children in diagnosing and developing a treatment plan in line with patient preferences and needs, including psychiatric medications if necessary. This bill will ensure that doctors have the support needed to initiate treatment for mothers and children with mental illnesses, so that California families can thrive. Maternal Mental Health Now, another cosponsor of this bill, writes that in Los Angeles County alone, 130,000 women give birth annually and the Department of Public Health estimates that 20% of these women experience depression, with a higher percentage affecting low-income communities. Maternal depression directly impacts the healthy brain development of young children. In addition, untreated perinatal depression and anxiety can result in developmental delays, child abuse and neglect. For these reasons, establishing a tele-psychiatry consultation line will ensure children and mothers receive immediate care and doctors are empowered with the ability to consult a psychiatrist to provide better care for their patients.
   
2. Opposition. The California Chamber of Commerce writes there is already a psychiatrist shortage in California. To take these much-needed professionals away from seeing patients and instead have them on call morning, nights and weekends, in case someone calls, may not be the best use of such valuable skills. CHBRP was unable to conduct a cost analysis; however, it is likely that this program will increase health care costs. This bill cannot be viewed in isolation when it comes to its cost impact. As the COVID-19 pandemic rages, the unexpected and dramatic cost to insurers and insureds is expected to cause health insurance premiums to rise in 2021. Covered California, the state's Affordable Care Act marketplace, projects that commercial insurers and employers could face a $34 billion to $251 billion bill for coronavirus testing and treatment in 2020. Their best estimate is $103 billion. If federal relief is not forthcoming, these costs could prompt commercial health insurers to increase premiums from up to 4% to 40% in 2021. According to the Association of California Life and Health Insurance Companies (ACLHIC) and California Association of Health Plans (CAHP), health plans and insurers are currently required to have a program in place when a woman wishes to contact their plan with MMH concerns. While CAHP and ACLHIC members strive to incorporate evidence-based care, they 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. Furthermore, CAHP and ACLHIC note that the CHBRP analysis of AB 1676 (Maienschein), an almost identical bill, noted that CHBRP found limited effectiveness of psychiatric eConsults generally and insufficient evidence on the effectiveness of psychiatric eConsults specifically for children and postpartum persons. Considering these findings, along with the significant cost of implementing these provisions, ACLHIC and CAHP believe that this bill is not necessary. The pandemic has forced us all to re-evaluate our priorities this year, focusing on the critical issues necessary to address this pandemic, and in this vein, CAHP and ACLHIC’s members remain acutely concerned about the cumulative impact of benefit mandates on premiums, particularly as they face the inherent pressures of an evolving and unstable market. The COVID-19 pandemic has only elevated how critical it is to maintain affordable premiums and not unnecessarily drive up that cost of care. The Local Health Plans of California (LHPC) write that proposed amendments provide some flexibility but (LHPC) must remain opposed unless the provision to require access to a psychiatrist “when appropriate or requested by a treating physician” is removed because of the workforce shortages in this field. LHPC indicates there are significant cost implications with implementing this program, as described.
   
3. Policy comment. CHBRP has found limited evidence of effectiveness of e-Consult programs for this specific purpose. However, CHBRP states that it stands to reason that the populations specified in the bill would experience the same effectiveness of psychiatric eConsults as the general population and incorporating telepsychiatry consultations for primary care providers who treat children and pregnant and postpartum persons could potentially increase access and timeliness to appropriate mental health care, especially for rural beneficiaries who may otherwise not have had their mental health concerns addressed by a psychiatrist due to shortages of licensed psychiatrists in rural areas. Health plans, insurers and health care providers are stretched in response to COVID-19 and may not have the capacity to establish a new program at this time. Should the committee wish to advance this bill, it may be necessary to allow for some flexibility in implementation during this uncertain time.
   
4. Amendments. The author has agreed to the following amendments in response to comment 7) above.
   
   SECTION 1. This act shall be known, and may be cited, as the Mothers and Children Mental Health Support Act of 2020.

SEC. 2. Section 1367.626 is added to the Health and Safety Code, to read:

1367.626. (a) (1) In order to more quickly diagnose and treat children and pregnant and postpartum persons suffering from mental illness, by July 1, 2021, a health care service plan shall establish or provide access to a telehealth consultation program that provides contracting providers who treat children and persons who are pregnant or up to one year postpartum with access to a psychiatric mental health consultation program during the treating provider’s standard provider hours, which may include evenings and weekends. The telehealth consultation program shall include a triage service and psychiatric consultation by a mental health clinician with expertise appropriate for pregnant, postpartum and pediatric patients, including a psychiatrist when appropriate or requested by the treating provider, by telephone or telehealth video, and shall include guidance on the range of evidence-based treatment options, including psychotherapy, as determined to be appropriate, screening tools and referrals.

(2) The telehealth consultation program described in paragraph (1) shall be implemented, at a minimum, pursuant to all of the following requirements:

(A) The program shall allow the treating provider to utilize a telephone line or video consultation service. The program shall include triage by a clinician trained in the appropriate specialty of mental health care, including a registered nurse, psychologist, licensed clinical social worker, licensed clinical counselor, or licensed marriage and family therapist. Clinicians triaging for pediatric patients shall have appropriate training in child and adolescent mental health. Clinicians triaging for perinatal patients shall have appropriate training in maternal mental health, which shall include a clinician certified in perinatal mental health (PMH-C). These requirements may be satisfied by providing access to one clinician who is appropriately cross-trained in both areas.

(B) The triaging clinician shall provide guidance on appropriate additional screening tools, if warranted, and evidence-based treatment options to assist with the development of a plan for further psychological assessment, if needed, and development of a treatment plan for the enrollee.

(C) If deemed appropriate by the treating provider and consulting clinician, the consulting clinician shall provide the treating provider with names and contact information for behavioral health clinicians within the enrollee’s network.

(D) If deemed appropriate, including if the treating provider requests consultation, the triage clinician shall then connect the treating provider to a consulting psychiatrist trained in child psychiatry or maternal mental health, or both, as appropriate.

(3) A health care service plan that currently has or develops an asynchronous e-consult program for consultation with psychiatrists is encouraged to provide that service as part of the consultation program, but shall also provide live telephonic or video consult access, or both.

(b) A health care service plan shall 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.

(c) A health care service plan shall monitor data pertaining to the utilization of its telehealth consultation program to facilitate ongoing quality improvements to the program, as necessary.

(d) A health care service plan shall include a description of the mental health consultation program required in (a) to the department in a manner and format described by the department.

(e)This section does not apply to a specialized health care service plan, except a specialized behavioral health-only plan offering professional mental health services.

Same changes in the Insurance Code provisions.

SUPPORT AND OPPOSITION:

Support: 2020 Mom (co-sponsor)
Maternal Mental Health Now (co-sponsor)
Advocacy Outreach Lead Mom Congress

American Academy of Lactation Policy and Practice
American Academy of Pediatrics, California
American Association of Birth Centers, California Chapter
American Association of Birth Centers, National Office
American Congress of Obstetricians & Gynecologists - District IX

Black Wellness and Prosperity Center

California Chronic Care Coalition
California Hospital Association
California Nurse-Midwives Association

California Pan - Ethnic Health Network
California Psychiatric Association
California Psychological Association

California State PTA
California Telehealth Policy Coalition

Children’s Specialty Care Coalition

Every Mother Counts
First Five Butte County Children & Families Commission

March of Dimes

Maternal and Child Health Access

Maternal Justice Campaign
Nurse - Family Partnership

Postpartum Health Alliance

Postpartum Support International

Postpartum Support International, California Chapter
Return to Zero

Sisterweb

Society for Maternal-Fetal Medicine
Steinberg Institute

The California Children’s Trust

The Children’s Partnership

Zero to Three

Oppose: Association of California Life & Health Insurance Companies
California Association of Health Plans
California Chamber of Commerce

Local Health Plans of California

-- END --

ASSEMBLY THIRD READING

ATR Bill Id:AB 2360

Author:(Maienschein)

As Amended Ver:May 7, 2020

Majority vote

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 insurers to maintain records and data, as necessary. Exempts certain specialized health plans and health insurers from these provisions.

Major Provisions

COMMENTS:

According to the Department of Public Health (DPH), one in five California women who recently gave birth experience symptoms of depression during or after pregnancy. That translates to about 100,000 women a year. All women are at risk for symptoms of perinatal depression; however, Black or Latina women, women who have low incomes or those who have experienced hardships in their childhood or during pregnancy are at heightened risk of having symptoms of depression. Depression during pregnancy is likely to lead to depression after the baby is born and is associated with serious risks to the mother and infant. Though not all women with symptoms of depression will be diagnosed with clinical depression, screening and appropriate care should be provided during prenatal care.

Often in rural or remote areas, primary care providers (PCP) assume full responsibility for treating their patients' mental health conditions due to a lack of available resources. Telehealth consultations have been introduced as one way to address this lack of resources by enabling consultations between specialists at a distance and PCPs.

In 2010, California designated May as Perinatal Depression Awareness Month. ACR 105 (Nava), Resolution Chapter 9, Statutes of 2010, also requested that several stakeholders including the DHCS, DPH, First 5 California, the American College of Obstetricians and Gynecologists, and Postpartum Support International work together on several issues. ACR 105 encouraged these stakeholders to explore ways to improve women's access to mental health care, increase awareness and education about perinatal depression, encourage the use of screening tools, and improve the availability of effective treatment options and community support services. In 2014, the California Legislative Women's Caucus introduced ACR 148 (Waldron), Chapter 96, Statutes of 2014, to explore untreated maternal mental health disorders and their impacts. The resolution passed and initiated a multidisciplinary Task Force representing stakeholders in mental health, medicine, public health, nursing, research, insurance, and hospitals. From 2015 to 2016, the California Task Force on the Status of Maternal Mental Health Care (the Task Force) examined existing barriers to screening and diagnosis, current treatment options, evidence-based treatments, and emerging treatments.

Funded by a legislative appropriation in the Department of Mental Health budget, the Massachusetts Child Psychiatry Access Project (MCPAP) was established in 2004. MCPAP is a system of regional children's psychiatric consultation teams designed to improve access to treatment for children with behavioral health problems. MCPAP seeks to strengthen pediatric PCPs ability to screen, diagnose, and treat children with mild to moderate behavioral health problems (e.g., anxiety, depression, attention deficit hyperactivity disorder) in primary care. It also supports PCPs in referring children with more serious behavioral health problems to appropriate psychiatric specialty care.

AB 1676 (Maienschein) of 2019 CHBRP analysis. According to the California Health Benefits Review Program (CHBRP), provider-to-provider telehealth consultations are referred to as electronic consultations or "eConsults", and include both synchronous (e.g., phone, videoconference) and asynchronous (e.g., email, electronic health record) modalities. 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. Since this bill is substantially similar to AB 1676, it is appropriate to use CHBRP's analysis of that bill, which indicates the following:

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. As a result of this bill, more enrollees with mental health care needs may have increased access to psychiatrist services including medications and psychotherapy through their PCPs as a result of a psychiatric eConsult program, but CHBRP is not able to quantify these indirect effects. 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 enrollees and 38% of MCMC enrollees are covered by plans and insurers that already have a psychiatric eConsult program in place.

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.

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.

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.

According to the Author:

According to the author, now more than ever we need to invest in expanding telehealth services, especially in fields where there are significant provider shortages. By increasing the capacity of screening PCPs to treat mental health disorders, this bill lays the groundwork to 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.

Arguments in Support:

2020 Mom, co-sponsors of this bill, writes that this bill will provide support to frontline screening providers to initiate much-needed treatment for mothers and children with mental illnesses, so that California families can thrive. Maternal Mental Health Now, co-sponsors of this bill, states that this bill is critical during the pandemic, as children and mothers has become even more vulnerable to experiencing mental health issues. The California Hospital Association writes that currently, one in five women who are pregnant or have recently given birth suffer from depression, making it more common than diabetes during pregnancy. Depression is also the leading cause of disability worldwide among women of reproductive age, and maternal suicide accounts for 20% of postpartum deaths among depressed women. Raising awareness of behavioral health and promoting good health before pregnancy, as well as better screening for and treatment of postpartum depression, would strengthen hospitals' efforts to ensure all moms and babies can receive the care they need, when they need it.

Arguments in Opposition:

The California Chamber of Commerce (CCC) contends that this bill requires a psychiatric consultation program to be made available to providers and also mandates that the health plan and insurer psychiatrists be made accessible to providers during standard hours, including evenings and weekends. CCC writes that physicians determine whether a patient's condition exceeds the scope of their practice and that it also falls within a physician's clinical judgment (not the health plans) to determine if the patient's condition requires the intervention of a specialist or separate provider, such as a psychiatrist or psychologist. 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. According to the California Association of Health Plans and Association of Life and Health Insurance Companies, the COVID-19 pandemic has only elevated how critical it is to maintain affordable premiums and not unnecessarily drive of that cost of care.

FISCAL COMMENTS:

According to the Assembly Appropriations Committee, uncertain, potentially significant costs to Medi-Cal managed care plans to develop or contract for "e-consultation" models (General Fund/federal funds).

Costs to Department of Managed Health Care of $50,000 in 2020-21, $550,000 in 2021-22 and $450,000 thereafter annually to issue regulations, review compliance and handle enforcement cases (Managed Care Fund).

Costs to the California Department of Insurance are expected to be minor and absorbable (Insurance Fund).

VOTES:

ASM HEALTH: 11-2-2

YES: Wood, Aguiar-Curry, Bonta, Burke, Carrillo, Limón, McCarty, Nazarian, Ramos, Rodriguez, Santiago

NO: Bigelow, Flora

ABS, ABST OR NV: Mayes, Waldron

ASM APPROPRIATIONS: 13-5-0

YES: Gonzalez, Bauer-Kahan, Bloom, Bonta, Calderon, Carrillo, Chau, Eggman, Gabriel, Eduardo Garcia, Petrie-Norris, McCarty, Robert Rivas

NO: Bigelow, Megan Dahle, Diep, Fong, Voepel

UPDATED:

VERSION: May 7, 2020

CONSULTANT: Kristene Mapile / HEALTH / (916) 319-2097 FN: 0002886

Date of Hearing: June 2, 2020

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Lorena Gonzalez, Chair

ABPCA Bill Id:AB 2360

Author:(Maienschein) – As Amended Ver:May 7, 2020

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 must be implemented among multiple Medi-Cal managed care plans, costs would likely be significantly higher than Massachusetts. 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 2020-21, $550,000 in 2021-22 and $450,000 thereafter annually 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 “e-consults.” The goal of psychiatric e-consults is for PCPs to be able to more quickly diagnose and treat mental health conditions. CHBRP estimated a similar bill last year, AB 1676 (Maienschein), would have increased providers’ access to specialists proportionally more for Medi-Cal beneficiaries compared to commercial plan enrollees, as 74% of enrollees in commercial plans and the California Public Employees' Retirement System (CalPERS), and 38% of MCMC enrollees are covered by plans and insurers that already have a psychiatric e-consult program in place.

CHBRP noted 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 improve 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 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 the Senate Appropriations Committee, creates a pilot program to increase provider capacity to effectively prevent, identify and manage postpartum depression and other mental health conditions.
4. Prior Legislation. AB 1676 (Maienschein), of the current Legislative Session, is substantially similar to this bill and was held on the Suspense File of this committee.

AB 577 (Eggman), Chapter 776, Statutes of 2019, extended the duration of the requirement that health plans and health insurers provide continuity of care for pregnant women to up to 12 months from the diagnosis or from the end of pregnancy, whichever occurs later, if the woman presents written documentation of being diagnosed with a maternal mental health condition from the individual's treating health care provider.

AB 744 (Aguiar-Curry), Chapter 867, Statutes of 2019, requires plans and insurers to reimburse for services provided via telehealth at an equivalent rate to services provided via methods other than telehealth.

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, required 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.

ACR 148 (Lowenthal), Chapter 96, Statutes of 2014, requested 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: May 18, 2020

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

ABPCA Bill Id:AB 2360

Author:(Maienschein) – As Amended Ver:May 7, 2020

SUBJECT: Telehealth: 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 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 for providers who treat children and pregnant and postpartum persons with access to a psychiatrist during standard provider hours, which may include evenings and weekends.
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. Establishes the California Health and Human Services Agency within state government and various public health programs throughout the state for purposes of promoting maternal, child, and adolescent health, including the Mental Health Services Division, within the Department of Health Care Services (DHCS), which administers a number of mental health programs for children and youth, adults and older adults, and the Maternal, Child and Adolescent Health Division, within the Department of Public Health (DPH), which works to improve the health and well-being of women, infants, children and adolescents throughout the state.
2. Establishes the Department of Managed Health Care (DMHC) to regulate health plans, including Medi-Cal Managed Care Plans, and the California Department of Insurance to regulate health insurers. Establishes the Medi-Cal program, which is administered by DHCS, under which qualified low-income individuals receive health care services, as specified.
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 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.
8. 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.
9. 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.
10. 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.
11. Requires a contract issued, amended, or renewed on or after January 1, 2021, between a health plan and a health care provider for the provision of health care services to an enrollee or subscriber, or a contract issued, amended, or renewed on or after January 1, 2021, between a health insurer and a health care provider for an alternative rate of payment to specify that the health care service plan or health insurer reimburse a health care provider for the diagnosis, consultation, or treatment of an enrollee, subscriber, insured, or policyholder appropriately delivered through telehealth services on the same basis and to the same extent that the health plan or health insurer is responsible for reimbursement for the same service through in-person diagnosis, consultation, or treatment.
12. 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.
13. Defines the following:
    
    1. Telehealth as the mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patient's health care while the patient is at the originating site and the health care provider is at a distant site. States that telehealth facilitates patient self-management and caregiver support for patients and includes synchronous interactions and asynchronous store and forward transfers.
    2. Originating site as a site where a patient is located at the time health care services are provided via a telecommunications system or where the asynchronous store and forward service originates.
    3. Synchronous interaction as a real-time interaction between a patient and a health care provider located at a distant site
    4. Asynchronous store and forward as the transmission of a patient’s medical information from an originating site to the health care provider at a distant site without the presence of the patient.
    5. Distant site as a site where a health care provider who provides health care services is located while providing these services via a telecommunications system.

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

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, now more than ever we need to invest in expanding telehealth services, especially in fields where there are significant provider shortages. By increasing the capacity of screening primary care providers to treat mental health disorders, this bill lays the groundwork to 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 DPH, one in five California women who recently gave birth experience symptoms of depression during or after pregnancy. That translates to about 100,000 women a year. All women are at risk for symptoms of perinatal depression; however, Black or Latina women, women who have low incomes or those who have experienced hardships in their childhood or during pregnancy are at heightened risk of having symptoms of depression. Depression during pregnancy is likely to lead to depression after the baby is born and is associated with serious risks to the mother and infant. Though not all women with symptoms of depression will be diagnosed with clinical depression, screening and appropriate care should be provided during prenatal care.

Often in rural or remote areas, primary care providers (PCP) assume full responsibility for treating their patients’ mental health conditions due to a lack of available resources. Telehealth consultations have been introduced as one way to address this lack of resources by enabling consultations between specialists at a distance and PCPs.

• 1. Perinatal Depression Awareness Month. In 2010, California designated May as Perinatal Depression Awareness Month. ACR 105 (Nava), Resolution Chapter 5, Statutes of 2009, also requested that several stakeholders including the DHCS, DPH, First 5 California, the American College of Obstetricians and Gynecologists, and Postpartum Support International work together on several issues. ACR 105 encouraged these stakeholders to explore ways to improve women’s access to mental health care, increase awareness and education about perinatal depression, encourage the use of screening tools, and improve the availability of effective treatment options and community support services.
  2. California Task Force on the Status of Maternal Mental Health Care. In 2014, the California Legislative Women’s Caucus introduced ACR 148 (Waldron), Chapter 96, Statutes of 2014, to explore untreated maternal mental health disorders and their impacts. The resolution passed and initiated a multidisciplinary Task Force representing stakeholders in mental health, medicine, public health, nursing, research, insurance, and hospitals. From 2015 to 2016, the California Task Force on the Status of Maternal Mental Health Care (the Task Force) examined existing barriers to screening and diagnosis, current treatment options, evidence-based treatments, and emerging treatments. In December 2016, the Task Force published “California’s Strategic Plan: A catalyst for shifting statewide systems to improve care across California and beyond.” The report included an overview of the current state and recommendations for California to improve maternal mental health care.
  3. Other states. Funded by a legislative appropriation in the Department of Mental Health budget, the Massachusetts Child Psychiatry Access Project (MCPAP) was established in 2004. MCPAP is a system of regional children’s psychiatric consultation teams designed to improve access to treatment for children with behavioral health problems. MCPAP seeks to strengthen pediatric PCPs ability to screen, diagnose, and treat children with mild to moderate behavioral health problems (e.g., anxiety, depression, ADHD) in primary care. It also supports PCPs in referring children with more serious behavioral health problems to appropriate psychiatric specialty care. In 2010, Massachusetts passed the Postpartum Depression Act. The law established a Special Legislative Commission on postpartum depression to assess current research and evaluate the state’s current practices. The law also established postpartum depression screening regulations and authorized funding to expand the MCPAP to MCPAP for moms, which uses a multipronged approach to help providers identify and treat postpartum depression.
  4. eConsults. According to the California Health Benefits Review Program (CHBRP), provider-to-provider telehealth consultations are referred to as electronic consultations or “eConsults”, and include both synchronous (e.g., phone, videoconference) and asynchronous (e.g., email, electronic health record) modalities. 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.
  5. AB 1676 (Maienschein) of 2019 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.

Since this bill is substantially similar to AB 1676, it is appropriate to use CHBRP’s analysis of that bill, which indicates 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. As a result of this bill, more enrollees with mental health care needs may have increased access to psychiatrist services including medications and psychotherapy through their PCPs as a result of a psychiatric eConsult program, but CHBRP is not able to quantify these indirect effects. 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. CHBRP does not expect impact for CalPERS enrollees to be different from the impacts to enrollees in other commercial plans or policies. 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. 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.
    9. COVID-19 telehealth policies. As recently as March 17, the federal government, specifically the Office of Civil Rights (OCR) at the Department of Health and Human Services (HHS), relaxed enforcement requirements under the Health Insurance Portability and Accountability Act (HIPAA). This guidance states in part: During the COVID-19 national emergency, which also constitutes a nationwide public health emergency, covered health care providers subject to the HIPAA Rules may seek to communicate with patients, and provide telehealth services, through remote communications technologies. Some of these technologies, and the manner in which they are used by HIPAA covered health care providers, may not fully comply with the requirements of the HIPAA Rules. OCR will exercise its enforcement discretion and will not impose penalties for noncompliance with the regulatory requirements under the HIPAA Rules against covered health care providers in connection with the good faith provision of telehealth during the COVID-19 nationwide public health emergency. At the state level and according to the DMHC, during the COVID-19 State of Emergency, a health plan may not exclude coverage for certain types of services or categories of services simply because the services are rendered via telehealth, if the enrollee’s provider, in his/her professional judgment, determines the services can be effectively delivered via telehealth. For example, a health plan may not categorically exclude coverage for Applied Behavioral Analysis services delivered via telehealth (video or telephone) during the State of Emergency. Likewise, during the COVID-19 State of Emergency a health plan may not place limits on covered services simply because the services are provided via telehealth if such limits would not apply if the services were provided in-person. For example, if a health plan allows an enrollee to receive a particular covered service up to three times per week if the enrollee receives the service in-person, the health plan may not limit the service to only once per week if the service is delivered via telehealth. Additionally, MCMC plans must take steps to allow members to obtain health care via telehealth when medically appropriate to do so. It is unknown to what extent providers are utilizing eConsults during the pandemic.

SUPPORT. 2020 Mom, co-sponsors of this bill, writes that this bill will provide support to frontline screening providers to initiate much-needed treatment for mothers and children with mental illnesses, so that California families can thrive. Maternal Mental Health Now, co-sponsors of this bill, states that this bill is critical during the pandemic, as children and mothers has become even more vulnerable to experiencing mental health issues. The California Hospital Association writes that currently, one in five women who are pregnant or have recently given birth suffer from depression, making it more common than diabetes during pregnancy. Depression is also the leading cause of disability worldwide among women of reproductive age, and maternal suicide accounts for 20% of postpartum deaths among depressed women. Raising awareness of behavioral health and promoting good health before pregnancy, as well as better screening for and treatment of postpartum depression, would strengthen hospitals’ efforts to ensure all moms and babies can receive the care they need, when they need it.

OPPOSITION. The California Chamber of Commerce (CCC) contends that this bill requires a psychiatric consultation program to be made available to providers and also mandates that the health plan and insurer psychiatrists be made accessible to providers during standard hours, including evenings and weekends. CCC writes that physicians determine whether a patient’s condition exceeds the scope of their practice and that it also falls within a physician’s clinical judgment (not the health plans) to determine if the patient’s condition requires the intervention of a specialist or separate provider, such as a psychiatrist or psychologist. 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. According to the California Association of Health Plans and Association of Life and Health Insurance Companies, the COVID-19 pandemic has only elevated how critical it is to maintain affordable premiums and not unnecessarily drive of that cost of care.

RELATED LEGISLATION.

AB 2164 (Rivas) establishes the E-Consult Services and Telehealth Assistance Program within DHCS. AB 2164 is pending in Assembly Health Committee.

AB 2624 (Aguiar-Curry) requires California’s Health and Human Services Agency to establish, develop, implement, and administer the Project ECHO (registered trademark) Grant Program, upon appropriation by the Legislature. AB 2624 is pending in Assembly Health Committee.

AB 3003 (Cervantes) requires the DPH to develop, and maintain on its website, a referral network of community-based mental health providers and support services addressing postpartum depression, prenatal delivery, and postpartum care to improve access to postpartum depression screening, referral, treatment, and support services in medically underserved areas, or areas with demonstrated need. AB 3003 is pending in Assembly Health Committee.

PREVIOUS LEGISLATION.

AB 1676 (Maienschein) of 2019 is substantially similar to this bill. AB 1676 was held in the Assembly Appropriations Committee.

AB 744 (Aguiar-Curry), Chapter 867, Statutes of 2019, requires health care contracts on or after January 1, 2021, to specify that the health plan or insurer is required to cover and reimburse diagnosis, consultation, or treatment delivered through telehealth on the same basis and to the same extent that the health plan or insurer is responsible for coverage and reimbursement for the same service provided through in-person diagnosis, consultation, or treatment. Updates other telehealth provisions in existing law.

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.

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. Requires, by July 1, 2019, a licensed health care practitioner who provides prenatal or postpartum care for a patient, to offer to screen or appropriately screen a mother for maternal mental health conditions.

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.

ACR 148 requests the California Maternal Mental Health Collaborative, a nonprofit organization, to establish a task force on the status of maternal mental health care.

POLICY COMMENT. 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. Thus, it is unclear if this bill will achieve the desired outcomes.

REGISTERED SUPPORT / OPPOSITION:

Support

2020 Mom (cosponsor)

Maternal Mental Health Now (cosponsor)

American Academy of Lactation Policy and Practice

American Academy of Pediatrics, California

American Association of Birth Centers, California Chapter

American Association of Birth Centers, National Office

American Congress of Obstetricians & Gynecologists - District IX

BLACK Wellness & Prosperity Center

CA Zero to Three

California Hospital Association

California Nurse-Midwives Association

California Pan - Ethnic Health Network

California Psychiatric Association

California Psychological Association

California Telehealth Policy Coalition

Every Mother Counts

First Five Butte County, Children & Families Commission

March of Dimes

Maternal and Child Health Access

MomsRising

Nurse - Family Partnership

Postpartum Health Alliance

Postpartum Support International

Return to Zero

Sisterweb

Society for Maternal-Fetal Medicine

Steinberg Institute

The California Children’s Trust

The Children’s Partnership

Opposition

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