Existing law establishes the Department of Health Care Access and Information, which is responsible for administering various programs with respect to health care professions and establishes various programs to facilitate the expansion of the health care workforce.

This bill would require a general acute care hospital to report report, annually and at the time and in the form requested by the department, certain information related to the types of specialties on the hospitals call panel to the department and would require the department to develop and maintain a searchable database of the reported information, as specified, and to make that database accessible to hospital staff.

Existing law establishes the Department of Health Care Access and Information, which is responsible for administering various programs with respect to health care professions and establishes various programs to facilitate the expansion of the health care workforce.

This bill would require a general acute care hospital to report certain information related to the specialties on the hospitals call panel to the department and would require the department to develop and maintain a searchable database of the reported information, as specified, and to make that database accessible to hospital staff.

Date of Hearing: April 24, 2024

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Buffy Wicks, Chair

ABPCA Bill Id:AB 2175

Author:(Lowenthal) – As Amended Ver:April 4, 2024

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

SUMMARY:

This bill requires a general acute care hospital (hospital) to report to the Department of Health Care Access and Information (HCAI) every type of specialty listed on the hospital’s call panel, whether each specialty is available seven days per week and 24 hours per day, and the telephone number for interfacility transfers. The bill also requires HCAI to develop and maintain a searchable database of hospitals by location and available specialties.

FISCAL EFFECT:

HCAI estimates costs of $1.97 million for fiscal year 2025-26, including $750,000 in consulting services, and $1.22 million for FY 2026-27 and ongoing (Health Data and Planning Fund). This estimate includes all aspects of creating the data and technical infrastructure to meet these new requirements, including the reporting system architecture, design, implementation, program management, business analysis, and maintenance and operations. HCAI states the new data collection and database program will require staff to engage stakeholders, oversee the program, develop regulations, conduct ongoing review, and provide technical support for data submitters and data users, which would require some type of authentication.

COMMENTS:

1. Purpose. The California Chapter of the American College of Emergency Physicians (California ACEP), sponsor of this bill, states the difficulty in transferring patients to other hospitals has been documented and exacerbates the problem of patient boarding, putting people at higher risk of complications. According to the author:

It has become increasingly difficult to transfer patients needing a higher level of care to other hospitals…Physicians and staff in the emergency department are spending valuable time calling surrounding hospitals, trying to find a hospital that may have an on-call specialist to treat a patient. Delays in transfers put patients at higher risk of complications and contribute to poorer health outcomes.

[This bill] will provide emergency physicians and staff with a valuable tool to help reduce the amount of time it takes to find a hospital that has on-call specialists to treat a patient needing a higher level of care.

1. Background.

Emergency Medical Treatment and Active Labor Act (EMTALA). The federal EMTALA requires the emergency department (ED) of any hospital that participates in Medicare to provide emergency screening and stabilization services without regard to the patient’s insurance status or ability to pay. State EMTALA imposes this requirement on any hospital that operates an ED. A hospital with an ED must also provide a list of on-call physicians available to provide stabilizing treatment after the initial medical screening. EMTALA further requires hospitals with specialized services, such as a burn unit, to accept patients needing those services, regardless of the patient's ability to pay or insurance status. When an ED contacts a hospital with specialized services to transfer a patient, the receiving hospital is not allowed to ask questions regarding insurance, and if a specialized facility has available beds and the ability to care for the patient, it must accept an appropriate transfer.

ED Crowding and Patient Boarding. ED crowding is a problem in the delivery of emergency care. When hospital occupancy is at or near capacity, patients may remain in the ED even after being admitted or placed into observation status, without being transferred to an inpatient or observation unit; this is ED patient boarding. There is evidence that patient boarding leads to increased patient morbidity and mortality for both intensive care and non-intensive care units, longer lengths of stay, and higher costs. Insufficient availability of inpatient beds can also lead to substantial loss of ED revenue.

Call Panels. EMTALA requires a hospital with a dedicated ED maintain a list of physicians who are on call to come to the hospital and provide treatment necessary to stabilize an individual with an emergency medical condition. California also requires an ED to maintain an on-call roster, or call panel. The on-call roster must meet the needs of emergency patients in accordance with the resources available to the hospital, including the availability of on-call physicians.

Specialty Services. A hospital may provide additional specialty services, as approved by CDPH. The Centers for Medicare and Medicaid Services (CMS) recommend hospitals “strive to provide adequate on-call coverage consistent with the services provided at the hospital and the resources the hospital has available, including the availability of specialists.” CMS does not require all of a hospital’s clinical specialties be listed on the call panel at all times, although state law requires on-call coverage in an ED for eight basic services required for licensure. On-call overage for other specialties represented on the hospital medical staff may be full-time or part-time.

Hospital Data Collected by HCAI. HCAI collects and discloses a variety of data on its website, including much of the information this bill requires.

1. Duplicative Requirement? The California Hospital Association (CHA) opposes this bill unless amended, stating the Department of Public Health issues each hospital a license that delineates every specialty and supplemental service it offers. In addition, hospitals annually provide to HCAI an inventory of all the services they provide. CHA notes they and the sponsors have been exploring whether the currently reported information could be used by HCAI to create the database, rather than having hospitals submit additional, duplicative information each year. CHA states it shares the goal of the author and sponsors to ensure that patients are transferred to an appropriate care setting as quickly as possible.
   

Analysis Prepared by: Allegra Kim / APPR. / (916) 319-2081

Date of Hearing: April 2, 2024

ASSEMBLY COMMITTEE ON HEALTH

Mia Bonta, Chair

ABPCA Bill Id:AB 2175 (

Author:(Lowenthal) – As Introduced Ver:February 7, 2024

SUBJECT: Hospital specialties database.

SUMMARY: Requires a general acute care hospital (GACH) to report all specialties listed on the GACH’s call panel to the Department of Health Care Access and Information (HCAI). Specifically, this bill:

1. Requires a GACH to report all of the following information to HCAI:
   1. All specialties listed on the hospital’s call panel;
   2. For each specialty, whether it is available seven days per week and 24 hours per day, or less than seven days per week and 24 hours per day; and,
   3. The telephone number to contact for inter-facility transfers.
      
2. Requires HCAI to develop and maintain a searchable database of GACHs by location and available specialties. Requires the database to be searchable by specialty and distance and to be accessible to hospital staff.
   

EXISTING LAW:

1. Establishes HCAI in the California Health and Human Services Agency to expand equitable access to quality, affordable health care for all Californians through resilient facilities, actionable information,  and the health workforce each community needs. [Health and Safety Code (HSC) §127000, et seq.]
   
2. Licenses and regulates hospitals, including GACHs, by the Department of Public Health (DPH). Permits GACHs, in addition to the basic services all hospitals are required to offer (medical, nursing, surgical, anesthesia, laboratory, radiology, pharmacy, and dietary services), to be approved by DPH to offer special services, including, among other services, an emergency department (ED). [Health and Safety Code [HSC] §1250 and §1255, et seq.]
   
3. Requires EDs, under the federal Emergency Medical Treatment and Active Labor Act (EMTALA) and also under similar provisions of state law (state EMTALA), to provide emergency screening and stabilization services without regard to the patient’s insurance status or ability to pay. Federal EMTALA imposes this requirement on any hospital that participates in Medicare. State EMTALA imposes this requirement on any hospital that operates an ED. [42 United States Code (USC) §1395dd; HSC §1317]
   
4. Requires GACHs with an ED, through federal and state regulations, to provide an on-call list of physicians available to provide stabilizing treatment after the initial medical screening described in 3) above. Requires hospitals providing basic 24-hour emergency services to provide on-call coverage for the basic services required for licensure, as described in 2) above. [42 USC § 489.20(r)(2); California Code of Regulations 70225(b), 70235(c), 70245(b), 70255(c), 70455(a)(3), 70413(l)(3) and (4), 70415(a)(3), 70577(d)(3), 70653(a)(4) and 71203(a)(1)(B)]
   
5. Requires hospitals to report various data sets to HCAI including, hospital patient discharge data, payment types and other financial data. [HSC § 128740]
   
6. Requires hospitals to prepare an annual equity report that includes an analysis of health status and access to care disparities for patients, measures from the Agency for Healthcare Research and Quality’s Quality Indicators, and pay data to the Department of Fair Employment and Housing. Requires HCAI to make all equity reports available on their website and annually prepare a report that includes a list of all hospitals that failed to submit equity reports. Authorizes HCAI to fine a hospital up to $5,000 for failure to submit and equity report. [HSC §127372 and 127374 (a)]

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

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, it has become increasingly difficult to transfer patients needing a higher level of care, to other hospitals. There is currently no database or source of information that lists what on-call specialists are available at any given hospital. Physicians and staff in the ED are spending valuable time, calling surrounding hospitals, trying to find a hospital that may have an on-call specialists to treat a patient. Delays in transfers put patients at higher risk of complications and contribute to poorer health outcomes. The author states that this bill will provide emergency physicians and staff with a valuable tool to help reduce the amount of time it takes to find a hospital that has on-call specialists to treat a patient needing a higher level of care. This bill requires the state to create a hospital capability database that is accessible to hospital staff and includes a contact number for inter-facility transfers, a list of specialties on the hospital’s physician call panel, and whether or not their services are available seven days a week. The author concludes that the database would be searchable by specialty and distance, making it faster for providers to identify the closest facility with the capability to care for their patient.
   
2. BACKGROUND.
   1. EMTALA. EMTALA was passed to address the problem of hospitals refusing to treat indigent, uninsured, or Medicaid patients, or “dumping” these patients by transferring them to county hospitals or other charity hospitals. Federal EMTALA obligates Medicare-participating hospitals that offer emergency services to provide a medical screening and treatment for an emergency medical condition, including active labor, regardless of an individual's ability to pay. State EMTALA imposes its obligation on any hospital that operates an ED, and has similar requirements to federal EMTALA. Hospitals are required to provide stabilizing treatment for patients with an emergency medical condition. A patient is “stabilized” when the patient’s medical condition is such that, within reasonable medical probability, no material deterioration of the patient’s condition is likely to result from the release or transfer of the patient. If a hospital is unable to stabilize a patient within its capability, then a patient is required to be transferred to an appropriate facility with the necessary specialized treatment services. Once a patient is stabilized, if the patient needs post-stabilization care, the hospital will typically seek more information about the medical history of the patient, including whether the patient has insurance.
   2. Transfers. EMTALA requires patients to be treated and stabilized: a hospital cannot refuse emergency care to patients based on their inability to pay, age, color, disability, ethnicity, immigration status, lack of insurance coverage, lack of pre-authorization, or national origin. EMTALA also requires hospitals with specialized services, such as a burn unit, to accept patients needing those services. This prevents specialized hospitals from refusing transfers based on the patient's ability to pay or insurance status. When an ED contacts a hospital with specialized services, they can ask no questions regarding insurance. If a specialized facility has the capacity (i.e, available beds and the ability to care for the patient), they cannot refuse an otherwise appropriate transfer. According to 2021 HCAI data, the most frequent transfers occur in patients with transplants and tracheostomies (13.4%), newborns and other neonates with conditions originating in the perinatal period (4.2%), patients with multiple significant trauma (4%), diseases of the circulatory system (2.9%), and, infectious and parasitic diseases (2.5%).
      
   3. ED crowding and patient boarding. ED crowding is a problem in the delivery of emergency care. In 2007, the Institute of Medicine (now the National Academy of Medicine) reported that between 1993 and 2003, the number of hospitals and hospital beds decreased, while the number of ED visits increased dramatically. More recently, the National Hospital Ambulatory Medical Care Survey evaluated ED characteristics for 2017, and reported 139 million visits with 10.4% requiring hospital admission. When hospital occupancy is at or near capacity, ED patient boarding occurs. Boarding is defined by the American College of Emergency Physicians as “a patient who remains in the ED after the patient has been admitted or placed into observation status at the facility, but has not been transferred to an inpatient or observation unit.”
      

According to a 2007 study in the Academic Emergency Medicine Journal, “The opportunity loss of boarding admitted patients in the ED,” boarding leads to increased patient morbidity and mortality for both intensive care and non-intensive care units, longer lengths of stay, and higher costs for the hospital. Insufficient availability of inpatient beds can also lead to loss of ED revenue estimated at millions of dollars.

• 1. “Call panels.” According to the 2018 edition of the California Hospital Association’s EMTALA Manual, under EMTALA, a hospital with a dedicated ED must maintain a list of physicians who are on call to come to the hospital and provide treatment necessary to stabilize an individual with an emergency medical condition (EMC). Some states, including California, also have licensing regulations requiring EDs to have on-call rosters. The on-call roster must meet the needs of emergency patients in accordance with the resources available to the hospital, including the availability of on-call physicians. The on-call physicians are considered resources available to a dedicated ED that must be used to provide emergency services for an individual who has or may have an EMC.
     
  2. Specialty services. As noted in Existing Law, above, hospitals may provide additional specialty services as approved by DPH. Periodically the Centers for Medicare and Medicaid Services (CMS) releases “interpretive guidelines,” written by CMS headquarters and sent to all state agency surveyors (such as DPH) to help them understand how to evaluate a hospital’s compliance with the Medicare/Medicaid Conditions of Participation, including the on-call requirements for specialty services.
     
     The Interpretive Guidelines state that hospitals “should strive to provide adequate on-call coverage consistent with the services provided at the hospital and the resources the hospital has available, including the availability of specialists. There is no requirement under the EMTALA regulations that all of the hospital’s clinical specialties be listed on the on-call roster at all times. CMS has explained that it has not set requirements on how frequently physicians are expected to provide on-call coverage. Therefore, except for the requirements under state law requiring on-call coverage in an ED for the eight basic services required for licensure, coverage for other specialties that are represented on the hospital medical staff may be full-time or part-time.
     

Under EMTALA, there are no fixed standards for part-time coverage, including the frequency of coverage by an individual physician (such as three to five days per month) or the periodicity of coverage (consecutive days, weekdays or weekends). These decisions are delegated to each hospital and its medical staff. However, the EMTALA regulations require a hospital to have written policies and procedures for handling emergency patients when a particular specialty is not available.

This bill will require hospitals to provide HCAI with information regarding the specialties listed on the hospital’s call panel, the hours of availability of each specialty, and a telephone number for hospitals to contact for inter-facility transfers.

f) Current Hospital Data Collected by HCAI. HCAI collects and discloses a variety of data, including financial and utilization information as well as hospital disclosures. These data are collected for a specific time period in arears and published on HCAIs’ website. The HCAI hospital utilization data includes:

• • 1. Hospital License Category and Type of Control (DPH source);
    2. Services Provided at the Hospital;
    3. Inpatient bed utilization rates (# of beds DPH source);
    4. Chemical Dependency Recovery Services (# of approved beds DPH source);
    5. Newborn Nursery Information;
    6. Number of GACH beds approved for Skilled Nursing care (DPH source);
    7. Acute Psychiatric Patients information including # of patients, ages, and primary payer;
    8. Whether the hospitals has:
       1. Short Doyle Contract Services;
       2. Inpatient hospice program;
       3. Palliative care program;
       4. EMSD Trauma Center Designation (EMSA source); and,
       5. Licensed ED Level (completed by HCAI from DPH source data).
    9. Types of services available on premises;
    10. ED Services;
    11. Number of Ambulance diversion hours that occurred at the ED each month;
    12. Types of Surgical Services (Inpatient or Outpatient);
    13. Types of Operating Rooms (Inpatient or Outpatient);
    14. Presence of ambulatory surgical program;
    15. Information about live births at the hospital;
    16. Information about cardiology and cardiovascular surgery services (DPH source);
    17. Distribution of surgeries performed in catheterization laboratory; and,
    18. Capital Expenditures.

This bill requires HCAI to develop and maintain a database with information provided by hospitals, much of which is currently being reported to HCAI.

1. SUPPORT. The California Chapter of the American College of Emergency Physicians (California ACEP), is the sponsor of this bill and states that when California ACEP surveyed their members in 2022 they found that “97% cited boarding times of more than 24 hours, 33% over one week, and 28% over 2 weeks,” as a major problem. The increased difficulty in transferring patients to other hospitals has been documented and is exacerbating boarding. Delays in transfers put people at higher risk of complications. California ACEP notes that the need to transfer patients occurs because not every hospital has every medical specialty available at all times. Thus, when a patient arrives in an ED, is assessed and treated by an emergency physician, some of them will need further care not available at that hospital. It might be a child requiring a pediatric Intensive Care Unit, or a patient requiring ophthalmology services, for example. Federal and state law prevent the transferring hospital from delaying care to get preauthorization of payment, and receiving hospitals are forbidden to consider ability to pay when accepting a patient. But, in order to accept the transfer, they must have the capability to treat the patient (e.g. have the necessary specialist) and have the capacity to treat the patient (an available bed). California ACEP concludes that our emergency care delivery system relies on this sharing of resources to save patient’s lives, however, unfortunately, while we all depend on this arrangement, there is in fact no governmental or non-governmental system to coordinate it or to ensure its robustness.
   
2. OPPOSE UNLESS AMENDED. The California Hospital Association (CHA) is opposed to this bill unless it is amended and states that currently DPH issues each hospital a license that delineates every specialty and supplemental service it offers. In addition, hospitals annually provide to HCAI an inventory of all the services they provide on HCAI’s Form 7401. CHA notes that they and the sponsors have been exploring whether the currently reported information could be used by HCAI to create the database, rather than having hospitals submit additional, duplicative information each year. CHA notes that it shares the goal of the author and sponsors to ensure that patients are transferred to an appropriate care setting as quickly as possible. However, hospitals should not be required to provide duplicative information to state agencies.
   
3. RELATED LEGISLATION.
   1. AB 1991 (Bonta) requires requires healing arts boards that regulate health care providers to require, rather than request, specified workforce data. AB 1991 is pending in the Assembly Business and Professions Committee.
   2. AB 3161 (Bonta) Requires DPH to collect self-reported patient demographics when receiving complaints regarding hospitals and long-term care facilities. Requires DPH to review, analyze, and publish trends among patient safety events in a manner consistent with patient privacy. Requires hospital patient safety plans to include specified methods to address racism and discrimination in health care, including procedures for staff to anonymously report instances of racial bias. Requires DPH to publicly publish hospital patient safety plans. Establishes a partnership between DPH, the California Department of Civil Rights (DCR), and Department of Justice (DOJ) to share data on racial bias in health care specific to patient adverse events. AB 3161 is pending in Assembly Health Committee.
4. PREVIOUS LEGISLATION.
   1. SB 363 (Eggman) of 2023 would have required the Department of Health Care Services, in consultation with DPH and the California Department of Social Services, to develop a real-time, internet-based database, to be operational by January 1, 2026, to collect, aggregate, and display information about beds in specified facilities to identify the availability of inpatient and residential mental health or substance use disorder treatment. SB 363 was held in the Assembly Appropriations Committee.
   2. AB 1204 (Wicks), Chapter 751, Statutes of 2021, requires hospitals to prepare an annual equity report that includes an analysis of health status and access to care disparities for patients, measures from the Agency for Healthcare Research and Quality’s Quality Indicators, and pay data to the Department of Fair Employment and Housing. Requires HCAI to make all equity reports available on their website and annually prepare a report that includes a list of all hospitals that failed to submit equity reports.
5. SUGGESTED AMENDMENTS.
   1. In order to ensure that hospitals provide a telephone number to contact for inter-facility transfers, the author is proposing the following clarifying amendment:
      
      (b) The department shall develop and maintain a searchable database of hospitals by location and available specialties information required in (a). The database shall be searchable by specialty and distance and shall be accessible to hospital staff.
   2. As currently drafted the bill requires hospitals to report what specialty providers are available on call. This requirement may raise privacy implications for providers, especially those performing sensitive procedures, about potentially having their name or contact information available to the public. The Committee may wish to amend this bill to clarify that hospitals only need to provide the information by specialist type, not by the individuals’ name.
   3. As currently drafted this bill does not include a required timeframe for hospitals to report the requested data to HCAI. The Committee may wish to amend this bill to require hospitals to report the data on an annual basis, at the time and manner requested by HCAI. This amendment will clarify that the data base does not have to operate in “real time.”
      
6. POLICY COMMENT. As noted by CHA, this bill may require hospitals to provide HCAI with duplicative data sets. Moving forward, the author may wish to work with HCAI and CHA to identify the data currently housed within HCAI that could be used to develop the requested database.
   
   

REGISTERED SUPPORT / OPPOSITION:

Support

California Chapter of the American College of Emergency Physicians (sponsor)

Opposition

None on file.

Analysis Prepared by: Lara Flynn / HEALTH / (916) 319-2097