Assembly Standing Committee on Health

Good afternoon. We'll go ahead and call to order the Assembly Health Committee meeting and encourage members of the committee to make their way down here. But since we do have representation on the committee, we have enough to go ahead and get started today. So thank you very much for being here. Before we begin, I'd like to make a statement about providing testimony at this hearing.

We seek to protect the rights of all who participate in the legislative process so that we can have effective deliberation on critical issues facing California. All witnesses will be testifying in person. We will allow two main witnesses for a maximum of three minutes each. Additional testimony will also be in person and limited to name, position, and organization if you represent one. All testimony comments are limited to the bill at hand. We do have bills proposed for consent today.

Any member of the committee may remove a bill from consent. The proposed consent calendar is item number two, AB 289, by Assemblymember Holden. Item number three, AB 385, by Assemblymember Ta. Item number five, AB 387, by Assemblymember Aguiar-Curry. Item number eight, AB 283 by Assemblymember Jim Patterson. Item number nine, AB 512, by Vice Chair Ms. Waldron, with amendments. We have a substitute today. Assemblymember Tom Lackey will replace Assemblymember Vince Fong for today's hearing.

We will be voting to adopt 2023-24 session rules, committee rules today. A copy of the rules has been provided to all members of the committee. New staff, we have a new staff member with the Assembly Health Committee. I'm pleased to announce that the Assembly Health Committee has a new consultant handling the Medi-Cal portfolio. Please help me welcome Lisa Murawski, who's come back to the Assembly. We're happy to have her. Welcome, Lisa. And we'll be seeing a lot more of her in the future.

We do not have a quorum, so we won't be able to vote on anything. But we can entertain a bill if we had an author, which we don't, except for me, and I think we'll wait on my bill. I'd say have a cup of coffee, but we can't offer that. As soon as we have an author, we'll get going. Thank you. Mr. Holden, whenever you're ready, sir. We're all in our places here with bright, shiny faces. I'm sorry. Whenever you're ready. Thanks.

Thank you, Mr. Chair. Members of the committee, I appreciate the opportunity to present Assembly Bill 236. Achieving health care for all has been a longtime goal of both California and the nation as a whole. In 2010, we took an important step toward that goal with the enactment of the Affordable Health Care Act. In 2015, California went one step further with SB 137, which created some of the strongest standards for health plans in the nation.

Despite this, we're still seeing health plans maintain inaccurate provider referral directories, a practice that restricts consumer access to promised healthcare services. These inaccuracies list are often referred to as ghost networks because they do not actually exist. For consumers, ghost networks means spending hours contacting dozens of healthcare providers referred to them by their insurance, only to be met with providers that are no longer accepting new patients, no longer accepting the patient's insurance, or sometimes even no longer in practice.

The struggle of navigating these complicated networks predominantly affects communities of color, those with disabilities, and those who may not have English as their first language. The issue here is not the quality or the cost of care, but the actual access. In an effort to eliminate these ghost networks and address rampant directory inaccuracies, AB 236 defines clear benchmarks and accuracy guidelines. This bill also establishes enforcement guidelines and administrative penalties which are given in the event a benchmark is not met or an inaccurate provider listing is found.

These standards will help ensure compliance with existing regulations and, more importantly, help Californians get the care that has been promised to them. Here with me to testify in support of AB 236 is Jose Torres Cassillas from Health Access California and Sarah Soroken, a licensed marriage and family therapist with Solano County Behavioral Health.

Thank you. As a mental health clinician, I have seen firsthand how inaccurate provider directories harm patients. In my six years as a triage and crisis therapist at Kaiser, it was a rare day that I did not speak to at least one patient reporting they called through lists of providers to initiate individual psychotherapy. The providers either did not call them back or weren't available. All the while, their mental health condition had worsened.

At Kaiser, the main option for weekly individual psychotherapies for conditions needing more than a brief duration of treatment is through a referral to the Beacon provider network, recently renamed Carelon. The triage and crisis team I belong to at Kaiser came to expect daily calls from patients unable to find an available therapist in the Carelon network. These were patients experiencing conditions such as depression, anxiety, and bereavement.

They were expected to call through the provider list of 2550 or more in an attempt to get connected to treatment, even though their symptoms made doing so extremely challenging. As an example of a tragic outcome patients can face from these ghost networks, I evaluated a patient in the emergency department who had attempted suicide after calling through a list of 50 providers. Most of the providers did not call the patient back, and the ones who did were unavailable.

The patient lost hope, gave up, and spiraled deeper into depression. This patient now has the trauma of a suicide attempt to add to their treatment needs. When I worked at UCLA's student counseling center, we spent valuable time that could have been used to provide assessment or treatment to students, calling through lists of therapists on the Anthem provider directory in order to create a more accurate list, we could give students to increase the likelihood of them getting connected to the psychotherapy treatment they needed.

Patients who need services in languages other than English or culturally competent care and children have faced particular difficulties finding a therapist available to meet their needs on these provider networks. Patients who have means end up paying out of pocket for psychotherapy when they cannot find an available provider covered by their insurance, leaving those unable to afford private pay left without treatment. This is, in effect, a two-tier system of health care.

We would be negligent if we didn't do everything in our power to ensure patients get the health care they need and pay for. AB 236 will hold health insurance companies accountable for the accuracy of their provider network lists, and this will improve access to care.

Great. Thank you very much. Next witness.

All right, good afternoon, Chair and members. Jose Torres with Health Access California, the statewide healthcare consumer advocacy coalition. I'm here today as a sponsor and supporter of AB 236, which would address the inaccuracies within provider directories. Current law requires that health plans maintain an updated list of in-network providers for their enrollees. These directories include doctors, mental health professionals, hospitals, labs, and imaging centers, just to name a few examples.

The information required under current law is pretty basic, name, phone number, address, languages spoken, and consumers rely on these directories to find an in-network provider in order to receive necessary care. However, current law does not require that the directories be accurate, and due to such inaccuracies in these directories, consumers will call dozens of providers seeking care.

The story that Sarah just mentioned or that shared with us about a patient calling 50 providers and losing hope and giving up, that is unfortunately way too common for consumers. As such, consumers may delay seeking necessary care or may decide to seek care out of network and pay high prices for out-of-network care even though they have insurance. These inaccuracies have the greatest impact on consumers who face the worst access, people with limited English proficiency, people with disabilities, and others in marginalized communities.

Health plans may say that they have been investing into their directories, but yet provider directories continue to have significant number of inaccuracies, and studies have shown that major health plans will have a range of inaccuracies, between 20% to 30% for primary care and specialty care providers. But then when you look at mental health providers, the inaccuracy percentages skyrocket and are even higher. And that is how you get consumers like the patient Sarah mentioned having to call 50 providers just to seek care.

AB 236 will help address the issue of inaccuracies by creating specific benchmarks that plans have to reach in terms of accuracy. It will require that plans audit their directories using the standards set by DMHC and that only the proper in-network providers with their accurate information be listed. Otherwise, the plan would face a financial penalty. It is time that health insurers are held accountable for provider directories. I thank you for your time and ask that you support AB 236 here today.

Thank you very much. Others in support please come forward. And just your name. Obviously, you have a support position in any organization if you represent one good afternoon.

Andrea Rivera on behalf of the California Pan-Ethnic Health Network, in support.

Thank you.

Chair and members, Autumn Ogden Smith with the American Cancer Society Cancer Action Network, also in support.

Thank you.

Good afternoon. Yasmin Peled, on behalf of Justice and Aging, in support.

Thank you.

Maxine Mantell on behalf of the National Multiple Sclerosis Society, in support.

Thank you. And now we will ask for witnesses in opposition. Please come forward. You can come up and sit down if you want. Have a seat anyway.

Thank you. Mr. Chair and members, Nick Louizos on behalf of the California Association of Health Plans. Regrettably, we are here in opposition to Assembly Bill 236, which would establish new and onerous accuracy deadlines, penalties, and other requirements for health plan provider directories. While our members do appreciate the intent of this bill, and we do share the author's concern about the accuracy of provider directories, this bill is unfortunately unwarranted, overly punitive, and ignores the shared responsibility component between providers and plans in developing these directories.

On this last point, members, health plans must list at least 13 pieces of information on the provider directory, almost all of which must be derived directly from the providers. Health plans are also required to check the directories for accuracy every 90 days at a minimum, sometimes more frequently. And in developing and maintaining these directories, our plans reach out to our contract providers via email, telephone, and fax, if they still use a fax, to survey the accuracy of the information we have listed.

If these outreach attempts are not responded to, we have no way of knowing if the provider's information is up to date. So just to restate if the health plans do not receive the information that's necessary to build the provider directory in an accurate or timely manner, then we cannot update them accordingly. Unfortunately, we don't believe this bill considers the shared responsibility component that's necessary here.

Instead, it solely punishes the health plan with enormous financial penalties when provider directories fail to meet accuracy thresholds, even when a provider fails to disclose the necessary information. And we believe that this enforcement mechanism is unnecessarily punitive and fundamentally unfair to our members, and it will not lead to more accurate provider directories. It is also important to note that much work is currently being done to improve the accuracy of the directories, including the health plans continued work with regulators and others in a stakeholder process around SB 137.

The original provider directory bill and the regulations are actually still in development on that, the final regulations. Health plans are also intricately involved with IHA and Symphony, which maintains a plan-funded, single-source database to better receive provider data. And the qualified health plans that participate at Covered California are required via contract to participate in this database. Health plans are also deeply involved in implementing new federal laws around this area.

The No Surprise Act at the federal level has new provider directory requirements and other recent federal action as well. So our member plans are dedicated to have a conversation, and they've already dedicated substantial time and resources towards this effort to try to address the issues that are outlined in this bill. And we remain committed to finding ways. We just don't believe that this particular bill is a solution and we can't do this alone. We need others to be at the table to resolve this issue, and for these reasons, we're opposed to AB 236. Thank you.

Thank you very much. And before you go, we have a quorum, and it's always tenuous, so we'd like to take roll so we can conduct our business. So, Madam Secretary, please call the roll.

[Roll Call]

Good afternoon. Christy Weiss, on behalf of the California Association of Dental Plans, also here in opposition. We share a lot of the concerns expressed by CAP, I think, in the dental space. Obviously the plans want to offer complete networks. They want their members to be able to accurate information, and the plans work very hard, very diligently with the providers to make sure that accurate information is available.

Obviously we need to have a larger conversation here about the provider's role in submitting that information back to the plans, and we look forward to having that conversation. On the dental side, I think that one of the biggest concerns for our plans is that dental is different. We talk about that a lot in this committee and for dental networks. Oftentimes they will have a specialty dental provider who may not see very many patients a year.

The language in the bill would have the effect of, in many cases, the plans would have to remove those providers from the network when they don't see, I think the threshold is five cases a year, and that's perfectly appropriate in some cases, depending on what their specialty is. So our client has submitted a number of, raised a number of technical issues which are outlined in our letter, and we appreciate the committee, including those in the analysis.

We think kind of writ large we all share the same goal, but the language in the bill is too far, it is too overreaching, and for those reasons, we are opposed. Thank you.

Thank you very much. Others in opposition? Just your name and organization. If you represent one.

Mr. Chair and members, Stephanie Watkins, on behalf of the Association of California Life and Health Insurance Companies, also regrettably opposed.

Thank you.

Good afternoon chair and members. Stephanie Morwell, on behalf of America's Health Insurance Plans, in opposition.

Thank you. See no one else. We'll bring it back to the committee. Questions or comments? Dr. Weber?

Thank you, Mr. Chair. Thank you, Assemblymember Holden and those of you who testify today, I have a lot of questions and a lot of concerns about this particular bill, but my first question will be to Assemblymember Holden. We just heard that there are different processes in place. They are already checking the directory, I think you said every 90 days.

And considering the fact that this is a shared partnership between the insurance companies and the providers, how exactly is this going to change since they already have a process in place to evaluate their directory?

I appreciate the representation of what efforts are underway to monitor and to change and to keep the directory up to speed. I think what we've noticed and what we've gathered is that it's the consumer who is going through this process of trying to find a provider who will be able to meet their needs and are having a hard time finding accuracy in this directory. So I'm kind of looking at it from a consumer lens, if you will.

I'm looking at it from the standpoint that, and I'm not going to say that all of the work that's being done is in some form of good faith in trying to figure out how to keep the directory accurate. But if you have consumers who are the ones who are falling through the cracks on this process, then something's not happening in the way that it should. The relationship between the plans and the providers. Yeah, it should work, but it obviously isn't.

There would not be a need for this bill or certainly this conversation if it were. The inaccuracies are of not just small proportion, it's rather large in discrepancy in terms of how inaccurate the lists are. And so it rises to a level of kind of not just a yellow light but a red light as it relates to consumers and their concern and how do we fix it from their vantage point?

And again, if this is a process that they normally go through, I'm not going to debate the process itself, but it just isn't working right.

I guess my question is it's a partnership, right? So if they are asking for this but they're not getting it back, but then they're going to be held financially liable, how does it improve the direct, like, how does this Bill improve it since it's a partnership?

Well, let's take it from the standpoint that this bill doesn't exist. And if you're a provider and you're reaching out to your partner and your partner is not getting back to you, or you're finding that there's something happening here that would suggest that if you're having a hard time connecting with them, what do you think the consumer is having on the other end? So then what do you do to remedy that? What becomes a common sense next step?

If you find yourself working with a partner that isn't either providing accurate information because you can't get a hold of them or there's some other issue that obviously the consumers, they would be getting the same reaction, if you will, and then I would look to the providers and the plans to then take an affirmative action to then say, we've tried, we need to take them off.

Because obviously this is someone who, if a consumer is looking to connect with a physician and they are having a hard time making that work, then, whether intended or not, the burden shifts back to them. So I would just say that the partnership either will work because there's contact and mutual communication, or if it doesn't, then they have to take the affirmative action, saying, we just need to take them off the list.

And just out of curiosity, have you brought the other piece of this partnership to the table to have a discussion with all parties involved to see how a system could be created that does actually produce an accurate directory?

We have just dealt with the fact that there's a need. I'm sure there's been some reach out to some degree, but the focus that we see and have seen kind of historically in these type of situations, and certainly we can talk about what is the appropriate level of a fine, but there needs to be a recognition that we would have to then go through the same list and start identifying who can come in and who can be a part of that conversation.

If the partnership exists with the plans, then I would also look to them to maybe say, hey, let's bring in some of our partners to be a part of that conversation, and maybe that is something that can happen. But I would also look to the plans to be the ones to sort of identify who they are and then help us answer the question by those partners coming to the table together. We shouldn't necessarily have to go out and identify each person when we already know.

It's a challenge to identify them based on what we're hearing from those who are.

Well, when I say the partners, the partners are the providers.

And I think we know how to reach out to those different groups to say, hey, the people who you represent are not responding to the surveys. I'm not even sure who exactly gets the surveys. If it's a large institution, does it go to that institution? If it's a smaller practitioner, does it go to that smaller practitioner? But I think we know how to reach out to the people that represent the medical providers to say, hey, this is an issue.

Correct.

How can we work together to fix it? My other question is about the deletion of providers if they have not paid claims. When you were speaking about some specialized dentist, it really hit with me as a specialist, right. Especially being here in Sacramento. I may not necessarily. Well, I'm not seeing as many patients as I saw before I came here, but that doesn't mean that I'm not still seeing patients and that I'm not still providing that care to the people in my area.

And so if I have seen four patients within a year, submitted four claims because I'm not seeing as many patients because I'm here, then I'm essentially removed from that provider directory. So when someone is looking for a PDG, I'm removed because I only saw four last year or provided four claims. I do find that problematic. Additionally, I think we all know that oftentimes providers will still have relationships and contacts with patients even if they're not submitting a bill.

You send messages all the time via electronic medical records. Or if you have other relationships, you may text and say, hey, I need a refill on this or this or that. So I do find that also very problematic. So I have a question for the insurance team, medical insurance team. So if a provider is removed from your list, how do they get back on?

Thank you, Assemblymember Weber. There's both state and federal law on this issue, and so under the current federal law, if I'm not mistaken, a plan may suppress a provider from their directory under certain circumstances. And I believe the one that you're raising is one of those circumstances. And then there's a period of time where the provider can furnish the appropriate information, and once that is established, they can be let back onto the provider directory.

Do you know what that time frame is? Is it like six months? A year?

I'd have to look that up. I don't know, off the top of my head.

And then if a provider is removed from the directory, are they informed?

I believe so, yeah. I was actually looking at some health plan policy pamphlets on the No Surprise Act and other recent federal actions, and there is a process in place. They'll have practice profile kind of data requests out to the providers that the providers can respond. Yeah.

If I may, just one comment to add. Nick is referring to the federal No Surprises Act, which apparently does not include dental. So there's actually not that same paradigm at the federal level, which is one of our concerns with this bill. This bill would create a process to suppress providers, but I don't believe that the dental plans have that same process outlined at the federal level to reinstate providers.

Really? Wait, so there's no process to reinstate them?

There is a process. However, the federal No Surprises Act, which is what Nick was referring to at the federal level, does not include dental plans. It only includes medical plans. So that's another place where the language in this bill is misaligned with the federal.

So you're saying that a dental provider can be removed from the plan.

Under this bill if you don't do your five claims.

Right, and he or she may or may not be informed?

I would need to check with the dental plans and find out kind of what their process would be. But as the plans were reviewing the bill, one thing that did come up is that because dental is treated a little bit differently, the federal law applies to medical plans, but not medical and dental. This bill would apply to medical and dental.

Okay. All right. And so there may not be a waiting period or whatever for them to respond. That's what you're saying.

It's probably a plan by plan process.

Assemblymember Weber, if I may add, also on this, so on the removal of providers. So there is specific provisions within the Bill to address. We did take into consideration rural providers who may not see patients as frequently, as well as specialists who may not see patients as frequently.

So there is a specific provision to allow those to stay on, and also with guidance being created with DMHC, that would create that specific guidance for these individuals, for these providers to be able to stay on the directory without being removed.

So would a provider have to take on that responsibility of actually filling something out and saying, that's what I would want, or how would that work?

So this would be up to the regulation that would be created under DMHC, but specifically within current law. There has been mentioned that providers can be removed already. This just goes to show that there is a special relationship between providers and health plans. And one of the biggest issues is that there has not been enforcement on provider directories as much as there should have been since the passage of the original bill.

It goes to show that the enforcement standards have just been inadequate and because they have been infrequent. This is why this bill is up today. This is why this bill is up today, so that we can address that consumers do not have to keep calling 50 different providers just to seek care. Right.

And we understand that there is a relationship between the providers and the health plans, and as such, have taken into consideration the special circumstances that may arise within specialty care, as well as providers that live are in a rural area that may not see patients as frequently.

Okay, thank you for that. And like I said, I'm very concerned about this bill. It's early, so we have time to continue the discussions and hopefully improve it before, if it hits the floor, and when it hits the floor, and for that reason only, I will be supporting it today. But I do think that, as written, I don't see how it's actually going to help the problem.

It is an issue, especially in the area of mental health and we discussed this in the behavioral health hearing that we had. There's just an issue with mental health providers or behavioral health providers taking any insurance, and most of them don't. And even if they're listed and even if the person can get reimbursed because it's just so much of a hassle, they put it on the patient themselves, the patient still has to come out of pocket, get that receipt and provide it to the insurance company.

And so there's a lot that we need to do in the areas of mental health. I did note that both of what you all were referring to really specifically address that, and we do need to fix that for everyone, and we need to fix our provider directory. I'm not sure if this is the way, but I think it's a good conversation to start having. Thank you, Assembly Member.

Thank you, Dr. Weber. Mr. Santiago.

Sure. And I'll make my comments. Think I support the bill, and I think that what you're trying to do is the right thing to do, make sure that all the directories are up to date, because that's important. I don't need an answer right now. But as you're moving forward, just if you could contemplate maybe some, I hate to use the word, but provider responsibility to make sure that the directories are up to date as much as possible.

I've worked with you on legislation before, so I have every confidence that you'll get there. And if some thought put to that as you move down the line, I think it would greatly appreciate and I do plan to support today. Thank you.

Ms. Aguiar-Curry.

Thank you, assemblymen, for bringing it. Know the plans have said that their inaccuracies are not fully in their control and that the bill's requirements will result in rural communities being left behind. What do you think of that complaint? Have you heard that complaint? Because you know me, I'm going to guard my rural communities.

As well you should. No, I think we've recognized that in terms of the rural communities, that there has to be some recognition of how we can make sure that this is providing the right kind of consumer benefits, but at the same time not doing anything that's going to undermine the services. I'm going to let my sponsor have a little bit of a comment on this, but I do hear what you're saying, and we're making sure that that area is covered as well. Of course.

And as mentioned, this was taken into consideration, especially within areas that are more rural that rural providers do not see as frequent patients. What's in consideration. We want to make sure that there is specific guidance created from DMHC and want to make sure that rural providers are still protected and kept on their directories through the guidance created by DMHC. But again, at the end of the day, we'll add on and say that we've been kicking the can down the road.

So who is ultimately know we keep throwing blame around one another, but consumers are being the most affected, both rural, urban and throughout California where we are facing and having individuals call so many providers just to find someone to take care of them. Right. As my colleague here mentioned, Hashi had the patient call 50 providers in San Diego last year. There was a story on the Washington Post about an individual who was seeking care and had to call 75 providers. Right.

And ultimately, at the end of the day, if we're going to do something on provider inaccuracies, we have to start somewhere. And this is a start to create a better incentive than what is currently being done, because what's currently being done on the incentives currently is not working.

Well, I just want to make it one more comment.

Sure.

Thank you. I mean, there's definitely a problem. How you get there, I don't know. But as we continue with this bill, and I'll support your bill today, if you continue to work on my rural communities, can't let them continue to be left behind. I don't need additional costs to them. I just want to make sure that we are not forgotten. So thank you very much for bringing it forward.

Mr. Lackey.

Yeah, thank you, Mr. Chair. I do appreciate really genuinely what you're trying to do here. And I believe it's an issue that needs to be addressed in a very serious way, including improving access to care in my district, as been indicated, it's also very, very rural, so people have to drive a long way to get to the doctor's office. And when that information is inaccurate, it creates quite a difficult circumstance for those people. And so I think that they do deserve accurate information.

But here's my frustrations. I don't believe that penalties seem to be the right answer. There are many moving parts with this complicated issue, but it seems like fines could actually make it more difficult and actually add gasoline to the fire. And I don't see how they ensure accuracy of information. And I'm hoping that you'll be able to work with the plans here to build some consensus, because I don't believe anybody's happy with the current status of the way things actually are.

If I could just ask the question to somebody on that panel, help me understand how finding these health plans large amounts of money actually leads to more accurate provider directory information. I'm trying to understand it. I don't understand it.

No, of course. Thank you so much for the question. So as been mentioned, California does have some of the strongest laws when it comes to provider directories. However, the compliance is at a very low level, partially due to the ineffective enforcement standards that are currently in place. So with these penalties, that would work as a better incentive than what's in place and understanding that there is a special relationship between health plans and providers.

So with the penalties affecting the health plans, there's also the connection to the provider where under current statute, providers can be removed. But with this Bill as well, if the provider does not provide accurate information, they can also be removed. So understanding that there is that special relationship between provider and health plan, but ultimately the buck stops with the health plans as they are the ones that are maintaining the provider directories.

Okay. I'd like to let the plans respond to that.

Yeah. Thank you, Assemblymember Lackey, for that mean. If the challenge is getting more accurate and timely information from the mean, we agree with mean, we fail to see how fines will magically lead to the receipt of this information from the providers. I have to say that we're still working with the department. The department's currently working on, department managed healthcare is currently working on informal rule making and is in the final stages of development.

Once at a certain point in the process, they're going to begin a pre notice stakeholder process with various folks, and draft regulations will be released, we believe, in May. And following the review of stakeholder comments, the departments could potentially revise the regulations and then move to formal rulemaking. All of which is to say, a lot of this is very premature. I mean, there's still a lot of work being done to make sure this process works at its highest possible level.

And with your indulgence, I just wanted to say back to Assemblymember Weber's comments about this suppression of providers on the don't we don't think that's a good consumer or a pro consumer solution to this information, to this situation. Even though the plans are allowed to do that, it's not a great option because it leads to a provider directory that's less reflective of the plan's provider network. And so I think there's an internal logic problem with this Bill and with the fines issue that you're raised.

Okay, well, thank you, Assembly Member. I know that you're a very skilled Legislator, very experienced one. And so I have confidence that you're going to be able to work with these other individuals. But in its current form, I'm going to be abstaining today and I hope to be able to support this on the floor when it gets there in its newer form. Thank you.

Thank you. Just a question for the proponent witnesses, if you don't mind, Assembly Member. I don't think you're suggesting that the health plans don't want to have updated information, are you?

Mr. Patterson.

No, they absolutely do. What this bill would do is just create a stronger incentive to actually create it would be provide a better incentive than what's currently being done in the current process. That's all.

All right. So just to, during the, everything was shut down for a while, we were looking for a mental health provider for a while and we did use directories and we're looking for, and we would call the providers on there. And I think there were some circumstances where for whatever reason, hours were changed and things like that.

But what I actually found calling through is that some of the providers, and maybe it's in this particular case, the one we ended up choosing, actually didn't seem to have a particular interest in having up to date information, wasn't really a priority of hers. She was pretty busy already. So if she's not making the effort, I just wonder why penalize the plans if she really didn't have an interest in updating it?

And so I'm curious what the plans, I mean, we talked about this a little bit, but what do you do right now to just high level to verify this information?

Right. So thank you. Obviously, we're complying with SB 137, which is the baseline law that was established in the State of California on provider directories.

As part of that process, at least every 90 days, there are some instances where the plan has to do weekly reviews of the directory, but at least every 90 days we're reaching back out to providers to verify information. We do the initial sweep to get the information from the providers and we're counting on that information to be accurate for the directory.

The plans currently are also working at the Covered California level with an entity called Symphony, which is intended to be a single source provider directory database that is currently receiving participation not only from the plans, but provider groups as well. So they're hoping that single source database will be something that folks can retrieve data from and try to reduce the administrative barrier on both plans and providers. So that is something that is launching this year.

So another reason why this bill is premature so yeah, so reaching out to providers on at least 13 pieces of information we need from the providers, the 90 day follow up requests and we ask providers to verify their data through, as I stated before, practice profile attestations, roster submissions and other sources of data, again, at least every 90 days. A lot of work being done.

Well, thanks. And I don't know if this information is really attainable, but it would be interesting to know what response levels are on that if you have it. I would love.

Yeah, if I may, Assembly Member, I appreciate it. I think there's not only a challenge of constructing the directories, I think measuring the accuracy of the directories is also a challenge and I want to take this opportunity here.

Some of the data that's been submitted by the sponsors is a bit dated, certainly prior to the eventual implementation of the single source database that Covered California and other standardized pieces of information that have come along the way throughout the years. So we have to say that also like telephone surveys and cold calling, doctor's office isn't always the greatest and most scientific way of establishing the accuracy of the directory because you don't know who's answering the phone and what they know, et cetera.

Maybe comparing composite data from various sources to make sure everything's accurate could be part of the equation as well. I think there's more work that could be done not only in constructing the database in an accurate manner, but even measuring it.

And I know we have administrative workload that has been put onto the providers, just generally speaking, over time. And I think personally I want to see a more accurate provider database.

Like I mentioned, we were sort of going through this process and I'm sincere in saying that I share that goal, in doing it. And I do think the penalty side of it when it seems like there's an existing process out there to get this information, and I'm not sure the health plans have the entire blame here and there's multiple parties. So if there's some way I can work on this in the future, it seems like we have much better experts in this space than me.

It's something I'm really interested in working on, sincerely, but I think right now it is a tough one for me to support. But I really appreciate you bringing it and hopefully consider, I know that hopefully the plans will work as well. I'm sure they will, and come up to a solution.

Any other members see, no one else bring it to myself. And I have some comments.

Actually more than anything I will say that when I was practicing dentistry, there were some specialty plans that I may only have seen one or two patients a year. I did some workers comp cases, and that was maybe one or two cases every couple of years for different carriers and a variety of other kinds of plans. Maybe that's not just a rural issue, maybe it's an urban issue as well. I suspect it is. And so I would hope that you continue working.

Obviously, the dental plans, I know this is a concern for them. It's probably a concern for others as well, just in general, too. Just because you take an insurance plan doesn't mean you're a contracted provider. I would hope that providers that are actually signing contracts know what plans they have signed for.

But I also found over the years that I was a contracted provider for one company, only to find out that somehow that meant I was a contracted provider for other companies, which I think is problematic. Maybe that's something more in dentistry than not in medicine, but I'm not so sure about that. I guess I go back to, yes, there is administrative burdens with everybody and every business, but I do believe that the providers should have some skin in the game on this.

They should have some responsibility for this as well. After all, they do hopefully want patients from the plans that they are providers for. So why they're not submitting information is frustrating at best, and challenging. I will go back to, and I'm going to ask Mr. Louizos in a moment about something, and I can't even read my writing here on this. This is scary.

But one of the things that I see, and we've talked about this internally in our office, is that, gosh, if we had a unified single database, a health information exchange, wouldn't that be a wonderful thing? Because then we could actually get access to this information. Providers could actually go to a single source and actually find out what plans they are covered by. Maybe there could even be a single kind of application form that people could submit and all be uniform.

Because I'm going to guess, and I don't even need to guess, I know that every insurance plan is going to have their own format for how they ask for the information. And we get countless pieces of mail in the practice in a day, and sometimes it looks pretty innocuous, and those innocuous things go to the bottom of the pile, quite frankly. So I do think it's warranted.

I think, obviously I'm going to support your bill today, but I would hope that as you go forward, there can be additional conversations going forward there. I want to go back and a history lesson, because I didn't know this myself. The genesis for SB 137, which we're talking about, came from Covered California. They went to Dr. Then Ed Hernandez in the Senate said, hey, we're having a hard time figuring out who contracted providers are. And that's where this started.

So it's disturbing to me to hear that we're still in a rulemaking process with the Department of Managed Healthcare. That was 2015. We ate almost eight years ago, and we're still in the rulemaking process. So it's hard for the plans to know exactly what the rules are because. Am I correct, Mr. Louizos?

Yeah, I talked to my legal and regulatory affairs people today about that, and I believe so. Now, that doesn't mean there hasn't been work done at the regulatory level, but there's still. It's not final. Yeah, it's not complete yet.

Right? Yeah. So we're here. Yeah, no, and I appreciate that, but we're seven plus years into the process with state government in the rule making process, that's not complete. So there are obviously challenges there. That's a fair.

Yeah, I believe so. I wasn't meant to be overly critical of the department, but one of the good things about where we're at is that there will be stakeholder comments and a process as a part of them winding down. On the regulatory side, I'll take that as an opportunity to say that maybe this is an issue that requires a meta legislative solution as opposed to something that we believe is kind of a hammer and a pretty big one and unnecessary one.

Thank you. I appreciate that perspective.

Any other questions or comments, we'll go ahead and bring it back. Looking actually first. But before we ask for a motion and give you an opportunity to close, Mr. Holden, you have amendments before us and you're accepting. Okay. So when there is a motion, it will be do passes as amended. But I'm going to ask Mr. Holden to close if you'd like.

Thank you, Mr. Chair.

Let me just say that if you're someone at home watching this proceeding today, and you have been trying to work through a directory, you're going to end up at the end of this day, more confused than you were when you started and when you have a plan and providers that say they work in partnership, but then they don't really know who's on first and who's on second, there's kind of an understanding. They're still trying to figure it out.

The rules are still trying to be clearly articulated in the meantime, the consumers are the ones that are falling between the cracks. That's why this bill is before us, because every day people are going to those directories with the expectation that it is going to work. They're not intimate in terms of studies that are still going on 10 years later. They're not aware of how the intricacies of these plans and providers work. They just know that they've been told to go to a list.

And that list should provide you with someone who can meet your needs. And if it's not working and then it's saying, well, how do you enforce it? Then? We don't have a lot of tools to work with to try to get enforcement. So, yes, we will continue to have conversations. Yes, we'll understand that this is still elements of ebb and flow.

But the bottom line here is this bill is trying to do something to protect people who right now aren't being very well protected and who are in need and who are looking for it to work, and it's not working. And so what do they do? Okay, so all I'm saying is that we will do our part. We've heard the concerns. We understand the dental community's issues, and we've understood them from the beginning. But we will continue to have conversations.

We'll continue to try to find ways of understanding. We look from some feedback, too. Here's what enforcement could work for us. Not we've got processes going on out there, and we're going to wait and see what happens at that level that ain't working. But if it comes back to within the context of this bill, within the context of this process, here's what we would suggest, then.

We'll certainly look at that and be willing to take those amendments should they make sense to the consumer on the other end and create some facilitation and expedition, expediting a process and cleaning up a process that right now has them twisted in knots. So with that, I respectfully ask for your aye vote.

Thank you very much, Mr. Holden. Happy to entertain a motion. Motion by Ms. Aguiar-Curry, second by Mr. Santiago. The motion is do pass as amended, to appropriations. Madam Secretary, please call the roll.

[Roll Call]

You have six votes. We have several committee members missing. So we'll leave that bill on call. Thank you very much. Before we go to our next witness, which will be Ms. Bauer Cahan, we'll be quick here. I see you there. We'd like to have a motion to adopt the committee rules. We have a motion by Mr. Santiago and a second by Ms. Waldron. Madam Secretary, please call the roll.

[Roll Call]

Committee rules. Thank you.

[Roll Call]

Committee rules are adopted. And then finally, before, if I let them all out at this point, I'd like to present the consent calendar, which includes item number two, AB 289, Mr. Holden. Item number three, AB 385, Mr. Ta. Item number five, AB 387, Ms. Aguirre Curry. Item number eight, AB 283, Mr. Jim Patterson. Item number nine, AB 512, our Vice Chair, Ms. Waldron, with amendments. Happy to accept a motion on the consent calendar. Motion by Mr. Santiago. A second by Mr. Mccarty.

Madam Secretary, please call the roll on the consent calendar.

[Roll Call]

90. That is passed. We'll go on. And Ms. Barrickhan, would you like to present AB 254? Turn the mic, please. There you go, thank you.

Thank you, Dr. Weber. I'm presenting AB 254. As you heard, this is a common-sense measure to protect reproductive health information. Nearly one-third of us women use reproductive and fertility tracking apps to guide them through their lives and their pregnancies and the end of their cycles. For menstrual cycle tracking, the first question users must answer before even entering the app is often, are you pregnant? These apps record when pregnancies begin and when they end.

These apps offer little in the way of protection for that data with obscure privacy policies and little meaningful regulation. A consumer report study found that none of the leading menstrual tracking apps offer transparency about who they share the data with. The study also found a majority of those apps use third-party trackers. This is unacceptable, especially in a postural world. Selling this health data could result in arrest.

AB 254 protects this data by adding CMIA the California Medical Information Act protections to reproductive and sexual health information collected by digital services. Reproductive health information is health information and should not be sold. With me today in support are Justin Brookman with Consumer Reports and Becca Cramer-Mowder with ACLU California.

Thank you. Please go ahead. Hello.

Good afternoon, Chair and Members. My name is Justin Brookman. No, I'm the Director of Technology Policy at Consumer Reports, urging support for AB 254 to extend CMIA protections to fertility and sexuality app data. Consumer reports have been around for 85 years, fighting for consumers. And for the last several years, that includes fighting to protect personal privacy and security. And a lot of our work has actually been around period tracking apps. Our first privacy security investigation back in 2015 was into the glow app.

We uncovered a number of privacy and security vulnerabilities, which exposed personal information that eventually led to a fine enforcement action from the California Attorney General's Office in 2020, we evaluated the five of the most popular period tracking apps for privacy and security attributes. None of them actually did a very good job. All of them, by default, did share data with companies like Google and Facebook and data brokers in 2022.

In the wake of Dobbs, we actually tried to seek out some of the best privacy-preserving period Tracker Apps. And there are actually some apps like Drip and Yuki and Periodical did a pretty good job. They kept the data local on the device. They didn't share. They allowed pseudonymous accounts. There was no location tracking, but they were the exception and not the rule.

And it kind of puts all the onus on consumers to try to figure out which of these dozens of apps does a good job. Are they expected to read through privacy policies, try to measure information coming off the device? I would argue that for data such as this, you should just expect it to be protected by default. When you go to the Doctor's office, you're not worried about your Doctor selling your data to Facebook.

That should be the same case for applications that have access to the same level of sensitive data. The CCPA provides some protections, but they still put the onus on consumers to go try to exercise opt-out rights, try to figure out what's going on, try to navigate different interfaces. The Federal Trade Commission has done a better job in recent years. They have brought some important enforcement actions, including against flow fertility app, but they're underfunded. The law is vague. It hasn't been tested in court.

And so I think AB 254 is a real opportunity to provide clear lines and clear, common sense protections for data that I think we all should agree should be protected by default. Thank you very much and happy to answer any questions you might have.

Thank you.

Thank you, Chair and Members. Becca Cramer-Mowder on behalf of ACLU California Action in support. Given the national climate, reproductive and sexual health information is becoming more valuable and poses even greater risk to users when shared without their consent. As states across the country criminalize people for receiving reproductive health care, it becomes even more important that California does more to protect against digital tracking.

The lack security of apps that track menstrual cycles or pregnancy means this data could easily be acquired and used as evidence to criminalize pregnancy loss, abortion, or gender affirming care. The data collected by these apps is extensive. Ads for reproductive health services may take a user directly to a survey that tracks family medical history, mood, medications, pregnancy status, and other information.

Unlike information provided in a Doctor's office, the information in these apps is not covered by HIPAA or CMIA because it is considered health information rather than medical information, a distinction that carries a big difference in terms of the protections and safeguards and legal obligations. But that is meaningless and nonsensical to the average user. The data sharing provisions and enforcement mechanisms governing health information currently do not provide adequate protection.

This Bill makes those claims of privacy real by adding this information to the CMIA Privacy Protection, and giving users with medical privacy protections that they oftentimes wrongly assume this information already has. Because of this, we are strongly in support of AB 254. Thank you.

Thank you very much. Others in support please come forward. Just your name and organization. If you represent one.

Good afternoon. Andrea Rivera, on behalf of the California Pan-Ethnic Health Network, in support. Thank you.

Thank you.

Mr. Chair and Members, I'm Erin Evans on behalf of NARAL Pro-Choice California and the California Nurse Midwives Association, both in support. Thank you.

Thank you.

Ryan Spencer. On behalf of the American College of OBGYN's district nine, in support.

Thank you. Are there witnesses in opposition? Testimony in opposition. Seeing none. Anybody? There's no one in opposition. We'll bring it back to the Committee for questions or comments. Any questions or comments from the Committee? Dr. Weber? Excuse me.

Thank you, Mr. Chair. Thank you so much for this Bill. It's interesting. I will often recommend one of the period apps for my patients to keep track of their cycles when they come in complaining of irregular periods or something. And it wasn't until after the Dobbs Case and a lot of discussions amongst OBGYNs in the country as to what that means that we started talking about whether or not we should continue to recommend these apps for our patients because of privacy concerns.

So thank you so much. I do have, reading through the analysis, one of the concerns was the broad definition of reproductive or sexual health application information, reproductive, or sexual health digital service. I would recommend that as you are continuing to move this Bill forward and continuing conversations, you kind of tighten up that definition. For example, like I have the aura ring, which is not a period app, or anyone would necessarily think would be something dealing with a woman's reproductive cycle.

However, it does keep track of my temperature, and it lets me know what my temperature is and if it's up or normal or below. And so they can correlate that to your basal body temperature, which is what we use all the time, in terms of when are you ovulating, especially for infertility patients. And so are you now going to pull them into this as well.

So I do think that the definition needs to be tighter so that other things that we use that you may not be thinking about aren't arbitrarily pulled into this Bill. But thank you so much for it.

Thank you, Dr. Weber.

Any other questions or comments? Yes. Ms. Boernar Horvath.

Thank you, I really appreciate you bringing forward this Bill, and I would love to be added as a co-author when the time comes.

Thank you.

Anyone else? No one. Would you like to close?

Yes. Thank you, Mr. Chair. And I just want to address what Dr. Weber said about the definitions. And I will point out that the organization is actually the same organization that opposed my mental health Bill that was almost identical last year. And through that process, it became clear that there are just organizations that want to make money off of this data. And so I imagine we will not be without opposition throughout this process because there are organizations that make a lot of money selling our private health information.

And the definition here, it requires several things. So they're complaining about the reproductive or sexual health application information definition. But if you look at how the Bill is written, it requires for them to be a reproductive or sexual health digital service. And in order for that to be the case, they have to satisfy three separate things, and all of those things have to be present, including, for example, that they market themselves as a reproductive or sexual health application. Right?

So they have to put themselves out into the world as someone who is serving you in the reproductive and sexual health space, which I don't think the aura ring does, and so they wouldn't qualify under this. And that they use the information to facilitate reproductive or sexual health services to a consumer so we can continue to work on it. But I think it is more narrow than the opposition has let on. I will say, and with that, I respectfully ask for an aye vote.

Thank you very much. Do we have a motion? Motion by Ms. Boerner Horvath. A second by Mr. Rodriguez. It does enjoy a do-pass recommendation by the Chair. The motion is do-pass to privacy and consumer protection. Madam Secretary, please call the roll.

[Roll Call]

Your Bill has 11 votes. None opposing. We'll leave the roll open for others to add on. Thank you very much, Ms. Bauer-Kahan. Ms. Aguiar-Curry. Ms. Aguiar-Curry has AB 48.

Thank you, Chair Wood and Members. First, I'd like to accept the technical Committee amendment suggested by your staff. And as always, thank them for their thorough review and thoughtful input. Members, I want to preface that this Bill is about taking care of our most vulnerable seniors and giving them the dignity, the fairness, the transparency, and the respect they deserve.

It is a sad reality that some nursing homes across the United States, including California, routinely give antipsychotic drugs to residents with dementia to control their behavior, despite rules against the misuse of such drugs as chemical restraints. These chemical restraints are being prescribed to sedate and subdue residents who often use behavior to communicate their pain, discomfort, or distress. AB 48 will help stem this practice in California. In 2018, a report by the Human Rights Watch found that this abusive practice has become more widespread.

The report estimates that every week in the United States, nursing facilities, more than 179,000 people, mostly older adults, and those living with dementia, are given antipsychotic drugs without an appropriate diagnosis. Antipsychotic drugs are meant to treat psychiatric conditions like schizophrenia. The FDA has never approved antipsychotic drugs as safe and effective for the treatment of dementia symptoms. Studies have shown that antipsychotic drugs nearly double the risk death in older people with dementia.

The Food and Drug Administration requires manufacturers to label these drugs with the strongest black box warning about risks they pose to people with dementia. However, when these drugs are administered without informed consent, patients and their families are not making the choice to take such a risk. AB 48 builds on existing protections for nursing home residents in state law and regulations.

First, this Bill codifies and expands rules to establish a nursing home residents right to provide or withhold written informed consent pertaining to the use of psychotherapeutic drugs. The Bill also specifies that residents and their representatives must be informed in writing about the content of the black box warnings for proposed drugs and whether the drugs proposed use has been approved by the FDA.

Finally, the Bill provides needed enforcement by requiring the State Department of Public Health to evaluate nursing facility compliance with these provisions during state licensing inspections. Thank you, Mr. Chair. And I'd like to introduce with me today in support Tony Chicotel, Staff Attorney with the Californians for Nursing Home Reform, and Yasmin Peled, Senior Policy Advocate with Justice in Aging.

Good afternoon, I'm Tony Chicotel. Senior Staff Attorney for California Advocates for Nursing Home Reform. Thank you for this opportunity to testify and thank you to the Committee Staff for their very thorough analysis of the Bill. I was at the Legislature in 2009 on behalf of SB 303. At the time, it was a Bill to codify written informed consent requirements very similar to this Bill.

And that Bill got through the Legislature, and it was vetoed by Governor Schwarzenegger, who in his veto message wrote, essentially, I'm not totally convinced there's a problem here. I'm going to have my Department of Public Health check it out.

And to its credit, the Department did it, did what they called an antipsychotic drug collaborative, where they looked at the Administration of Antipsychotic Drugs in nursing homes and came away with a report that said that there was all sorts of violations related to informed consent and the rules that we had at the time, we should have probably come back at that point and asked for written informed consent requirement. But our energy at that time was absorbed at the federal level.

There was a lot of federal attention to this issue, 2012-2013. We spent a lot of time on it. We made a fair amount of progress. Over the last four or five years, though, we've had a lot of regression, and we're at the point now where about 80% of all nursing home residents is all-time high. About 80% are receiving a psychotropic drug. So we came back last year. We had Assembly Bill 189 from Assemblymember Aguiar-Curry.

That Bill was also vetoed, but it was solely because there were some mistakes made at the very end with what amendments were submitted to legislative council at the last second, and we didn't get them all in. So we've got them in now, and we're comfortable that the Department of Public Health will support this. The Governor will support this. We've never needed it more than we need it now.

We've tried lots of other approaches to get at this problem, and I think by far the strongest approach is to educate our consumers, the residents themselves and their representatives, and ultimately give them the decision on whether they're going to approve these drugs or not. Thank you. Thank you very much.

Thank you.

Good afternoon, Mr. Chair and Members. My name is Yasmin Peled. I'm a Senior Policy Advocate with Justice and Aging. We're a national legal advocacy organization focused on supporting the rights of low-income older adults. We are here today in strong support of AB 48, this important Bill to ensure that nursing facility residents are not medicated against their will with psychotherapeutic drugs. These medications include antipsychotics, anticonvulsants, hypnotics, among others. Like any other Californian, a nursing facility resident should be entitled to basic informed consent protections.

A medication should only be administered after the person has been given clear information about the medication's benefits and risks and after receiving that information, has clearly assented. As the Assemblywoman mentioned, nursing facility residents for decades have been medicated with antipsychotics and other psychotherapeutics in order to sedate them and to make them more easily managed. Psychotherapeutics slow down the brain's ability to function.

As a result, they can decrease people's ability to understand their surroundings, negatively, affect their quality of life, and, especially for the case of antipsychotic medications, increase the risk of death. These antipsychotic medications, like the Assemblywoman said, carry these black box warnings, but they're dangerous to older patients, and the risks are currently not being communicated. Overuse of psychotherapeutics has plagued nursing facilities for decades. Back in 1987, a Congressional Committee reported on the overuse of these drugs.

And now, 35 years later, as the Assemblywoman said, there was just a recent OIG report from the Department of Health and Human Services finding that 80% of nursing facility residents are still routinely receiving these medications and that many residents are being inappropriately drugged. Information and choice are a nursing facility resident's best protection against inappropriate medication, and AB 48 ensures nursing facility residents are given important information upfront about medications that are prescribed for them and a fair opportunity to consent or withhold their consent.

For these reasons, we're in strong support and request your aye vote today. Thank you.

Thank you. Others in support? No one. Are there witnesses in opposition to the Bill? Please come forward.

California Health Coalition Advocacy, in support of AB 48.

Oh, I'm sorry. I didn't realize you were in support. Okay, thank you. I was a little too quick, I guess so. Anyone in opposition? Okay. Seeing no one, will bring it back to the Committee for questions or comments. Dr. Weber.

Good afternoon. Thank you so much for this Bill. I guess my question is, there is already a consent process in place for these medications requiring the healthcare provider or the attending physician to do this. So how exactly is this different?

Thanks for that question. So there are regulations, state regulations, in the books right now. They were adopted in the 1980s as a result of litigation that my organization had filed against the state a long time ago. We believe that those regulations are important, and it's a good starting point. The primary difference between what is there now and what would be in this Bill is that the current regulations require a conversation, and the only documentation of that conversation is up to the facility.

And if you go through nursing home medical records, what you see are the three letters ICO, which mean informed consent obtained. So you'll see a prescription. And then we've heard from lawsuits and from staff workers at these facilities. They're trained to just reflexively write ICO, informed consent obtained. There's no requirement that there be an actual record from the resident or the resident representative that they participated in this conversation.

So AB 48, the big piece is that there's going to be now a written form that will have to be signed by the resident or their representative to verify that that conversation took place.

Okay, so essentially what you're creating is like a form that patients use before they have a surgical procedure. That's the difference, right?

Yeah.

All right, thank you.

Thank you. Anyone else? Mr. Rodriguez?

Yes. I want to thank the Member for bringing this Bill forward. It comes to mind, in all my years working in the ambulance industry, a lot of those facilities are calling 911 and we're showing up. And not to hamper the good facilities are working. There's a lot of bad actors out there. That's only obvious what they're doing to some of these patients by giving them these types of medication, just to kind of put them aside and don't have to worry about it.

So I really thank you for bringing this Bill forward. It really makes a lot of sense. It's way overdue, and hopefully the Bill gets out on and gets signed and become law. Thank you.

Thank you. Anyone else? Seeing no one. Would you like to close? Ms. Aguiar-Curry.

Isn't it a shame, that we're sitting here 14 years ago, we tried to bring this across the line. Isn't it a shame that the families that have suffered and the patients that have suffered. I ask for your aye vote for today to make sure that this doesn't happen any longer. And I hope we get this signed and across the final finish line. Thank you.

Thank you very much, Ms. Aguiar-Curry. Do we have a motion? Okay, we'll make you the second, Mr. Rodriguez, but we'll make the motion to Dr. Weber. So the motion is do-pass as amended to Judiciary. And before we call, I just want to say thank you, Ms. Aguirre Curry, and your advocates for bringing this forward. It's a shame that things get wrapped up in technicalities. But I'm glad to see you're back and that this is well on its way to passage and signature, hopefully so.

Thank you very much. Madam Secretary. Please call the roll. The motion is due. Pass as amended to judiciary.

[Roll Call]

That's 10-0. We'll leave the roll open for others to add on. Thank you very much, Ms. Aguiar-Curry. Mr. Rodriguez, you have AB 70.

Thank you, Mr. Chair and Members. Thank you for allowing me to present AB 70, which requires certain public and private buildings that undergo renovations or modifications with costs that exceed 100,000 to install and maintain six trauma kits on the premises in order to treat people in need of emergency medical care during a traumatic emergency event. This Bill is an expansion of AB 2260 from last year, which required the placement of six trauma kits in similar new construction buildings.

In response to the tragic mass shooting at Sandy Hook Elementary School, a group of doctors convened a panel of national experts from law enforcement and emergency medical services to create an improved response system directed primarily at the control of life's threatening blood loss. In their recommendations, the group of experts concluded that bystanders immediate responders should be trained and empowered to stop hemorrhaging in order to save lives.

These experts also recommended trauma kits to be placed in public places such as shopping malls, schools, sport venues, transportation centers, et cetera, next to AEDs. Recognizing the difficulty in maintaining direct pressure, they also recommended the use of tourniquets to control severe bleeding. With mass casualty events becoming more common. In 2015, President Obama launched Stop the Bleed Campaign to encourage bystanders to become trained and empowered to take life-saving action while EMS personnel are en route.

During these tragic events, a person suffering from severe blood loss can die within five minutes, so every second counts. That is why it's important to ensure our immediate responders have the instructions and equipment needed to save and render emergency care at the scene of emergency.

With me to provide testimony are Dr. Craig Goolsby, Chair of the Department of Emergency Medicine at Harbor UCLA Medical Center and Professor of Clinical Emergency Medicine at the School of Medicine at UCLA, and Dr. Sigrid Burris, who is the Trauma Surgeon and Associate Professor of Surgery and Trauma Division at Loma Linda University on behalf of the American College of Surgeons and the California Chapters of American College of Surgeons.

Thank you very much. Please go ahead.

Good afternoon. Thank you for the Chair and the Committee for the privilege of addressing you. I am Dr. Sigrid Burris, a double board-certified trauma surgeon and surgical intensivist at Loma Linda University Medical Center. Loma Linda is an American College of Surgeons verified level one trauma center and we see bleeding on a daily basis. I represent the American College of Surgeons and the Three California Chapters of the ACS and myself. Bleeding is the leading cause of death after injury, and early use of bleeding control techniques is essential for improving survival.

Trauma surgeons have recognized the need for community members to learn bleeding control techniques and have access to bleeding control kits after the Sandy Hook Elementary School shooting. As was mentioned, this resulted in a collaboration between surgeons, first responders, and the military with the subsequent development of the Stop the Bleed Course by the American College of Surgeons, which is now housed under the Department of Defense. The education provided by the Stop the Bleed classes, with access to equipment such as tourniquets and packing, have saved countless lives.

It gives patients the means to stop life-threatening bleeding and the much-needed time to get to a hospital. For example, data from LA County shows that utilization of tourniquets has decreased the in-hospital deaths from 9% to 1% when tourniquets are implemented in the field. In addition, a recent peer-reviewed article showed that 95% of families wanted their junior and high school students to learn Stop the Bleed, including tourniquet placement. This then requires access to bleeding control kits to help save a life.

The stop the bleed course came out of all these mass casualty events, but the life saving techniques can apply to many other circumstances, such as motor vehicle crashes, workplace injuries, and natural disasters such as earthquakes when there's injury to major vessels. One example is a recent worker who sustained a partial amputation of his upper extremity with his chainsaw. A bystander was able to apply a commercial cat tourniquet, stopping the bleeding and saving his life.

It takes only a few minutes to bleed out from such an injury, but that is what is needed before paramedics or other pre hospital can arrive. Everyone deserves access to a bleeding control kit. We don't know when we will need them, but they need to be present. California led the way with AB 2260 to place bleeding control kits in newly constructed buildings, and we thank you for your support.

Let us lead the way to continue to improve access to bleeding control kits for your community members, I urge you to vote yes on AB 70. Our patients in our community deserve and need this to save lives and to stop the bleed. Thank you.

Thank you.

Thank you, Mr. Chair. My name is Craig Goolsby. I'm an emergency medicine physician and Chair of the Department of Emergency Medicine at Harbor UCLA Medical Center in Los Angeles County. I previously served in the United States Air Force, deploying twice to a military hospital in Iraq, and later served for a decade at the Uniform Services University in Bethesda.

I created and Chaired the Stop the Bleed Education Consortium, and I'm a Member of the American Red Cross's Scientific Advisory Council, and I'm here today on behalf of the Red Cross to offer my support for AB 70. I became interested in public bleeding control after seeing soldiers survive terrible wounds in Iraq and knowing that they would have died from those same injuries in other places I had worked in the United States.

Quick actions by their fellow soldiers, who often had little to no medical training, and the use of very simple devices such as tourniquets and gauze, proved to be life saving for those soldiers. Military studies about the effectiveness of tourniquets are so compelling that the Defense Department now trains all Cyprus Members to use them and equips them when they deploy with these basic types of equipment. While the battlefield data is clear, the use case for the American public is also persuasive.

Trauma is the leading cause of death for young people in the United States and a top killer for all ages. And trauma is not just violence. It's an every one, everyday problem. It's workplace accidents, traffic collisions, bicycle falls, broken glass, and even injuries at school. For severe injuries, minutes matter. An ambulance may take eight minutes or longer to reach someone who's injured. And some people with treatable injuries will bleed to death before a paramedic can save their life.

Public defibrillators save the lives of those in cardiac arrest, and public trauma kits will do the same for the injured. My research team has enrolled more than a thousand members of the public, including children, in studies all over the country. We found repeatedly that the public can and will apply tourniquets. I wanted just to share a quick story of a nine year old from Georgia. Her story was published widely in the news at the time.

She fell from a piece of playground equipment at school, and another child fell on top of her. During the fall, she broke her arm and she severed her brachial artery and was rapidly bleeding to death. Fortunately, her school nurse had a publicly available stop the bleed kit and recent training and quickly applied a tourniquet to save her life. While this may be a somewhat unusual story among California's 39 million people, there are unusual injuries like this every day.

Public access to bleeding control supply will save lives. And I thank you very much for your time and consideration.

Okay, thank you very much. Others in support? Is there any opposition to the Bill? Okay. Seeing none, we'll bring it back to the Committee for comments or questions from the Committee. Ms. Aguiar-Curry,

First of all, thank you for your service, both of you, really do appreciate it. The thing that caught my ear was eight minutes or longer for an ambulance to get somewhere in the rural communities. It could be a half hour of 45 minutes. So I will be supporting your Bill today.

Thank you. Anyone else? Mr. McCarty? Thank you.

I support this. Maybe just give us an example. Like in this building. We have one of these here. And where would it be?

Well, probably next to the AED. Wherever the AED is. It'll be right next to the AED. That's where we're looking at placing them. So the ad may be out in the hallway somewhere. Somewhere it's visible where there's a lot of traffic.

So it'll just be a box, below that, right next to the AED. So you'd find places where there's an existing AED and put it right.

Yes. Correct.

Yeah. Okay, perfect. Thank you.

Great. Thank you. Anyone else? We have a motion by Mr. Lackey, a second by Dr. Weber, I think. No, I'm sorry. Ms. Aguiar-Curry. Sorry, hearing voices. Mr. Rodriguez? Would you like to close?

I'll respectfully ask for you aye vote to help save lives. Thank you.

Thank you very much. Madam Secretary, the motion actually is do passed to Judiciary. Madam Secretary, please call the roll.

[Roll Call]

9-0. Your bill's out. We'll leave the roll open for others to add on. Thank you. We have one more Bill, which is me. So I'm going to turn this over to our Vice Chair, Ms. Waldron.

Chairman AB 242.

Thank you very much, Madam Chair. Madam Vice Chair and Members. AB 242 eliminates the five-year sunset on a prior Bill of mine, AB 2024, and another similar pilot by Assemblymember Wesley Chesbro from 2004 to 2011. This Bill permits federally certified critical access hospitals to employ physicians and be able to Bill for their professional services. Critical access hospitals are often referred to as frontier hospitals because most of them are located in remote rural areas. There are 34 such hospitals in the state.

They all have 25 or fewer beds. While these hospitals are small, they provide critical services and value to their communities. Without these hospitals, people would need to drive many miles before reaching another hospital. One of the issues I continue to hear throughout my district is how difficult it is to recruit physicians. Six of the 34 critical access hospitals are in my district. Other hospitals throughout the state are hospitals like Bear Valley Healthcare, Catalina Island, Eastern Plumas District Hospital, Santa Yunes Valley Cottage Hospital.

I have a hard time imagining that's a big hospital, and they all have similar characteristics. Having been a healthcare provider myself, I understand the concerns of the medical community about whether allowing hospitals to employ physicians will change the nature of the physician's clinical decision. But the opportunity for these hospitals to hire physicians has been piloted two times with no negative feedback.

The opposition has requested a sunset remain in place while I remain open to their concerns pending the results of the report called for in my earlier legislation. Today, I believe that two pilots is adequate to determine if there are any concerns allowing the hospitals to hire physicians. It's important to point out that a continued sunset creates uncertainty to physicians who may be seeking employment and whether the length of employment could end abruptly by the sunset.

This is what happened with the end of the original pilot by Mr. Chesbro. AB 242 is a modest Bill and provides a limited exemption for those hospitals most at risk of closing their doors if they cannot address their physician staffing needs. In support of the measure today I have Ted Owens, the Executive Director of Governance and Business Development with the Tahoe Forest Healthcare District, and it must have been fun getting here, Ivory.

I can assure you that's true. I'm surprised I'm here, Mr. Chairman, Members of the Committee, I'm Ted Owens, Executive Director of Governance and Business Development for the Tahoe Forest Health System. The Tahoe Forest Health System is a critical access hospital based in Truckee, California, serving the West and North Shore communities of Truckee, Donner, Summit, and Lake Tahoe. Under the provisions of AB 2024, Tahoe Forest engaged in physician direct employment, and today, with few exceptions, Tahoe Forest employs the majority of all physicians in our region.

It has proven to be a great benefit for the organization, for providers, and for our patients, particularly true in a rural setting and for the following reasons. In our area, it has stopped physician turnover or physicians who have established a clinical business and then closed and moved to other locations. Direct employment has produced exceptionally strong retention. We have lost only one provider in the time that we engaged in this process, but he was moving to Colorado, and for family reasons.

It is far easier to recruit established physicians by eliminating the challenges of expensive clinic space, business office staff, insurance provision, and regulatory compliance. It has enabled Tahoe Forest Hospital to recruit young physicians coming out of residency and or fellowship by provision of a strong employment package so they may pay down their educational debt and establish a career.

Our recruitment efforts have taught us that young physicians want employment, not establishment of standalone clinical business, because it does not make financial sense for them, and it is a valuable tool for very rural hospitals to retain and recruit in regions where loss of a single provider can be the difference of survival for the hospital, not to mention the impact of the community that it serves.

Should AB 242 fail, and this, for now, is unique to the Tahoe Forest Health System, it will place us at a fork in the road to make a decision whether to comply with the State of California or the Federal Government. We recently concluded a dispute with the IRS and the Social Security Administration over Tahoe force contracted services for the 2014 year utilizing as common a professional service agreement with providers. Both agencies claimed physicians under professional service agreements to be employees.

These federal agencies ultimately determined that physicians must be employees regardless of California's corporate practice medicine laws. Direct employment has put us in compliance with those federal agencies. I am happy to provide through the Chairman's office, documentation of this now concluded dispute. If this is of interest to the Committee, we strongly support AB 242, and thank you for your time.

Thank you. Are there other witnesses in support?

Madam Chair and Members. Sarah Bridge, on behalf of the Association of California Healthcare Districts. Here in strong support of AB 242.

Thank you.

Good afternoon, Members. Connie Delgado, on behalf of the District Hospital Leadership Forum, in support.

Nassette Short, on behalf of Adventist Health, in support.

Good afternoon. Ronnie Verdugo, on behalf of the California Hospital Association, in support. Thank you.

Jeannette Carpenter, on behalf of Providence Health and strong support. Thank you.

Thank you. And witnesses in opposition, please come forward.

Thank you, Mr. Chair, Madam Vice Chair, Members of the Committee. Brandon Marchy, with the California Medical Association here in an oppose unless amended position. We thank the Chairman for his work on this issue and on his previous legislation that we ultimately did end on a neutral position for the Chairman summed up our arguments quite well and our amendments.

We would like to see the results of that report in January 1 before we can agree to a permanent expansion of the ban on the corporate practice of medicine. So until that report is done and those results and any type of impact to patient care or practice availability in the region is conducted, we respectfully ask that the sunset be extended for five years. Thank you.

Thank you. Are there any other witnesses in opposition? Seeing none, we bring it back to the Committee for questions of the author. Dr. Weber.

Thank you so much for this Bill. I will start with a question. How exactly do you become a federally certified critical access hospital?

It is a federal definition. I believe that it is. Basically, it's 25 beds or less. And typically, these are hospitals that are remote. They're not all necessarily remote. But the key piece of that are there are 25 beds or less.

Okay, thank you. You know, it was interesting, when I was looking at the outcome of your Bill for the expansion, or the previous Bill for the expansion of the prohibition or whatever, of the corporate practice of medicine, that there weren't very many hospitals that actually hired physicians. I want to commend Tahoe Forest Hospital District because you guys did what you're supposed to do. The purpose of a pilot or an extension is to see if there's a need and whether or not this will fulfill their need.

I was very disappointed to see that of the 36 hospitals that could, less than two actually hired 10 or more physicians, and you all being one of them, and you all did an outstanding job. So thank you so much for recognizing the need of your community and going out and getting physicians to actually serve your residents. Thank you for that.

I think one of my concerns is that with the corporate practice of medicine, it prevents employers or physicians by a corporation to interfere with their independent ability to make medical judgments. And we have seen that with some of the hospital systems that are using their religious exemption. And so one of my concerns is that if we just completely remove this corporate practice of medicine here in California, that people wouldn't necessarily need to use the religious exemption at times.

And so we are a state that has stated that we value everyone, regardless of their gender, regardless of their sexual orientation, that we value a woman's right to choose.

And I just want people to remember that as we are creating this Bill to make sure that we don't put ourselves in a situation where in these areas, especially these rural areas, that have limited access to providers, that we're not limiting it even further by allowing these hospitals or these clinics to come that do not provide a full access of care to everyone.

So just want to make sure that we are keeping that in mind as this Bill continues to move forward, recognizing that we have an issue of physician shortages, we have an issue with hospitals closing, and we have to fix that. I just don't want us to make those who are already lacking access have even further lack of access under the shield that we have provided a hospital or clinic service in that area. So thank you very much.

Any other comments or questions from Committee? Seeing none. If you would like to close, Mr. Chair?

Thank you. Thank you, Madam Vice Chair. Yes, I would. And first of all, I'll address the concerns of the opposition. I would have thought by now that if there were adverse outcomes, that we would have heard about it from hospitals. We have not heard of any, I would venture to guess, and it's a guess at this point, but the uncertainty of a five-year sunset makes it difficult to attract somebody long-term. And some of these are very remote areas.

So the certainty of the ability to be hired and stay there long term, I think will show, and I hope will show an increase in the numbers regardless. Those hospitals that have hired physicians have seen a positive benefit from that. I will note that I would say this hospital, Tahoe, the Tahoe Hospital, is different than many of the others most of these hospitals have hired a physician or two physicians. They are not going to be providing all services that a larger, more urban hospital would provide.

So they might not be providing gender affirmative. They're likely not providing gender affirming care. They're likely not providing abortion services. It doesn't mean that there's a prohibition, necessarily, but they may not have the capacity, the experience, to do that. However, the value of having a Doctor at the hospital is significant in some of these small communities. The population doesn't make it easy for someone to establish a practice and then get hospital privileges to belong to the hospital. That's the problem we're trying to solve here.

And there are a number of communities that are just like that. And so I believe there is no harm done here. I believe that this is important for rural communities. And as such, I ask that we remove the sunset, allow this to continue, and I respectfully ask for your aye vote.

Thank you, Mr. Chair. The recommendation is do-pass to appropriations. Do we have a motion? I guess Mr. Lackey for the motion. Mr. Patterson for the second. Madam Secretary, please call the roll.

[Roll Call]

That Bill is 12-0.

Thank you, Madam Vice Chair. And Members who are not present, I'd ask that Members are not present. Please come down so we can conclude our business here. In the meantime, I'd like to go through the agenda from the top. All of the bills have passed, so what we'll be doing. Item one has not. Oh, I'm sorry. With the exception of item one. Excuse me. So, my bad. So at this point, I ask Madam Secretary, please open the roll. Call the absent Members for item number one, AB 236 by Mr. Holden.

Number one, AB 236 by Mr. Holden. And lift the call.

[Roll Call] Nine to one

That has nine votes. The vote is nine to one. Items number two, three, five, eight and nine are the consent calendar. Madam Secretary, please open the roll call. The absent Members on the consent calendar.

[Roll Call] 12-0

That's 120. Please open the roll call. The absent Members. Item number four. AB 48 by Ms. Aguiar-Curry.

[Roll Call]13-0.

That's 13-0. Please open the roll call the absent Members. Item number six. AB 70 by Mr. Rodriguez.

[Roll Call] 12-0.

That's 120. Please open the roll call the absent Members. Item number seven. AB 254 by Ms. Bauer-Kahan.

[Roll Call]13-0.

That's 13-0. We did just do item number 10. There are no new Members who came in. Mr. Maienschein just entered item number 10. AB 242 by Assemblymember Wood. Please open the roll call. The absent Members.

[Roll Call] 13-0.

That's 13-0. AB 70. Check. We'll check that out right now. We have an aye vote Mr. Santiago. So we'll go back. We need to open the roll on some items for Mr. Maienschein. So I'll ask item number one, AB 236 by Mr. Holden. Please open the roll call the absent Member.

[Roll Call] 10-1.

That's 10-1. Content calendar. The Content calendar item numbers two, three, five, eight and nine. Please open the roll and call the absent Members.

[Roll Call] 13-0.

13-0.

Item six.

Item six, AB 70 by Mr. Rodriguez. Please open the roll call the absent Members.

[Roll Call] 13-0.

13-0. Okay, I think we got it covered. Thanks very much. One Member missing. The other Members are not going to be able to make it today. So the business of the Health Committee is now concluded. We will go ahead and adjourn. Thank you very much.