Senate Standing Committee on Health

The Senate Committee on Health will come to order. Good afternoon, everyone. What a full and beautiful house we have today. We have 14 bills on the agenda. We'll see who lasts the longest and stays for the whole Committee. Three of them are proposed for consent. I am so glad to see one author is here already to kick us off in order with file number one on SB297. Senator, you may proceed. We're going to start with as a Subcommitee.

Thank you, Madam Chair. I came on time, early, I should say. I know you'd like to be on time, so I appreciate the opportunity to present this panel Bill, SB297. I would like to start off by accepting the amendments from the Committee.

I also want to extend my deepest gratitude to Melanie for her invaluable collaboration with my staff on SB297. They really, really, really appreciate it. And that's because valley fever is near and dear issue for the Central Valley. Not long ago, I spoke with a group of farm workers in the Central Valley.

Many shared stories of sick for weeks, persistent cough, fevers and fatigue that made it difficult to work. But they kept pushing through. Most didn't realize they had been exposed to valley fever until the symptoms became severe. For some, the road to diagnosis took months. For others, it never came at all.

These workers who harvest our food and build our communities are on the front lines of a growing health crisis, one that too often goes unnoticed and untreated. SB 297 requires local health departments to annually report to the California Department of Public Health confirmed cases of valley fever.

The Bill further mandates screening in high incidence areas and ensures health insurance providers, including Medi Cal, covered screenings for valley fever without cost to patients. Valley fever is no longer a localized issue as climate change causes temperatures to rise and drought storms to lengthen this fungus that causes valley fever.

I'm not going to pronounce it because it's a little difficult for me to pronounce. Is spreading to areas previously unaffected. Communities, including those in California and the Central Valley, are facing an increasing number of cases.

This Bill is necessary to address a growing public health crisis affecting thousands of people, particularly vulnerable populations such as farm workers, construction workers and other individuals with weakened immune systems. Valley fever underdiagnosed and many cases go unreported. Between 10,000 to 20,000 cases are officially reported each year, but the true number is likely much higher.

Inconsistent testing and reporting practices make it difficult for public health agencies to fully understand the scope of this disease. Outdoor workers, like farm workers and construction crews are at heightened risk of valley fever. These workers unknowingly inhale fungal spores while on the job, leading to flu like symptoms, exhaustion, coughing and fever.

You know, valley fever isn't just a health issue, it's also an economic one. Many individuals in the Central Valley that have had valley fever, it just becomes really a vicious cycle that goes into poverty and continued health issues. So one critical aspect of this Bill is that it ensures the valley fever screenings are culturally and linguistically appropriate.

Many outdoor workers, especially those in vulnerable communities such as farm workers, may not fully understand the risks of valley fever or how to get tested.

SB297 also tackles this issue by requiring local health departments to annually report to the California Department of Public Health confirmed cases of valley fever, mandating screenings in high incidence areas when medically necessary, and ensuring health insurance providers, including Medi Cal, cover screenings at no additional cost to patients.

To align with the existing law, the Bill prohibits cost sharing for screenings with exceptions only as required under federal law for high deductible health plans. And today I have with me Job Purdy, co founder of Fight for fungus, and Dr. Brian Cruz with Altura Family Healthcare Medicine medical Director to testify and support.

You have a total of five minutes together. Please begin.

Good afternoon, chair and Members. My name is Dr. Brian Cruz. I serve as the clinical Director of family practice and specialty medicine at Altera Centers for Health, a federally qualified health center in Tulare, California. I'd like to thank Senator Hurtado for the invitation to speak today and for unwavering leadership on an issue that deeply affects our community.

Valley fever. I've lived in the San Joaquin Valley since 1993. In our practice, I often see families whose lives have been upended by this disease. I can think of one patient in particular, a farm worker, a father of three, who came in exhausted and coughing. Assuming it was just another bad cold.

He kept working through the pain because he couldn't afford the time off. But by the time he was diagnosed with valley fever, it had progressed to a severe infection and required hospitalization and months of treatment. If it had been caught earlier, his recovery would have been smoother, his family less burdened, and his medical costs much lower.

Valley fever is caused by inhaling spores from a fungus that's in the soil that's common to our area. Symptoms can mirror other illnesses, such as fever, cough, chest pain, night sweats.

For some, it's a mild infection, but for others, especially those with limited access to care, like many in the agricultural industry, it can be devastating, even life threatening. SB297 will help us catch these cases earlier by identifying high risk areas and ensuring screenings are offered in a culturally and linguistically appropriate way.

Importantly, this Bill ensures that screenings are covered by insurance at no cost to the patient, removing a critical barrier for the uninsured and underinsured. Some have expressed that concern about SB297 overriding clinical judgment. But I'd like to be clear. This Bill does not replace medical expertise.

It equips us with better tools to apply our judgment earlier in the diagnostic process, especially in high incidence areas where we need to be vigilant. For my patient, my patients, time is not just money. It's health and sometimes life itself. Thank you for your time and for considering this life saving measure.

Thank you. My name is Rob Purdy. I'm a Valley Fever patient diagnosed in 2012 with coccy meningitis. So I'm in what they call the lucky 1% patient whose valley fever left their lungs and went into their central nervous systems. Because of that, I will require a lifetime care, very highly specialized care, and daily antifungal drugs to survive.

I'm lucky that I was diagnosed in only six weeks, which sounds crazy with any other disease, but with Valley Fever the average is 90 days. And rather than talk a lot about my experience, I want to share the experience of some of the other patients that I've spoken with.

We can talk about my friend that's a patient in San Diego who also had coccy meningitis. And while she was in the hospital waiting for a diagnosis because of the delays, she had a stroke and another stroke and multiple strokes.

Now they've diagnosed her Valley Fever and controlled her disease, but the damage done by those strokes is irreversible. The impact to her life is irreversible. And she, like me, is going to be a financial burden estimated to the State of California of approximately $1 million.

Because many patients like me eventually end up on Medi Cal or Medicare or Medicaid or Medicare. I myself was on Medi Cal for approximately half of the last decade. I lost a decade of financial stability. And everyone in this room, whether they recognize it or not, lives in an area that has been impacted by this disease.

When it does impact you, the impact is immeasurable. It doesn't just impact you or even you and your spouse. It's a multi generational impact. My experience with the disease changed the behavior patterns of my children. I have a son that the day he turned 18, went to work because he saw the struggles that we had financially.

He's now 26 years old. He has never worked less than 40 hours a week. The day he turned 18, he went out and got a job working in the fields because that was the easiest job for him to get and he has worked every day since then.

I am now a grandparent and it impacts my ability and my interactions with my grandchildren as well. So this disease touches everybody and every patient that is diagnosed earlier. That you prevent becoming a patient like me is a savings of the State of California over $1.0 million over their lifetime.

So thank you for your consideration of this Bill. I wholeheartedly urge you to vote in favor of this Bill. Thank you so much.

Thank you so much for both of you, your testimony, for you to share in your personal story with us. Now is the time I'd like to turn for anybody who'd like to do a me too in support of this Bill, you please step forward to the MIC name organization and your stance on the Bill.

Nisette Short, on behalf of St. Agnes Medical center in Fresno in support. Thank you so much. Seeing no one else. Any formal opposition, lead opposition, please step forward. Ladies, same time, five minutes total.

Thank you. Good afternoon Chair and Members of the Committee. My name is Dr. Anna Yap and I'm here on behalf of the California Medical Association in respectful opposition to the screening mandate in SB297.

First, we want to thank Senator Hurtado for highlighting the importance of Valley Fever and to the those who've barely shared their stories, CMA supports efforts to improve awareness, to strengthen data collection, and to ensure appropriate coverage for appropriate screening.

However, SB297 would mandate that all adult patients in high incidence areas be offered Valley fever testing regardless of symptoms. This removes physician discretion and could lead to unnecessary testing and treatment. According to the CDC, 60% of people infected with valley fever are asymptomatic and 90 to 95% cover without ever recovering, recover without ever needing treatment.

And for those who do require treatment, it often involves antifungal medications taken for three to six months or longer. These medications can cause serious side effects like liver toxicity and hormone related issues such as hair loss and decreased libido.

And widespread use also contributes to antifungal resistance, making it harder to treat severe cases in the future, much like what we've seen with antibiotic resistance testing. People who don't need it may not only strain laboratory resources and delay results. For patients who are truly sick, it can cause unnecessary anxiety.

A positive test in somebody with no symptoms can lead to fear and the risk of starting treatments that aren't needed. Exposing patients to harm without benefit. While we appreciate the intent behind this Bill, we believe that testing decisions should be guided by physician judgment by patient symptoms, so patients receive care that is tailored, thoughtful and evidence based.

For these reasons, we respond respectfully, oppose SB 297 as written. Thank you so much.

Thank you. Now is the time for me toos in opposition. Please step forward.

Good afternoon, Madam Chair and Members. I'm actually a tweener. I'm Farrah McDae Ting with the County Health Executives Association of. California. And our folks had adopted an opposal less amended position. However, Senator Hurtado's staff had worked for many hours with us and the Committee amendments, we thank the Committee staff as well, are agreeable to us.

We'll be taking it back to our Members to remove our opposition. Great. Thank you so much. Thank you.

Okay. Nope. Bringing it back to my colleagues in the Committee, Senator Dr. W.E.B. Pearson.

Good afternoon, Senator. Thank you, Chair. I want to thank you so much for presenting this Bill and highlighting this very significant issue. As you know, you and I, I think, may have talked or you've heard the vast majority of this Bill I support. However, in keeping with what I have always said, I am a.

I'm strongly opposed to putting clinical practices into statute. Clinical practices change. Statute takes longer to change. Laws take longer to change. And I've been pretty consistent with that since I've been here in the Legislature. So trying to dictate what should happen and put it into law is not something that I support.

Additionally, in the language, it states that an adult patient, blah, blah, blah, shall offer a valley fever screening test to the extent that these services are covered under the patient's health insurance. As a practicing physician, I don't know that information when I'm seeing a patient. I have no idea what an individual patient's insurance will cover.

So that here is problematic. And then it goes on to say, based on latest screening indications recommended by latest national clinical practice guidelines, which again, I don't understand if you're saying go by national clinical guidelines, why we need to put that in statute.

But also it, as was stated, it prevents the flexibility because you may be in an area that has a higher prevalence of this and you may need to go above and beyond what nationally is done. But what you've stated here is you are restricted to only go by national guidelines.

And so although I agree with everything else, want to really thank both of your witnesses for coming. Thank you so much for giving your story. It is not easy to stand up here and reveal that kind of information to a bunch of strangers. So thank you so much for that.

But I just do not believe in placing clinical practice guidelines into statute, and for that, I will not be able to support it today.

Thank you. Senator, would you like to respond to that or we can continue with questions?

Yeah, absolutely. I mean, look, I. I represent a region that has been dealing with a lot of issues, valley fever, for some time, but more recently, we've also been dealing with a bird flu. Right.

And so it almost seems like, you know, a region is high risk for, you know, these different diseases and illnesses that cause disposal, bad health for people. Right. And I have seen firsthand that there is a need to do more. There is a need to improve our surveillance.

There's a need to expand the type of testing that is being done so that people can be diagnosed in time before things get worse. And so that's. That's kind of what I'm here to say. I know we had a hearing earlier this year on the bird flu, but it goes back to.

There is more that needs to be done, and this is my way of trying to advocate for the region and ensuring that things don't get worse and that there's early diagnosis, if possible. So I hope that.

No, I completely understand what you're trying to do. I don't believe in placing clinical guidelines into statute.

And one of those reasons would mean that you are actually constraining the providers in your area from actually going above and beyond national guidelines based upon what's happening in your region, because you've just put into statute that you need to go based on national clinical guidelines.

So as a provider, I would not have the flexibility to say I understand nationally what they're doing, but in this particular area, I think I will test you regardless of what national guidelines say, because of what's in statute. And then the.

And the insurance thing is also interesting because as providers, I have no clue what your insurance will cover. But thank you so much for this. Thank you, Senator Durazzo.

Thank you. I'm sorry, I might have missed the beginning. You might have answered this already. I really think what you're doing is great. Our communities sometimes need us to take this on in the Legislature, especially poor communities, which obviously you represent.

But I wanted to ask, if you haven't already answered, why test adults who present who, you know, come with no symptoms? Somebody could respond to that.

If you'd like to respond to that. Dr. Yes. Yes, you may. Either one of you can respond.

Well, medical guidelines, I wouldn't test anybody who has no symptoms for Valley fever. It's only if they've had symptoms for some time, and if they have certain things on X rays, you know, like what looks like an infection in the upper lobes of the lungs, then I'd consider testing them for that.

But if they didn't have symptoms, I'd be a little apprehensive to start testing for Valley fever. It says here that it's not really supposed to supersede our clinical judgment. And so my clinical judgment at that point wouldn't be to test for Valley fever without symptoms.

Yeah, I would say that it really does align, that the Bill in a lot of ways aligns with the clinical guidelines. So the IDSA guidelines from 2016, you only test symptomatic patients. The CDC algorithm that was recently released two years ago that I worked with CDC on has a testing algorithm for CAP.

And when patients present with CAP, I would say that that is certainly going to support that. Additionally, a lot of the patients, at least in our area, may not be true in your area, depending on the clinic. Some physicians do know immediately because they're at a clinic where they see Medi Cal patients or Medicaid patients.

And those patients, obviously that is not a concern. And that's anywhere from 30 to 70% of patients within the State of California, depending on what your area is. So I would say that they are aligned, more aligned than you would think, based on your expressed concerns.

Senator, before we move on, I'd like to establish quorum Committee. Assistant, if you can call the roll.

Senator Menjevar. Here. Menjevar. Here. Valaderas. Here. Valaderas. Here. Durazzo. Here. Durazzo. Here. Gonzalez. Grove. Limon. Padilla. Richardson. Here. Richardson. Here. Rubio. Weber. Pearson. Here. Weber, Pearson. Here. Wiener. Here. Wiener. Here.

Before I go Back to you, Dr. Wood Pearson. This was Senator Durazzo's question, so I'd like to turn back to her if you have a follow up. Senator?

Well, I'm not quite sure. I guess. I guess I'm hearing two different. Potentially two different things. Is this testing of everyone, regardless of symptoms, or is it only with symptoms?

Anyway, if I may, the guidelines are you. Only since it's referring to the guidelines. The guidelines are you would only screen those symptomatic, so the guidelines would indicate what happens. I would also say that most people that are presenting it at clinics are going to have some type of symptoms.

And statistically, the most common ICD10 code, at least in the EDS, is if you exclude trauma is pulmonary symptoms, which would require screening, then in that case.

Okay, maybe I need to go back. But it didn't seem to be clear that it was only with symptoms.

It's based on the current guidelines. So in a high infectious area, given the current guidelines, and then we can read off certain things that are already incorporated into that to be offered the screening.

So it would be based on, based. On the guidelines, it would be only those with symptoms. Yes.

Let me read this whole thing to you.

In high incident areas.

Initial presentation. Okay, so I'm going to read all this. So consider testing an initial presentation of community Acquired pneumonia or cap, or a word I cannot pronounce. Erythma erythema nodosum.

Erythema nodosum.

Thank you, sir. Following recent respiratory symptoms. So there are some symptoms have to be present and not just the symptoms. You have to live in an area and then be connected to an outbreak, which we know often happens in the Senators area.

Okay, thank you.

Like to come back to Dr. Weber Pearson. Thank you. So I think that's one of the potential issues with putting clinical guidelines into statute. It does make it very confusing. And it's what providers should be doing already. And clinical guidelines change based on the nature of the disease, the organism, the virus.

But when we have put it into statute, when we have voted and put into law what providers must do, we are not able to be very flexible with that, nor are we able to use our own clinical judgment. And so that is why I do not generally so support putting medical guidelines into statute.

I'm going to turn over to my Vice Chair now.

Yeah. Just to. I would like to hear both witnesses or have you weigh in on the Senator from San Diego's concerns on whether or not you think that this language is actually going to limit your ability or minimize your flexibility.

Let me add some context to that before they respond. This isn't the first time our body, this Legislature, has approached this kind of legislation. We have other examples. We have passed hepatitis B screening, mandatory HIV testing in primary clinics, syphilis and HIV in pregnant women, maternal mental health screenings, hearing screenings in newborns.

These are mandates that this body has passed that also exist that have mandated providers to do this kind of care. So this is a new approach and is in line with something we've done in the past. But I'd like to turn to now to your question.

Okay. I guess to answer your question, kind of as chair Manjarvar says, SB297 is not supposed to override providers clinical judgment if there's, if there's high risk for this particular infection.

If there's symptoms that are present that could possibly be this infection, it's really supposed to be a tool to help us a little bit sooner than we maybe normally would. You know, kind of depending on what insurance will be. But we never know what insurances do until we've gone ahead and ordered something.

You know, a lot of times patients will come back, didn't cover it, and then they get the Bill. But still, we don't let that change our practice.

So really, it's supposed to be just a tool to help us get things done a little bit sooner so that people who are underinsured or uninsured or really anybody in this particular case can be tested without fear of cost. But no way to override our clinical judgment.

I think overall, we as physicians absolutely want our patients to be taken care of appropriately. The issue with mandates from the Legislature or anywhere else is that unfortunately, other factors oftentimes force physicians to have to practice in ways that we don't want to.

We have hospital systems or the way that our regulators have decided to interpret laws or bills to then come and have it be down on us. And unfortunately, a lot of times these mandates don't come with the appropriate funding necessary to make sure that our patients can get the care that they need to afterwards.

When our patients have to get all these extra screenings and they have a positive test for which they don't actually need indicated treatment for it, then what do our patients do? And so that's why overall, we are opposed to having mandates in the legislation.

We are absolutely supportive and do work on educating physicians and our providers to make sure we give the right care to our patients appropriately.

So I just want to let the. Author know that I will be supporting your Bill today, but I do feel like it does need some work and want to Reserve my right to change my vote should it come to the floor, because I understand the necessity, especially for your region.

And thank you for tackling this very complex issue for your community.

Thank you.

See no other questions or comments. I do want to clarify because I know we've been having some questions on the insurance part. And you know, DMHC does clarify that medically necessary screenings are covered benefits for insurance. And I do want to note, you know, you're valid.

I mean, your opposition is always going to be valid, that you want no mandate, but it doesn't stand alone against any other legislation that we come up with here. Every opposition we're going to hear today is going to be upset about a mandate on their practice, on their business. So it's all within the same kind of arena.

It doesn't sit alone on its own of not being regulated or legislated against. Senator, I do appreciate this comprehensive approach to an issue that is near and dear to your district.

I mean, I've even seen articles of families having to travel to Tijuana to get treatment for valley fever when they should be doing it here in California where they reside. So this issue is real, and we need to do something different, because what we're doing right now is not working.

And that is why I'm recommending an aye vote. Committee assistant, please call the roll.

You may close. No, thank you, Madam Chair. Thank you for working with my team. And I respectfully ask for an aye vote.

Thank you. Now, Community assistant, please call the roll. Before that, I do need a motion moved by my Vice Chair. Motion in front of us. This do pass is amended and we refer to the Committee on Judiciary.

Menjevar. Aye. Menjavar. Aye. Valaderes. Valaderas. Aye. Durazzo. Durazzo. Aye. Gonzalez, Grove. Limon. Padilla. Richardson. Richardson. Aye. Rubio, Weber, Pearson, Wiener, Wiener. Aye. That's 50.

Currently, Senator has a 5:0, but we're missing Members, so we'll keep it on call. Since we have a quorum with Senator Allen, we're going to do consent calendar first and then get to you. Can I get a motion on the consent calendar moved by Senator Durazzo?

And the items on the consent calendar are going to be file items 3, SB 669. File item 7, SB 439 and file item 9, SB 764. Community Assistant, please call the roll.

Menjavar. Aye. Menjavar, aye. Valladares. Aye. Valladares, aye. Durazo. Durazo. Aye. Gonzalez, Grove, Limon. Padilla. Richardson. Richardson, aye. Rubio. Weber. Pierson. Aye. Weber. Pierson. Aye. Wiener. Wiener. Aye.

Consent calendar currently has a 6 to 0 vote. We're going to put that on call. Moving on to file item 2, SB367 by Senator Allen. Senator, you may begin when you're ready.

Yes. Well, good afternoon, chair Members. Let me thank the chair and Committee for working with us on the Bill and we're accepting the Committee amendments. So, we've got a lack of coordination in the behavioral health system that can lead to gaps in care and a confusing experience for individuals and families.

Our current model is simply leaving too many people suffering with significant psychotic disorders in oftentimes incredibly unsafe situations, leading to severe injury, incarceration, homelessness, or tragically, death.

Currently, people In a mental health crisis who are involuntarily detained out of concern for their well being are brought to an emergency department or mental health facility for an initial assessment before being held for further evaluation and treatment.

And while there's statutory guidance on the required elements of an evaluation, which must be completed by a behavioral health specialist, no such guidance or requirements exist for an assessment. And this can lead to quick releases and continued cycling of 30 second holds, as they call them, without a more comprehensive analysis of an individual ever being completed.

Overburdening our emergency departments with extra patients who oftentimes are in the system without any care plan and so, outpatient psychs and emergency physicians encounter barriers advocating for higher levels of care for their patients who are caught in the revolving door of the behavioral health system.

With so many restrictions on who can make a referral, there's no avenue for psychiatrists and physicians working outside of a certain facility to submit a petition to the county public's conservator for consideration of a mental health conservatorship.

Now, if a mental health conservatorship is granted, treating facilities then have to create an individualized treatment plan, an ITP, within 10 days. But there are no best practices or required elements in an ITP and no oversight of the patient's progress under the current system.

So, in the absence of a strong ITP, patients are more at risk of being warehoused in a facility without appropriate treatment for extended periods of time.

And in some cases, conservatorships have been prematurely terminated when beds are not available because minimal goals were met, even though the patient still met the definition of gravely disabled and didn't yet have the necessary skills to live independently.

So, this Bill seeks to address a number of these issues by defining reasonably available and relevant 50150 assessment criteria to minimize the cycling of patients in and out of the emergency departments that I was just describing.

And also ensuring that there's no wrong door for gravely disabled individuals to be referred to the public conservator for investigation and connection to appropriate supports. The Bill also provides referrals to less restrictive alternatives that can meet patient needs should the public conservator determine that an LPS conservatorship petition not be filed.

And then finally, it requires ITPs to specify goals related to stabilization, evidence based treatment, and movement to a less restrictive setting. So, here with me to testify in support of the Bill today is Dr.

Emily Wood, who's President elect and chair of government affairs for the Southern California Psychiatric Society, and she's also a psychiatrist for MBI California Skid Row, which is a mental health clinic providing care to individuals in the Skid Row neighborhood of Los Angeles.

And we also have Dylan Elliott who's here, who's a legislative advocate for the California State Association of Psychiatrists.

Thank you. You have a total of five minutes together. You may begin.

Thanks, so much. So, civil rights, including access to care should not differ from county to county and psychiatrists, we take our take this very seriously that we have been granted the power to impinge on an individual's civil rights by holding them against their will. Currently, the difference in LPS conservatorship investigations from county to county is frankly frightening.

It shows no consistency in evaluation. Someone may be lucky enough to be in one county where they get help, denying few people, or unlucky enough to be in another county that denies many. There is no data to suggest that the people of San Francisco are more likely to be gravely disabled than those of San Diego.

Yet 7 out of 10 San Franciscans are conserved versus less than 1 in 10,000 San Diegans. During my time working in the LA County Jail, inpatient settings, emergency departments, and the community, I have met innumerable patients who cycle through the system without getting the long term consistent high level of care that they need to stabilize their symptoms.

This requires stable housing, as we know, building relationships with providers and peer supports, and a comprehensive individualized treatment plan. As an example, an ITP cannot just say improve independent hygiene. It must have a long term occupational therapy component that helps people walk through the steps of that process. These are things that are currently missing in our process.

So SB367 is really about tightening up LPS conservatorship laws to increase access to life saving treatments for those in need, to improve appropriate oversight of the conservatorship process and conservators, and to better connect conservatorship with the full continuum of care.

A core component of 367 is a focus on these evidence based individualized treatment plans with the goal of transitioning individuals to less restrictive levels of care sooner and with more success.

You know, we understand that many if not most individuals with chronic serious mental illness will go through periods of more stability and periods of worsening of symptoms and functional decline. Therefore, a flexible system that allows for coordination of care through high quality ITPs that are created with the patient as much as possible are really critical.

Thank you, Madam Chair Members. Again, I'm Dylan Elliott here on behalf of the California State Association of Psychiatrists. Just want to begin by thanking Senator Allen for his leadership on this measure and you, Madam Chair, and your Committee staff for the hard work on the amendments, really do think that they improve the Bill in a meaningful way.

I think Senator Allen and Dr. Wood have really outlined the nature of this Bill and why it's necessary. I just want to spend some time clarifying some of the concerns and explicitly saying what this Bill does not do. It does not change the threshold that must be met for an individual to be conserved.

It does not take away discretionary authority for public conservators or judges. And it does not force people meaningfully willing to accept voluntary treatment into conservatorships. Again, we are proud of the work that the Committee amendments do. We believe they address many of the concerns that have been raised by opposition.

First include narrowing what providers assessing individuals for an involuntary hold must consider.

They clarify that the expansion of providers who can refer to the public conservator have an established relationship with the patient and are treating them for a relevant condition and ensure that recommendations for conservatorship consider an inability to follow through with relevant plans for self care rather than something that could be interpreted as a plan, but as in fact something more trivial.

We recognize a lot of components of this Bill. We think it provides a really systematic and deeply interwound set of fixes to the behavioral health continuum of care and to better ensure that the most vulnerable individuals in our state are receiving appropriate care. Thank you for your time and happy to answer any questions.

Thank you, senator Allen. We're actually going to take a quick recess. We're having a printing error and I don't have mock up amendments for my Committee Members, so we're just waiting for that. So, senate Health will take a quick recess until we get that.

Senate Health Committee is back in session. Now is the time for me too's in support of SB367. Please type your you say your name, organization, and your stance.

Thank you Chair and Members. I am Moira Topp. Here on behalf of San Diego Mayor Todd Gloria. He is a co-sponsor of this important measure and respectfully asks for your aye vote.

By expanding conservatorships, SB 367 will take away more people's rights and subject many of them to grave injustices. We ask for your opposition. Thank you.

Thank you.

Angela Hill on behalf of the California Medical Association in support.

Thank you. Seeing no others for me too's in support. Is there any lead opposition for this Bill? You may begin when ready. You have five minutes total.

Thank you Chair and Members. Samuel Jan with Disability Rights California. We thank the author for their engagement and the Chair and Committee staff for their work on amendments. The amendments address several of the items that we raised, but we still have remaining concerns and are here in opposition to SB367.

SB367 makes it easier to place people on conservatorships and harder to remove them. Conservatorships are legal instruments that take away an individual's fundamental rights, such as the right to choose where they live and the right to control their own finances.

Conservatorships should only be used for the most impaired individuals and only for the least amount of time needed. However, they are frequently overused and individuals on conservatorships are more likely to be subject to abuse, neglect, and financial exploitation. This includes high profile cases like Britney Spears.

Nearly two decades ago, I worked in a for profit locked psychiatric facility that primarily served individuals on conservatorships. The first thing that you noticed when you walk into the facility was the smell. The air was thick with urine because many patients were so over medicated that they could not get up to use the bathroom.

As a 20 year old kid, I was tasked with leading takedowns, placing people in restraints, and holding them down where they're forcibly injected with powerful sedatives. These incidents happened constantly. We were not properly trained on how to conduct these interventions and patients and staff got hurt.

Conservatorships subject individuals to abuse, neglect, and warehousing in facilities like the one I worked in. Instead of expanding conservatorships, we should focus on upstream interventions like housing and high intensity outpatient services that help prevent the need for conservatorship in the first place.

Madam Chair and Members. Michelle Cabrera with the County Behavioral Health Directors Association of California. CBHDA is opposed to this Bill as it adds a number of new requirements for counties in terms of how they administer LPS.

At its core, LPS is about establishing due process standards to protect against the indefinite involuntary detention of individuals with behavioral health conditions. However, when it was passed in 1967, the LPS act was structured as a transfer of responsibility from the state to the counties with no dedicated resources.

In fact, lawmakers at the time put on the record the statement that, quote, "the Bill makes badly needed procedural reforms but does not enact new financing or administrative changes on the state or county level", end quote. This statement is important because it establishes the basis for local control and discretion in how LPS is structured.

In the years since its passage, this shift has been largely recognized through the closure of state hospitals. In 1957, there were approximately 36,000 individuals in California's 14 state hospitals. Today, our state hospitals serve a fraction of that number. 6,000 individuals across five hospitals.

With almost every other law passed by the Legislature, it is understood that new mandates require state funding in order to implement those changes.

The trade off with LPS from the start has been local control in exchange for that transfer of responsibility without resources. This Bill would significantly remove that local control while still not resourcing the desired policy shifts that the author and sponsors seek.

It would require counties to respond to referrals without the funding to hire the staff needed to responsibly follow up. It would require counties to duplicate existing requirements embedded in insurance coverage laws and regulations under Medi Cal and commercial insurance that did not exist in 1967 when the LPS act was established.

And our Members fear that by adding new upfront requirements to the criteria to be considered in placing a 5150 hold, it will actually increase legal challenges and compromise our ability to save lives by involuntarily detaining those who might be a danger to themselves or others.

In addition, vague concepts in the Bill such as a failure to address self care are not defined in state law and would drive more additional inconsistencies and legal challenges which will serve as new barriers in connecting individuals with needed care.

We would argue that insurance coverage, both in medi Cal and commercial insurance, is also severely lacking and contributes much more to the issues raised by the author and sponsors. For these reasons, we must respectfully oppose this Bill.

Thank you. Me too's in opposition. Name, organization.

Deb Ross with Disability Rights California here on behalf of Mental Health America of California opposed to the Bill. Thank you.

Molly Maula on behalf of California Association of Public Administrators Public Guardians and Public Conservators with respectful opposition look forward to ongoing conversations with the sponsors and author. Thank you.

Thank you.

Maya Angelou with Call Voices in opposition.

Thank you. Lynn Rivas, California Association of Mental Health Peer Run organizations in opposition.

Thank you. Coming back to the dais. Seeing no questions. You know, Senator, you, you and I. Oh, Senator Durazo.

This is a broad, broad question, but obviously there's some big disagreement here. I don't know if you think that there are specific things that you could work on that would help to close that gap or, and kind of like how do you, how do you see responding to those?

Well, you know, but certainly there's some details I definitely want to sit down with administrators to chat with them. I think the amendments at the very least should go a significant way toward addressing some of the opposition's concerns, but I understand, you know, that there's still some outstanding concerns.

I mean, at the end of the day, this doesn't change the you know, the requirements that have to be met to get a conservatorship.

It just talks about, you know, it basically clarifies what has to be considered by providers who may be prematurely discharging patients or, you know, don't have an avenue for referring them to the public conservatorship for a public conservator. So, you know, I think that, I mean, I guess, I guess the challenge here is how much are we.

There's tension from previous legislation, right? I mean, Senator Eman's legislation and other, you know, previously passed bills. When I say tension, I don't mean in between us, I just mean, you know, kind of in the policy discussion space.

But, you know, I'm certainly very committed to working with the opposition and seeing if we can, you know, address whatever concerns they have. They go beyond kind of the broader philosophical concerns about 5150s. I mean, if people don't like that model, this bill's,

to the extent that this Bill is continuing or expanding, people who can offer those 5150s, then we're probably not going to agree. But in terms of tweaking the details, so open. But I don't know if any of the witnesses on either side want to comment.

I think that, I mean, I think some of these are philosophical disagreements so that, you know, that's something we will be continuing to work on. It is always assumed that every individual that's on a conservatorship really doesn't want to be, and that is not the case.

I have had numerous patients, especially those who have been in and out of the jails, who when I'm with them in the inpatient setting and they're receiving better care

and we discuss what a conservatorship can get for them, have requested and to be on a conservatorship because they understand that they have a real difficulty when they leave, the places is continuing on with their care. They have done it over and over.

They can foresee that they will struggle with that and that they want there to be more support for them. And I know that goes against the sort of concept of what it means to do this voluntarily, but I think it's really important to recognize that that's a critical component. Also.

There's a vast difference in how public guardians and how the behavioral health departments work with these, with these patients. And that's the thing we're trying to rein in. We know that this is something counties need more support probably monetarily on.

And also it shouldn't be so different from county to county to be able to get the right care.

And in conversations with the author, you know, the goal here was to not address and getting more people on 5150s, the goal for him were the people who are already on these codes and then get discharged and are cycled in and out.

I know that all too well as I used to drop off patients to these psych hospitals and sometimes I would get the same patients going in and out. So, in conversations and some of the amendments we're trying to finesse that right question. Hey, the focus should not be at the beginning.

It's the focus where we're trying to put the onuses on. Once they're in the system, how do we then keep them? Do they need more higher care, level of care? And that's where the amendments we're trying to get to.

And I know there's going to be still a lot of work, but we were pushing the focus away from the 5150s holds in the beginning and more so on. How do we then do we transfer when appropriate? Because you're right, you know, I know what some of these psych hospitals are doing, especially the for profit ones.

It's not a scenario where I want to put a lot of people in. I'm very mindful of that, but we were just trying to make sure again some of the amendments were striking out who can recommend someone to be on LPS?

You know, I didn't want an array of people just off the street, just wanted people who had a direct connection. So, I know there's still going to be a lot of work on this, but that's the shift we were going to.

Thank you, Chair. Thank you, Senator Allen, for presenting this Bill and allowing us to have this conversation.

Really want to thank the chair and staff for the amendments because prior to the amendments it was very broad and, you know, and so I, you know, although I still think there are some things that are pretty broad, like self care, but we have that caveat now. But I would like a little bit more discussion.

And I'm not sure if the opposition has seen the amendments, but one of the things that, you know, struck me and is the possibility, and I think someone mentioned it, the possibility of increasing the number of patients that actually end up on conservatorship.

And I know in your opening you were saying, oh, well, there's this great disparity between San Francisco and San Diego, as if San Diego should have more. So, could you elaborate on that a little bit more? And then, you know, let us, let me know if that's something that you see based on this Bill.

If I may respond, Dr. Weber Pierson, there are several elements to this Bill right. So, there's the attempt to, as the sponsors say, apply more consistency across counties in how they do evaluations.

While that is a laudable goal, applying new LPS specific criteria will be an unfunded mandate that sits on top of existing medical necessity criteria that exists in insurance laws that did not exist in 1967 when LPS was passed.

And so clinicians who are doing evaluations around level of care, admission, etc. They are looking at those criteria to determine the appropriate setting for treatment. LPS really has to do with is that treatment something that this person can and should consent to or not? Right. Is it happening voluntarily or against their will?

Because constitutionally, we all have a right to make medical decisions for ourselves. And this basically creates that exception to that constitutional right and the due process procedures legally that come along with that.

So in trying to define what we have to do in terms of that evaluation criteria specific only to the involuntary nature of treatment, we are essentially, again, layering on top of existing insurance and clinical decision making brand new criteria without any means to staff that appropriately to implement it. There's no funding structure.

It's basically what I'm trying to say is the trade off historically was local control in exchange for no state resources. And we don't have many places in law that exist like that. So this is LPS is weirdly an anomaly. Like historically, these Bills don't go through appropriations even if they add a bunch of new responsibilities.

Which is why I'm raising these issues in policy, because we won't have an opportunity to discuss fiscal impact.

And that's real because at the end of the day, in order for our doctors to get the quality and outcome changes that they want, the consistency in how these policies are applied, we need more people to do things in a standardized way. And that is what is lacking in the legal framework.

It's a problem that was created in the 1960s. The other piece that has to do with sort of increasing referrals kind of goes back to the same thing.

If we as counties are required under LPS law to entertain brand new referrals from a bunch of new sources, but we don't have additional resources from the state to accommodate that, our partners here are going to continue to be deeply disappointed and upset with the counties when really it's not that we don't want to identify, and resource, and support those people in much better quality settings than the one that Samuel worked in back in the day.

We want that. But fun fact, the Federal Government also does not cover inpatient and residential treatment for mental health and SUD conditions under Medi Cal and hasn't since the inception of Medi Cal. And we all know what access to commercial insurance is like, I don't think I need to say much there.

So, you know, the structural issues and access to behavioral health really come back to the origin story for both insurance as well as LPS act, which is people thinking that somebody was going to come along and provide a service that nobody wanted to really pay for.

And again, BH Connect is going to allow us to do some short term mental health inpatient reimbursement under Medi Cal for the first time ever, but that's for a limited number of days. It still won't cover the most severely sick the longest term needs.

And you know, we really agree with a lot of the concerns from the behavioral health directors, particularly the capacity concerns. I'll just highlight three specific things that we feel like are going to significantly increase referrals for conservatorship and thus increase conservatorship. So the first one is, it greatly expands who can actually refer recommend conservatorship.

And that includes any treating physician. And the amendments do narrow that and we agree that moves it in the right direction. But there's still nothing that says how long, long ago that physician needed to treat that individual.

And that's a pretty significant expansion of any treating physician for grave disability criteria when currently it's limited to actual entities like the county. There's another provision that says that anyone who recommends conservatorship can actually contest the sufficiency of that investigation.

So, as Michelle stated, that that's going to raise, you know, huge issues as far as capacity and be a big expense for the counties as well as mean more people are going to be on conservatorship because of that.

And we didn't want to touch that, and we left that for our counterparts in Yudish to focus on, which is why we didn't touch that part.

Yeah, that makes sense. Thank you, Chair. And then the other one I'll highlight is, the Bill bypasses the requirement that an individual who is willing and able to be voluntary cannot be placed on conservatorship. So we are very concerned about that provision.

You know, this is a core tenet of LPS, is that people who are willing and able to receive voluntary treatment should not be subject to involuntary treatment, including conservatorship and we feel that even with the amendments that, that provision is bypassed in this Bill.

I'm sorry, can you restate that last thing again?

Yes. So, one of the requirements currently under conservatorship is that an individual cannot be willing and able to be voluntary to be placed on a, so if an individual is willing and able to receive voluntary treatment, they cannot be placed on a conservatorship.

So, we feel that even with the amendments, the Bill bypasses that requirement, and people who are willing and able to receive voluntary treatment can still be placed on an LPS conservatorship.

So could we get a little bit more clarity, like, why would we do that?

Yeah, that last part is actually, I'm so glad you brought that up, because this is exactly the issue. There is actually, it's important that he said willing and able, so a person can be willing to accept care and not able to participate meaningfully without assertive, without people asserting that they will help them.

So I think, I actually completely 100% agree with what is being said, that we all agree that if a person is willing to get the treatment and is able to get the treatment, as in, they can be in a situation where they will continue to get it. We 100% agree.

The issue here is people who have demonstrated time and again that they are not able and/or there is a clear clinical indication that they will not be able to, given what we have seen with them in the hospital.

Right. But I think what he just said is that there are provisions in the Bill where you can get around that. So you can be willing and able but still be placed under conservatorship. Is that what you were saying?

Yes. Yes. Under current law. And there are two components to voluntarily, so you have to be willing and able. And this Bill would bypass that. So even for individuals who were willing and able to get treatment voluntarily could still be placed on a conservatorship.

And it's the provision that it used to be stated plans of self care, and then that was changed. But it's that provision specifically that we have that concern with.

And that's the one we were talking about. We took out the word stated and now self care is only as it relates to them being gravely disabled. So, it's not just your inability to care for yourself, it's your inability to carry for yourself as a result to you being gravely disabled.

Right. But because it's an or, individuals can still can still be placed on conservatorship even if they are willing and able to receive treatment.

Madam Chair.

You had something to say to that.

Yeah. If I may, I think what our perspective on what the language says is that it requires a consideration of a verbal willingness to engage in treatment, but that it still requires a finding of grave disability in order for the individual to be conserved.

That does not trump that there are still two distinct components to that conversation that must take place. While that would be a consideration, if an individual has said multiple times, I'm going to engage in treatment, I'm going to engage in treatment, that hasn't taken place, this would now require a consideration of that.

But a grave disability as defined in statute is not touched by this Bill, would still need to be found.

In effect, yes. And that's how I understood it. Because personally, I wouldn't be okay with that. And that's how I understood it. But if, of course, we always need to further clarify, and I know the Senator is on board. Or even further clarify absolutely that there's not an or.

Because that's right.

It's an and.

This is factors of consideration. What Dylan said expresses our intent. So if we need to clarify that further, happy to do so.

Yeah. If I could just, from the sponsor's perspective, we 100% share that goal. This is not, we're not trying to overlook that component. This is not. If you've said you're going to get treatment and you aren't, that you are now going to be placed on a conservatorship, that is in no way the intent of this Legislation.

I mean I think that the only concern we would have about this language around the individual's plans for self care if relevant to being gravely disabled, it says the person has demonstrated an inability to follow through with, these self care related to grave disability.

And I think the challenge there is, inability could mean you're low income, there's no coverage, you don't have a transportation and so by virtue of being poor you could be at much higher risk for being conserved, which you already are. But.

And I specifically ask those questions because I gave the scenario what if you're living in a car. Exactly. So I, it was my intent to make sure that we addressed that. But I don't want to spend the rest, you know, this isn't the place to have going back and forth in negotiation with the languages.

We provided some amendments. I do recognize there's going to still be because I also said to the Committee here and the authors, like this is a big, big, big Bill. And we did as much as we could recognizing this is the first policy Committee and it would continue to be addressed moving forward.

And Senator, you even mentioned is keyed fiscal Bill.

Yeah.

So, it will be addressed there as well.

But let me just say I welcome the expertise of this Committee, especially after the, you know, I mean this is a good discussion because I think we're, I think that clearly we've got to tighten up some of the language to meet our intent and not allow for the kinds of scenario that has been raised by our friends in the opposition.

So I welcome the Committee's engagement actually as we further.

Thank you Senator. I did, you know, I jotted some notes out there. I appreciate that my Committee will be in conversation.

I really appreciate that.

And Senator Umberg and the Chair of the next Committee has been very well engaged in this process and I know he'll have something to say on this vote as well. Seeing no other questions, I'd like to give you an opportunity to close.

No, I appreciate the robust discussion, welcome the Committee's engagement to get these issues, these intent issues firmed up. This is going to Judiciary and approves. So it's got a, it's got a long road. But I really look forward to further work with the Committee as we hone the language and with that I respectfully asked for my vote.

Thank you so much. Motion in front of us is due pass is amended and we refer to the Committee on Judiciary. I need a motion moved by Senator Richardson. Please call the roll.

Menjivar. aye. Menjivar, aye. Valladares. Durazo. Aye. Durazo, Aye. Gonzalez. Grove. Limon. Padilla. Richardson. Aye. Richardson, aye. Rubio. Weber Pierson. Aye. Weber Pierson, Aye. Wiener. Aye. Wiener, Aye.

Thank you Members, and thank you to all the witnesses. Thank you. Thank you so much.

She had. Yes. And I have. I brought an extra one. She just kind of followed along on. This bottom part, but I do have more. That's the one she's been using. I do have a more detailed one of you. Okay. If you want that kind of like.

Okay, that vote has 5 to 0. We will leave it open. We will now move ahead to file item 11. SB68 Senator Menjivar, thank you so much.

I appreciate the Senators that allowed me to go in front of them as we have a lot of nine year olds here that are wanting to voice their stance on a specific issue. SB68 Senators is really near and dear to me.

The Adde Act ever since I was a little girl, I've been called the bubble girl because I'm allergic to a lot of things. In her pantry you will see an array of nuts related snacks that I can't partake in because I'm deadly allergic to everything under the nut family. I'm also really allergic to 80% of fruit.

I don't remember what watermelon tastes like. Melon, cantaloupe, papaya. Because since I was a little girl I was allergic to it. In fact, in third grade when I thought I was no longer allergic, I had a big slice following cheerleading practice. Yes, I was a cheerleader in third grade.

I had to get sent to the ER because my throat completely closed up and I was unable to breathe on my own and I actually got intubated. Fast forward to 19 years old. I started becoming allergic to peanuts. So I definitely remember what Reese's Pieces taste like and Snickers, making the situation even sadder.

However, it took me a little while to really understand what these allergies entailed. Understanding what foods had nuts and so forth. So in my mid-20s I went to eat with my mom at Red Robin. I ordered a pesto pasta not knowing that pesto was made out of pine nuts.

We continued shopping and I started feeling really different and I was starting to learn what my body did when I having an allergic reaction. The moment I lost my sight, TMI became incontinent. I couldn't speak anymore. My mom thought I was dying in front of her eyes and she couldn't find the hospital.

That is one of the three instances in my life where I've been sent to the ER because I've eaten something at a restaurant. Another time I ordered an horchata, a very common Latino drink that is always I feel I could drink.

But this restaurant decided to make it with almond milk without putting any disclosure on their menu that their horchata, unlike any other restaurant, was made with almond milk. That sent me to the E.R. new Year's Eve and I spent my New Year's Eve in a hospital because of this. This lack of disclosure are very life threatening.

So SB68 wants to change that for the 10% of individuals who have a life emergency threatening allergy. We want to make sure that while. Yes, you have to carry your EpiPen everywhere. Yes, you have to make sure what's in the food, but we want to make it a little easier for you.

Don't you want to go to a restaurant and have that restaurant tell you what is in that food? Oh, wait, if you go to the EU, that is already happening in Europe. Since 2016. Since 2014, restaurants have disclosed what's in their meals.

When I travel over there, I get so excited because I don't have to worry about if I'm going to die today from the food that I eat. So SB68 is looking to do what a lot of restaurants are already doing. Disclose the main allergens that are FDA mentioned and put them on their menus.

Madam Chair, I'd like to turn over to the heartbeat behind this bill. The individual who brought this issue to my attention, even though I've been a bubble child my whole life. I don't know why I didn't introduce this, but she's the reason why we are here in front of you with SB68. Thank you, Senator.

We will now move to our lead witnesses. You both will have five minutes together. You may begin.

I'm Adde. I'm nine years old and I am in third grade. My whole class is with me today. I am allergic to dairy, peanuts, tree nuts and sesame. I have had anaphylactic food allergies since I was a baby. I always have to be careful and carry my EpiPen wherever I go.

But my EpiPen may not always be enough. I have to avoid the foods I'm allergic to since it's like poison to my body and can harm me. But how can I know it's in my food? To dine safely at a store, I can check the label. The top nine allergens are clearly stated in bold.

This keeps me safe at a restaurant. It's hidden like a secret. People may think it's easy to spot my allergens. Like avoid cheese and don't drink milk. Obviously avoid peanut butter. Nope. My allergens are often hidden. Chicken nuggets made with milk in the batter. Steamed veggies with butter, cashew used for dairy, free cheese.

Even my favorite food dumplings often have sesame oil in it. Often times I have to pack safe food wherever I go. But this is not always possible. I want to be able to eat out with my friends and like everyone else, how can I protect myself?

When we ask the waiter, they don't know for sure and often need to check. Most of the time no one knows for sure. Even when the chef knows, it's loud and busy. And it's like that game telephone. How do you know what they tell you at the end is true?

If they're wrong, I won't just get a rash. I could die. I have to trust what they say with my life. There must be a better way. Please pass SB68 ADDE so that restaurants will label the top nine allergens on their menus. This will keep me safe. I want to die an allergy safe.

I am one of 4 million people in California with food allergies. Please protect us. Please protect me.

Thank you.

Thank you Adde and thank you Chairwoman Menjivar for bringing forth this very important bill. Knowing what's inside our food is helpful. It's nice for most, but for people with food allergies, it's essential. It's life saving information.

Why is it that across 27 countries and the United Kingdom and the EU, menus have listed allergens for over a decade, yet here in California, they still don't. Good afternoon.

My name's Alexa Jordan and I'm proud to be here on behalf of the Asthma and Allergy Foundation of America, 30 state and national organizations and over 500 California medical professionals who signed our joint letter in support of SB68.

This impressive list of organizations standing in solidarity includes the American College of Allergy, Asthma and Immunology, the Food Allergy Nursing Association, the American Academy of Pediatrics, California and Stanford Medicine Children's Health. In addition, I bring forward the voices of 44,000 individuals who signed a petition led by the best friend of Dominique Brown.

We believe that SB68 gives diners and restaurant staff essential baseline information they need to engage in meaningful conversations to significantly reduce the risk of allergic reactions. This isn't the end of conversations, it's just the beginning. The status quo of today is no information.

Right now, customers must rely on verbal assurances playing that game of telephone that Adi mentioned. In the words of Amy Lewis from Carmichael. As someone who served people with severe allergies before forever developing her own, she knows from experience that knowledge of the menu is only as thorough as the menu itself.

At ahfa, we are open to many menu display options that ensure all allergen information is accessible to all patrons at point of sale and do not exacerbate existing disparities for the burden of disease of food allergy.

New measures to promote public health might seem daunting, just as indoor smoking bans did in California, U led the way in 1995, becoming the first state to prohibit smoking in restaurants. California set the tone once again in 2008, pirating the first menu labeling law for nutritional information.

We hope to celebrate California's leadership on menu allergen labeling as well. Thank you, and I'm very happy to answer any questions you may have.

Thank you so much. And now we will hear from any other witnesses in support. Please come to the mic. State your name, your organization, and your position.

My name is Andrea Reich, and I'm a pediatric nurse, and I'm in favor of the bill.

Thank you.

My name is Ina Plavia, pediatric nurse. In favor of the bill.

Thank you.

My name is Julia Magania. I am a Professor of emergency medicine at UC Davis. I tell you that not because I'm representing UC Davis's views, but for identification purposes only.

I am here in support of Adde bill because I have treated countless children who have presented to my emergency department after eating allergens that they were not aware of. And I am also here as a private citizen, an aunt of Gideon and Cyrus who have food allergies as well. Thank you for considering.

I'm Jay Mohsen, and I have allergies and I support.

I'm Caitlin Richter's mom, and I support. Thank you. My name is Renee Edwards. I'm Adde's teacher, and I support this bill. Thank you.

My name is Cara Cooper, and I support this bill.

My name is Zuri Gonzales, and I support this bill.

My name is Arden McCumber, and I support this bill.

My name is Owen Hall, and I support this bill.

My name is Osman Suri, and I support this bill.

My name is Max Fuentes, and I support this bill.

My name is Angelina Moradian, and I support this bill.

My name is Leo Tako, and I support this bill.

My name is Leo Holdow, and I support this bill.

My name is Callie Grundofer, and I support this bill.

My name is Alexandra Finnell, and I support this bill. So Adde can eat safely.

My name is Isabel Arnaud, and I support this bill.

My name is Frankie Perino, and I support this bill.

My name is Ryan Miller, and I support this bill.

My name is Grant Yonker, and I support this bill.

My name is Graham Mello, and I support this bill.

My name is Eleanor White, and I support this bill.

My name is Abby Bliss, and I support this bill.

My name is Khalila Donjo, and I support this bill.

My name is Dr. Serena Singh. I'm a budding pediatrician and also a food allergy mom to my son Lucas, and I support this bill.

I'm Dr. Katrina Marks, local pediatrician, and I support this bill.

I'm Dr. Roland Watson, pediatrician in training, and I support this bill.

I'm Dr. Alyssa Ota. I'm a pediatrician in training and I support this bill.

I'm Dr. Megan Branson. I'm also a pediatrician in training and I support this bill.

I'm Paul Huey, Adde's grandfather. I support this bill. Millions of parents are looking for more. Safe dining options to enjoy with children like Adde. Thank you.

Thank you. My name is Beverly Jan. I'm from Scotts Valley, California. I have the mother of two children with multiple life threatening food allergies, as well as at least seven other Members in our family who have food allergies. And I support this bill.

Thank you.

Good afternoon. My name is Christine Miyauchi and I support this bill. I am the mom of teens with several life threatening food allergies, and I want to bring the joy back to dining out for a family. Thank you for your time.

Thank you.

I'm Myra Harris, a student from Rio Americano, a student in the Civitas program. Program, which is our civics program, and I support this bill.

Thank you.

Hi. Kim Nichols, a severely food allergic person who developed allergies in my late 20s, and also the mom of a food allergic, allergic teenager. In support of SB68.

Thank you. Hi. My name is Shannon Nadamo. I am the mom of a child with food allergies and I would love to be able to take him somewhere to eat besides In N out. Although we love In N Out, the other kind of part of my life is I'm a pediatric gastroenterology nurse.

So I care for children with Celiac Disease, Crohn's, Ulcerative Colitis, Eosinophilic Esophagitis. Some of those conditions are partially controlled by elimination diets, and elimination diets are only as effective as they're able to be maintained. And going out to eat is very important to many of our kids.

And in order to do that safely, this bill would have to be passed. Thank you.

My name is Tyler Sutherland and I support this bill.

Thank you.

My name is Ben and I support this bill.

My name is Jennifer Sutherland. I'm a pediatric nurse and I support this bill.

Thank you.

My name is Jordan Magania and I support this bill.

My name is Robin Lazzarini and I support this bill.

My name is Liliana Green and I support this bill.

My name is Addison Rose Jewel and I support this bill.

My name is Isabella Lazzarini and I support this bill.

My name is Maisha McClure. I'm the parent of a 10 year old with severe tree nut allergies, and I support this bill.

My name is Meg Shafer. I'm a local pediatrician and I also support this bill.

My name is Georgia Hand, and my sister has food allergies, so I support this bill.

My name is Megan Hand. I'm a pediatric nurse. My daughter has food allergies and I support this bill.

Is that my name? Her name is Avery Paulus. She's allergic to nuts, dairy, and wheat. Last time she went to ER was on her younger sister's birthday. We ordered cake, we asked them three times what's in it, but they still sneak in like little teaspoon of almond milk and she end up at ER on her sister's birthday.

So we really do not want that kind of tragic to happen to us or to any of other kids or adults. So we support this bill. Thank you.

Thank you.

Good afternoon, Madam Chair Members. Jessica Moran with the, on behalf of the California Association of Nurse Practitioners and support.

Thank you.

Hi, my name is Ashley Kim. I'm the mom of a child with food allergies and I support this bill.

Thank you.

My name is Joshi Niverto, and I come from Los Angeles. Los Angeles Unified School District, more specifically.

I'm a therapist, and I would highly encourage you to include sign language in the language when provided because our kids need it. Thank you.

Thank you.

All right. Seeing no other witnesses in support, we will now move to lead witnesses in opposition. You will both have a combined five minutes. Thank you.

Thank you, Madam Chair and Members. Thank you, Senator Menjivar. And I'm impressed. I'm really excited about the civic engagement here. I'm Matt Sutton with the Restaurant Association. This is an issue we take seriously, we've taken seriously for a long time.

My friends will say that food is not the enemy, and we agree with that. We have restaurants of all sizes, and so we have independent restaurants, we have chain restaurants. We have all sorts of ethnicities.

And I guess what I'm getting at here is, you know, many of us think of restaurants as either two buckets, quick service or full service. And we've got a wide variety. I think there's 10 different concepts in the restaurant space. And that's what we're trying to sort of keep in mind here. I, myself am an allergy sufferer.

I carry an EpiPen. I have one on me now. My wife is allergic to almonds and all sorts of smoked products. I've got other family members allergic to eggs. I'm really proud of what CRA, the Restaurant Association, has done on this issue over the last 10 years.

I've been with the organization for nearly 20, and I'm excited about what we've done. We've done a lot of focus in this building and we've done a lot of focus with our members and beyond our members for best practices. I think specifically we have on the books a couple different laws.

And so I guess what I would just say here is we are absolutely, for the goal, we continue to work towards greater allergy awareness in restaurants. The issue is the complexity of the supply chains that we deal with.

They are ever changing, and we need to keep up with them for a lot of different types of restaurants and food establishments. That's why we have focused in this building in the past on getting more allergy awareness into the training programs for restaurants. And we have that on the books.

The staff analysis mentions two of those that we have. And we have, you know, current law is SB 1067 that requires a food safety certification exam for every food facility to include all major food allergens and the symptoms that those allergens could cause individuals. The next one is AB 1532.

And that required that elements of knowledge related to major food allergens, foods identified as major food allergens, and the symptoms that a major allergen could cause in a sensitive individual would also be included. So those are things that we're very proud.

We're proud to educate the restaurant community about those, and we are excited about a number of resources this bill requires on menu printing. We have a vastly dynamic supply chain network, and this bill, we believe, takes a static approach.

No doubt technology was coming into the restaurant space prior to the pandemic, but during the pandemic, we all saw QR codes for menus, for ordering, for all sorts of things. Those are more wildly popular than we ever would have believed with consumers, and so they're here to stay.

And we think that getting real time information on such sensitive information is probably the best resource that a diner like myself or a diner like others that are sensitive to these issues need. So it's quick, it's real time, and we hope dynamic enough to stay up with the supply chain changes.

Happy to talk more, but would like to reserve some time here. So thank you.

Thank you. You have Two minutes.

Good afternoon, Chair and Members. I'm Craig Fontenot. I'm the Chief of Staff at FARE, Food Allergy Research and Education. I'm here at the request of Dr. Sung Pobletti, CEO of Phar, who is unable to attend in person. On behalf of FARE, we respectfully oppose SB 68.

We appreciate Senator Mengavar's leadership in fostering dialogue between the food allergy community and restaurants. This is not a position we take lightly. Fair's mission is to improve the quality of life and health of those living with food allergies through transformative research, advocacy and education. We have invested over $190 million towards that mission.

More than 33 million Americans suffer from this potentially life threatening disease and as said earlier, almost 4 million Californians. FARE is working closely with the California Restaurant Association and other partners in the industry to create a shared responsibility for providing safer dining experiences. We believe a solution engaging all stakeholders is the right path forward.

Unfortunately, SB's fixed SB68 focuses narrowly on menus as a point of risk disclosure. But menus cannot capture allergen risk introduced through sourcing, manufacturing or even cross contact during kitchen prep. As written, the bill would create a false sense of security for food allergy families.

Moreover, the bill prioritizes litigation and penalties before we've had a chance to collaborate on solutions. And the timeline of July 2026 risks driving rushed, unsustainable fix. Many restaurants, particularly small and family owned businesses, may respond by excluding food allergy diners altogether or face financial hardship. California is a culinary leader.

We can build a model of true partnership that sets the standard nationwide protecting food allergy families without unintended harm to businesses. We look forward to further discussions with the author and stakeholders to find a comprehensive end to end solution. Thank you for your leadership.

Thank you so much. If there are any other witnesses in the audience that are here in opposition, please come to the mic. Give your name, organization and position. Seeing no other witnesses, I want to thank all of our witnesses and I will turn it back to our Members to see if there are any questions or comments. Senator Wiener.

Move the bill.

Senator Wiener moves the bill. Any other questions or comments? Senator Durazo?

Yes, thank you to the author. Could you explain? I guess there's different ways that foods would eventually get into a restaurant or even a store. And so where does the responsibility or liability start and end?

Not just liability, like legal liability or financial liability, but everybody wants to be able to prepare a dish or package food without the issues faced through allergies. So how do you Best do that without. I think there was just one thing that the gentleman just said without creating this false security that, zero, everything is.

Everything has been checked. When sometimes it may be impossible. I'm not sure.

Sure. There's already a false security now, right. Because waiters, waitresses, have to tell someone who's consuming. If they ask, they're like, zero, I think it doesn't have anything.

And you've heard examples where even last weekend at the Latino Caucus retreat, I said, I'm allergic to nuts, and they brought me, at the end of dessert, a dessert with nuts, and I started eating it because I had already mentioned it, and I realized they had nuts in it. There's already a false sense of security.

This is actually going to move us forward. Additionally, you can see if you have something in front of you. The nutrition label says what the item has inside, and then at the bottom, it says, was made in a facility that manufactures a yaz. And I have that phrase memorized because we always have to stare at that.

What we're looking to do is what the food is made with. Just like you see in some restaurants that do this already. You see at the bottom in fine print. This item has shellfish. This item has nuts. This item has three nuts. That's where we're looking to end and start.

Well, I want to thank you, Senator Menjivar, for bringing this bill forward and for allowing us to discuss it. I want to thank Adde for your testimony and all of our young constituents who came and testified today. It just warms my heart.

My boys are here on spring break, and I tried to get them to come today to testify for my bill, and they said, absolutely not. I am really excited to see all of you with that. The motion is do pass. Oh, go ahead. I'm sorry. Yep.

My apologies. Menjivar. First of all, thank you so much for bringing this. Thank you to everyone, all the kids and the pediatricians and the parents.

And I can only imagine what it is like to be the parent of a child where you have to, like, for all the millions of ways that parents have to, like, watch out for the safety of their child and all the different risks. Just one more thing, like one little slip, you know, that could.

So I thank you to the parents because I know it's just this additional burden and stress that you bear out of love. This is just incredibly important. And I know I don't have food allergies, thankfully, but I know people who do, and I know how scary it can be. And this is a matter of life and death.

I also know that this is. We're early in the process, and obviously it's important for this to be implementable by a wide array of kinds of restaurants of different sizes with different levels of staffing and different resources.

And so I'm confident that as we go from the beginning of the process, now through the process, there will be ongoing implementation logistical conversations. And so I'm happy to support the bill.

Thank you, Senator Wiener. With that, the motion is due. Pass and rerefer to the Committee on Appropriations.

May I close?

Oh, I'm sorry, yes. Would you like to close?

I do the same thing.

You know what I see.

Something happens when you sit in that chair.

I know how that happens.

I'd like to close and address what Senator Wiener brought up. You're 100% right. I had a meeting with the opportunity position February 26, and I asked for amendments because the concerns they brought up, they brought up to me in the meeting.

I followed up on March, March 3, and then April 1, asking for amendments, and I received nothing as a response. So I have opened my door for collaboration and conversation, but I have received nothing in return and will continue to have my door open and am amendable for things.

But there has to be another person on the other side to have a conversation with without respectfully asking for an Aye vote.

Thank you, Senator Mentravar. Assistant, please call the roll. Motion once again is do pass, as amended and rerefer to the. I'm sorry, do pass rerefer to the Committee on Appropriations. Assistant, please call roll.

[Roll Call]

4 to 0. We'll put that on call.

Stern, we're going to wait till the hustle and bustle gets out.

Senator Wiener, we're going to start on file on 5 SB363, is that correct?

Yes, that's correct, Madam Chair.

We're going to wait till the door closes here. It's a little loud out there. All right, Senator, you may begin.

Great. Thank you so much Madam Chair here today, colleagues to present Senate Bill 363 and I'm happy to accept the Committee amendments outlined in the analysis. I want to thank the Chair and the Committee for working with us on this bill.

Colleagues, we know that denials of health insurance coverage happen all too often and can result in devastating consequences for patients when they are denied medically necessary care that can often be life saving.

Senate Bill 363 provides long overdue transparency and accountability for health plans by requiring health plans to report data on denials and modifications to provider recommended care.

It also imposes fines, significant fines so that they are not just cost of doing business fines to hold plans accountable when they have an unreasonably high rate of denials being overturned during the independent medical review process.

Right now when we have very, very little insight into health plan denials, we have a sense we can sometimes cobble together data but we do not have comprehensive data. When a physician prescribes treatment and it's denied, there are very few reporting requirements and so very little publicly available data.

And so that results in a lack of transparency accountability so that we can make necessary reforms. And again, we all know these can be life or death decisions.

Last year, you may recall, actually the last two years I have attempted and this Committee has passed, but ultimately Appropriations Committee did not agree bills to trigger automatic independent medical reviews for certain kinds of behavioral health treatments for kids. This year In Senate Bill 363 we are really trying to get to the heart of the matter.

And so the bill will require much greater data transparency and it will also we know that the rate of over of health coverage denials that are overturned during the independent medical review process is very high and it is well over 50% sometimes into the 70s when you're talking about mental health.

And what that says is that because we know that most people may not even know that they have the right to an independent medical review. They may not have the wherewithal or the time to seek it. We know that IMRs are overwhelmingly sought in English and so non English speakers are seeking IMRs at a much lower rate.

And so when we have IMRs health care denials being overturned at such a high rate, that is the tip of the iceberg. And so when we have a health plan that is being overturned at a high rate, over 50%.

There will be a significant fine, and if it keeps going, the fines will escalate so that we have actual accountability and an incentive for the health plans, not just to view this as a cost of doing business. So, colleagues, I ask for your support on Senate Bill 363.

With me today to testify is Christine Matlock-Doherty, who's the mother of Ryan Matlock and Dr. Ijeoma Ijaku, a physician and President of the California Academy of Child and Adolescent Psychiatry. And then for technical questions, if they come up, we have Colleen Corrigan from Children Now.

You may begin. You both have five minutes total.

Hi. My name is Christine Matlock-Doherty. My son, Ryan Michael Matlock, was born July 8, 1997 and died March 23, 2021 at the age of 23 from a fentanyl overdose.

As much as I would love to talk to you today about how well liked he was by everyone, his amazing blue eyes, his kind heart that cared about everyone, or his infectious laugh, I'm here today to talk about how my insurance company let Ryan, me and my family down by not approving his provider's recommended care for him during his time of recovery and addiction.

I still remember the night Ryan came to me and said, "Mom, I need help. I can't do this anymore." He had tried rehab before, but this time he said to me, I need help from someone who understands what I'm going through.

The facility he had been in previously, which was recommended by my insurance company, did not treat fentanyl specifically, which is highly addictive and is what he was addicted to. So this time we asked the insurance company to help us find a facility that specifically dealt with fentanyl for three and a half weeks.

I heard him every day on the phone talking to our insurance company, trying to get them to find an appropriate place for him to go. Three and a half more weeks, he had to suffer this horrible disease. So we did the research.

We found the place that dealt with his addiction, and we did the paperwork and submitted it to the insurance company. I remember the day I dropped him off and he said, mom, "I'm going to make it this time. I'm tired of living like this."

When we arrived, it was recommended that Ryan undergo seven days of detox, followed by 90 days of residential treatment. But after three days in detox, after Ryan was put on withdrawal medication by his doctors, my insurance company said his vitals were good and he was no longer having suicidal thoughts, so he could go home.

Not to another rehab, not to a residential facility, but home. This was contrary to what his doctors, psychiatrists and counselors all recommended. It never dawned on me that after three days that Ryan would be able to go home.

We were told by my insurance company that since he had been in prior treatment programs that he already knew what to do and he did not need the level of care that was recommended by his physician and care team.

I was told this was directly contrary to ASAM standards and because he had relapsed and recently overdosed right after leaving the residential facility in the past, he needed a higher level of care, not a lower level of care. I put in an appeal. Ryan put in an appeal.

His rehab care team put in an appeal, but without ever speaking to my son. Our insurance company denied the appeals. The insurance company said he did not need support.

You're feeding into her time or you're encroaching into her time.

They told me to go ahead and do that.

Okay.

Sorry. They told me to read it. Denied the appeals. The insurance company said he did not need more support. He could do it on his own in an outpatient program with only nine hours of outpatient treatment per week, rather than the 24 inpatient care seven days a week recommended by his healthcare team.

This denial and step down treatment came only three days after he started his detox. While he was still on detox medication. I remember on the phone we talked of how the facility was helping him get back on track.

They were talking to him about how to get his EMT license back and how to enter the fire academy, which was his dream since he was 4 years old. This program was working. He just needed more time. All of which was explained to my insurance company. But the insurance company wouldn't listen. They wouldn't talk to Ryan.

They kept referring to the chart that showed up his basic statistics, his vital signs, his age, and the fact that he had completed a 30 day program in the past and said he would be fine. They said they knew better than his physicians he could control the addiction if he only wanted to.

I remember him calling me and saying, mom, "They're going to release me soon. I'm not strong enough yet to do this on my own. I need help." That was the last time I spoke to my son. He was released the next morning and died 48 hours later from a fentanyl overdose.

Even after four years, there's not a day I do not think of him and miss him so much. We light a candle every night in his honor. Our lives will never be the same without Ryan. He wanted help. He asked for help. He deserved help. But was denied the level of support he needed.

Based on a generic chart of numbers, There's a hole in our hearts that will never heal. In his memory, I will fight for bills like AB363. So not another family faces the tragedy we live with today.

Good afternoon, My name is Dr. Ijeoma Ijaku. I'm a board certified child, adolescent and adult psychiatrist, Associate Professor of psychiatry and President of California Academy of Child and Adolescent Psychiatry. One of the co sponsors of this bill, SB363. My colleagues and I already stretched thin.

We do not have the time to be making calls to insurance companies trying to get them to approve services we already determined to be medically necessary. We should focus on patient care. For over 15 years I have worked with underserved and under resourced youth. And I know what happens when they don't get the help they need.

I have a six year old patient, ADHD diagnosed with ADHD who had who needed stimulants. Was on a generic stimulant that gave him some weird reaction. The brand stimulant worked. Insurance company would not approve of that. He deteriorated and he got kicked out of school.

Thank you. Thank you. Thank you. We are now going to turn to. Sorry, it was five minutes for both of you. That's what I was trying to tell you. You were bleeding into her time. It's okay. We will now turn to those for #metoos in support of this bill. Name organization in your position.

Good afternoon Madam Chair, Members. Mari Lopez with the California Nurses Association and strong support.

Thank you.

Nora Angela with Children Now in support.

Omar Altamimi, California Pan Ethnic Health Network. In support.

Katie Van Deynze with Health Access California and support. Thank you.

Good afternoon. Angie Minetti with the Steinberg Institute and support.

Hello. Michelle Johnston, National MS Society. Also in support.

Tim Madden representing the California chapter of the American College of Emergency Physicians in the California Rheumatology Alliance. In support.

Annie Thomas on behalf of the California alliance of Child and Family Services and support.

Good afternoon. Tyler Rinde on behalf of the California Psychological Association. In support.

Cher Gonzalez on behalf of my clients, the American Diabetes Association, Behemoth Council of California, the Association of Northern California Oncologists and the Medical Oncology Association of Southern California all in strong support.

Nicole Wortelman on behalf of the Children's Partnership and support.

Lauren Pinke of the County Forum and support.

Alex Kahn on behalf of the California Chronic Care Coalition, a proud co sponsor of the measure and The ALS Association and support.

Melissa Cortese on behalf of Autism Speaks and the Council of Autism Service Providers in support.

Ryan Souza representing San Francisco AIDS Foundation and support.

Sherry Daley with the California Consortium of Addiction Programs and Professionals in support.

Thank you. Seeing no other MeToos in support, are you the opposition? Yes, ma'am. Perfect. Any other formal opposition? Okay, the other party is coming. Only two people get to speak. Same rules, five minutes total. So I could stop you at two and a half, so it could be fair. Do you want to go first? Okay.

Thank you, Madam Chair, Members, Nick Louiseos, on behalf of the California Association of Health Plans, or CAHP, we are on opposition to the bill.

I'll try to keep it short here, but, you know, I just want to say, you know, we do represent 41 Knox Keen licensed health plans that are the backbone for coverage for about 28 million Californians. Our members process hundreds of millions of claims and paid $220 billion in claims in 2023 alone.

A testament to the scale and financial stewardship of our Members. You know, we do operate within a massive health care system, one that we acknowledge is not without its challenges. And we are committed to embracing sensible solutions. Unfortunately, we don't view this Bill as such.

You know, we thought we had a decent conversation with the author's office and sponsors. You know, I think, you know, there's a path to go on transparency.

And we pointed them to a final federal regulation on prior authorization that we think should be used as a model to avoid duplication, since our plans are going to be implementing those reporting requirements at the Medicare and federal exchange level.

But the penalty provisions in this Bill are just a non starter for us and they demonstrate a misunderstanding of imr. IMR is a venue to resolve differences of opinion regarding the medical necessity of a covered service. The practice of medicine is not an exact science. Unfortunately, it's nuanced.

And equally qualified and credentialed physicians can have differences of opinion about what the right course of action is for a particular patient. So to impose the types of penalties that are in this Bill that are on our Members we think is punitive and overreaching.

We do take the outcomes of IMR seriously, and our Members review their policies and procedures if they see trends in IMR overturns. And these are the basis of discussions with our regulator as well. So we just think arbitrary and excessive fines are not going to solve the problem.

So we're opposed to the bill and we have a physician here as well to talk about their experience.

I just. I do have opposition that was here first. I'd like to turn to you.

Yeah. And I will try to leave you some time if you want to pop in. If that works. Only two formal oppositions can speak. So. My name is Erin Friday. I'm the President Our Duty, a lifelong Democrat. And normally this would be a bill that I would support. However, there are two significant issues with it.

This bill will be used as a cudgel to pressure insurance carriers to cover medically unnecessary gender interventions like the 200,000 facial feminization offered to Luke by his doctors that encouraged him to enroll into the UC schools to ensure that this would be free to him.

Insurers who know that minors patients gender dysphoria will not be resolved by the removal of healthy breasts will be afraid to deny coverage. Like California Layla Jane who had her breasts removed at the age of 13 despite the carriers knowing that she had severe mental health issues.

Where is the data gathering on insurance providers who will only cover transition interventions but deny coverage for the thousands who want to return to appear as their natural self?

Ma'am, I want to make sure you're speaking on behalf of the actual bill. This bill does not call out anything like that. This is on IMR and if you're not going to stick to that, I'm going to go to the next.

The bill talks about following procedures for gender identity and for discrimination versus gender identity. So it's going to penalize insurers who refuse to provide gender interventions on kids when they know that it's wrong because they're going to be fearful of the administrative fines that they're going to receive.

So it's going to be more likely that these kids are going to get these interventions.

Clarifying that there's no specific call out to procedures in the bill whatsoever.

There's a whole list in the bill, if you read it, where it talks about gender identity.

What bill are you speaking on?

363.

There's no specific call out to any procedure in the bill.

There is on tracking. What are you tracking? You're tracking based on gender identity. You're not tracking detransition.

Demographic.

Right, but the demographic of detransitioners.

No, it's not the demographic tracking. If you're denying for a demographic not on a procedure.

You need to read the bill. It says gender identity.

Ma'am, you need to read the bill. I'm now turn to the next person in opposition. You may proceed.

Thank you, madam. Thank you, Madam Chair, Senator and Committee for considering the need for better accountability and transparency with our care decisions and thank you for sharing your story. My name is Gabrielle Gaspar. I'm Chief Medical Officer for Hill Physicians Medical Group. We are a risk bearing organization and have delegation with 14 health plans.

We serve about 475,000 patients in Northern California. I have direct oversight for our utilization management and care management services. We have a denial rate of about 2.5%. 80% of those are for out of network care. I'd like to share a story.

We have a patient who was seeking surgical care for her treatment and we approved it in network at a tertiary academic center. The patient wanted to have an out of network physician do the procedure in fewer surgeries against the clinical guidelines that we were using.

We went back and forth with the DMHC and the health plan for several months trying to resolve this and out of fear of a DMHC action, our denial was overturned and we were forced to allow the Member to go to the more aggressive physician.

A couple weeks later the patient had an adverse post operative event and required hospitalization for severe pain, swelling, fluid accumulation and infection. This is just an example.

This is just an example of While the intent of the bill is for transparency and accountability, the way it is written will force risk bearing organizations like ours who do a lot of hand holding coordination with patients to make decisions outside of good clinical judgment in order to avoid penalties.

So our concern is not about the intent of the bill. Our concern is about the practicalities that it interferes with our commitment and our oath to do no harm and our commitment to provide prompt access. We manage care locally with physicians we know and who we vetted and with facilities that we can trust.

And we have many, many examples of either DMHC or health plan overturns because of the fear, even without penalties, with the fear of the repercussions on the decisions that we've made. Thank you.

Thank you ma'am. Now I'm going to turn to #metoos in opposition.

Steffanie Watkins, on behalf of the Association of California Life and Health Insurance Companies, also in opposition. Thank you.

Madam Chair and members. Rand Martin, on behalf of the AIDS Health Care Foundation, which most people don't know is also a small managed care plan under Knox-Keene. We unfortunately oppose this bill. Thank you.

Thank you.

David Bollog, SFV Alliance. We are in opposition.

Thank you. See no others. Bringing it back to the dais for my colleagues. Questions? Senator Durazo.

Yes. Could you explain there's a particular reason as to the threshold that you've selected at 50%. Just explain that and why, what does that mean?

Sure. So we know that currently 72% denials that go to independent medical review are overturned. 72%. So we initially started with the penalties would kick in if a majority were overturned. We lowered it to 40%. In working with the committee, we're moving it back to the 50% plus 1 or 50%. About a majority or half. Yeah.

And so the idea is if you're being, if you're not magical about that percentage, it could be a little higher, it could be a little lower. But if you're being overturned at that kind of significant rate, there is a systemic problem and there should be like real accountability.

And unfortunately the fines that we often see now are low enough that they're viewed as a cost of doing business. And we also know that unfortunately the Department of Managed Healthcare does not have the strongest record of consistent enforcement.

Right. That's why I was asking if it was if the number should be lower, you know, because of that. I'm not, I'm not trying to negotiate that here, but it just seemed like it was a logical thing to do because of that.

We went with 40%, the Committee preferred 50 and we're happy to do that. So that's. Yeah, that was, it was a dialogue.

Right. We wanted to make sure that we got to a place where these fines would go, would be implemented if it was more than 50%. We thought 40% didn't meet a high enough threshold for the amount that the author was looking for to find.

Vice Chair.

Thank you. I would like to ask our opposition, can you share your experiences with independent medical review?

Happy to do so. So as I mentioned, many times our contested cases or appeals don't go to IMR because of eventual overturn at the health plan level due to wanting to avoid following through with an uphold and then going through the dmh.

But as a local risk bearing organization and we have an RKK, we have had one IMR in 2023, we had one good IMR that negative outcome puts us at 100% of IMR overturn. So this is our concern.

Because we are a small local risk bearing organization relative to health plans. We are not protected because there's not a base threshold and the IMR overturn is not put up against your overall number of claims, your overall denials, et cetera.

Vice Chair, this opposition came really late in our conversation and we weren't able to address any of the concerns. I do want to note that.

Yeah, I can also respond if you, if you'd like. Yes, thank you Senator. So yes, it was very late, not a criticism of anyone. It happens. It's this is the first, no, don't apologize. This is the First Committee. It's a long process and so we've already started to have conversations with the risk bearing organizations.

We'll continue to have those conversations. I do wanted to say that Hill is sort of like Brown and Toland. There are these different groups that it's complicated. They are type may not be classified as a health plan but they're still effectively providing coverage and making coverage decisions.

With that said, we understand it's a different kind of entity and we'll continue to have conversations with them.

So I'm not going to be able to get to support this bill in committee today. But I would like to see you work with the opposition on clarifying and.

Yeah, we will. We started to have those conversations and we'll continue to have them.