Assembly Standing Committee on Health

Review of AB 744 by Aguiar-Curry, statutes of 2019, and AB 32 Aguiar-Curry, statutes of 2022, both related to telehealth. The purpose of the outcomes review process is to assess, review, and improve implementation of key enacted legislation to ensure the laws passed by the legislature continue to improve the lives of Californians.

I wanna commend Speaker Rivas for launching a powerful new tool in the legislative toolbox to help us practice oversight of the legislation we passed and recognize majority leader, Aguiar-Curry, for bringing this outcomes review forward to the Health Committee, which he has served on for many years. Telehealth is not new to California. Our state first recognized telehealth in law thirty years ago with the passage of telemedicine development act.

In the decades since, a steady stream of legislative administrative and advocacy efforts built the pathway to expand access to telehealth services across the state. That groundwork mattered enormously. When the COVID 19 pandemic hit and in person visits became limited or impossible, California was already positioned to scale telehealth rapidly. Audio, video, and asynchronous modalities went into service to meet a wide range of medical needs, and that elevated used diff and and and that elevated use didn't disappear when the emergency ended.

Patients and providers adapted, and in many cases, they haven't looked back.

Patients and providers alike report high satisfaction with telehealth. A growing body of evidence indicates that telehealth can match in person outcomes for a range of conditions, including behavioral health. This is not a story of a stopgap measure that outlived its usefulness. It's a story of delivery of a delivery model that for many patients and many conditions continues to be a viable mode for patient interaction with health care providers. But it's not a story without its gaps.

Despite these gains, some disparities remain in who accesses the telehealth and who can use it effectively. That brings us to today's hearing. Consumer experience, evolving research, technological advances, and broader changes in our health care system have all driven legislative and administrative action to support telehealth's continued adoption.

Today, we're going to focus on our our attention on two specific pieces of legislation authored by our majority leader, AB 744 and AB 32, and examine what impacts they've had, what's working, where the gaps remain, and what the legislature should be thinking about going forward. With that, I'd like to turn it over to our majority leader, Aguiar- Curry, for any introductory comments she would like to make.

Great. Thank you. Thank you. I wanna start by thanking Chair Bonta and the committee staff for organizing today's outcomes review hearing. I also wanna thank Speaker Rivas for creating the outcomes review process and giving the legislature an important tool to evaluate the impact of laws.

Anyone who knows me that I knows that I take implementation of my bills very seriously. I often say in my office, what's the problem, how do we fix it, and how do we implement it? As legislators, we sometimes focus on passing A Bill and forget that implementation is where the real work begins. Today, we are looking at two bills I am especially proud of, AB 7744 and AB 32.

These bills share one goal, making sure Californians can access the care they need when they need it.

For rural communities, farm farm worker families, older adults, and working families, getting to a health care provider can be challenging because of distance, transportation, and scheduling barriers. Telehealth helps break down those barriers by giving patients another way to connect with their providers. AB 744 was a critical step forward by establishing payment parity for telehealth services. It gave providers the certainty they need to invest in telehealth and make it sustainable part of our health care delivery.

The timing of 744 AB 744 was especially important because it was enacted just before the COVID pandemic.

When that pandemic hit, California was prepared to expand telehealth and maintain access to care because we had already built that foundation. The pandemic also showed the importance of ensuring telehealth works for all patients, including those who lack reliable Internet or technology access. AB 32 helped add address that need by expanding access to audio only telehealth visits for Medi Cal patients in appropriate circumstances. Together, these bills have expanded access and given patients more options for receiving care.

But I know that there's still more work to do to address barriers like broadband access, additional care, differences in telehealth use among communities.

I look forward to hearing from our panelists today about their experiences implementing these policies and the impact they have had on patients and providers. I wanna thank all of our witnesses today for being here and for their continued service to Californians. I appreciate the opportunity to discuss how we continue to building these policies and improving health care access across the state. Thank you.

Thank you so much, majority leader. And we are joined by our Assembly Member, doctor Patel. With that, we are going to move on to our first panel. We're honored to be joined by a number of panelists today who are sharing their perspectives with us. We plan to provide time for member questions after each panel and will allow public comments after our second panel.

With that, I'd like to invite up our first panel, who will provide an overview of California's telehealth landscape and background on a b '70 July '32. I'll ask each panelist to introduce themselves with their names, title, and and organization. We are joined first by Marissa Montano and Amy Durbin. I think you'll have to press the button there.

There we go.

Thanks so much.

Thank you. Thank you, Madam Chairs Chair and committee Members for the opportunity to speak today. If I could, have the slides up on the screen. My name is Marissa Montiano. I'm a senior policy officer with California Health Care Foundation.

The foundation is an independent nonprofit philanthropy that work to improve the health care system for all Californians, especially those facing the greatest barriers to care. Today, I'll, I'll discuss California's health policies, how they've evolved, what we've learned from the evidence, and what it means for patients, across the state. First, I'll start by defining Telehealth broadly. So our Medi Cal program defined Telehealth broadly as the access information and communication technology to facilitate, and, consultation around, health care.

I wanna double click on, telehealth could be live or synchronous, where a a patient interacts in real time with their provider via some sort of telecommunications, whether that be via video or audio only.

Telehealth can also be, asynchronous or store and forward. This is when a patient or a provider, consult with another provider in a different location via electronically. A popular example of this is Econsults. Remote patient monitoring is also part of telehealth. And remote patient monitoring is a collection of health and medical data from a patient in one location transmitted to a provider in another location with the goal of supporting that person's care.

And then mobile health is also something that helps all of these different modalities, where folks can providers can use access to technology for education, and other support for, for care. I wanna call out that in our research when we're talking about telehealth, we're not talking about autonomous health. So AI, chatbot are part of virtual care, but not part of the definition of telehealth we used in some of our research and the data that I'll show today.

Over the past nearly three decades, major policy changes in California coupled with consumer experiences, advances in technology, and changes in the health care system have greatly expanded access to telehealth for many throughout the state. While COVID nineteen was certainly the catalyst for telehealth adoption, especially for Californians in the Medi Cal program, California made key telehealth policy related advances prior to 2020 that set the stage for tremendous progress during and after the pandemic.

Coverage of telehealth began in 1996, making Medi Cal a leader in reimbursement for telehealth in California. Policy made, telehealth access more lenient than in Medicare, for example, allowing telehealth outside of rural and health professional shortage areas. Prior to 2020, telehealth was primarily used clinic to clinic, for example, for specialty care access, and e consult programs were robust, particularly within county's health systems.

Policy changes from 2020 onward allowed for expanded use of telehealth initially as a result of waivers that introduced flexibility during the public health emergency but have evolved into a permanent policy, allowing telehealth from home and other locations, ongoing payment, medical payment, payment parity, and other supportive policies such as those surrounding broadband access, access to community health workers, and school based services.

These policy changes, also, allowed for the data collection and availability of data over the past decade or more to which allows us to, have more robust research and and to understand how patients interact with and experience telehealth as well as to really study the effectiveness and use of telehealth across the state.

Patients patients say they're satisfied with telehealth and would like to continue using it. Evidence shows that patients are satisfied and experience rapport with their providers during telehealth visits, and about half of all patients found that their telehealth experience paralleled their experience with in person care. By listening to low income Californians, we learned, and as you can see from examples of quote on this slide, that patients appreciate the way that telehealth removed barriers to accessing care and would forego or delay care without the telehealth options.

And what about telehealth effectiveness? Telehealth is a is a very effective mode of care for patients, particularly for behavioral health and chronic care management.

This evidence is strong across, both video and audio telehealth as well as in econsults. More research candidly is needed to understand hybrid hybrid models of care and the extent to which telehealth serves an improved outcome for different population. During the pandemic, we saw an incredible increase in telehealth utilization, and data up until 2022 shows that in California, utilize utilization remained higher than pre pandemic utilization rates, even once the public health emergency has ended.

This evidence is strong across, both video and audio telehealth as well as in econsults. More research candidly is needed to understand hybrid hybrid models of care and the extent to which telehealth serves an improved outcome for different population. During the pandemic, we saw an incredible increase in telehealth utilization, and data up until 2022 shows that in California, utilize utilization remained higher than pre pandemic utilization rates, even once the public health emergency has ended.

National data in Medicare, which has more payment restrictions than Medi Cal, also shows that telehealth use remains steady through 2025.

National data in Medicare, which has more payment restrictions than Medi Cal, also shows that telehealth use remains steady through 2025.

We've also learned that audio only is crucial is a crucial access point for maintaining care.

This is especially true for patients, with digital barriers to care, like lack of sufficient broadband. It is also shown to be important in the clinic setting for patients accessing primary care and behavioral health visits. The evidence for telehealth use and its availability to expand access to care centers on the way patients experience care. Longstanding barriers to accessing care regularly, particularly for low income Californians, like lack of transportation, inability to miss work, lack of childcare are reported to be ameliorated, with the use of telehealth.

Patients want to continue to access care when they can through telehealth.

And for immigrant communities today, national threats, for nonwhite immigrants in California have escalated, making telehealth essential for maintaining access to care when fear of public spaces is high. There are, however, some still some disparities for, accessing telehealth, for, a notably for older Californian and Californians that speak a language other than English, language access remains one of the barriers to using telehealth. And in conclusion, telehealth is a really important and effective tool for expanding access to care.

It increases flexibility and allows Californians to receive the care they want and need. It's not a replacement for in person care, but it is a crucial mode of care to maintain, maintain access for many.

Telehealth, including audio only, reduces, reduces, barriers to preventing patients from timely access to care, and patients really want to continue using it. And with that, thank you so much for the opportunity to speak, and my contact information is included in the slides.

Thank you so much, and we'll hear from our next panelist. Alright. You'll have to press the button as well.

Alright. Thank you, Madam Chair and Members of the committee. My name is Amy Durbin, and I am here today on behalf of the Center for Connected Health Policy or CCHP, which convenes the California Telehealth Policy Coalition. CCHP is a program underneath the Public Health Institute that was established in 2009. Here we go.

And since 2012, we have been acting as the federally designated National Telehealth Policy Resource Center, providing technical assistance on telehealth policy nationwide to policymakers, providers, and patients. CCHB founded the California Telehealth Policy Coalition in 2011 when engaging on AB 4151 of the bills that established the state's foundational telehealth laws. And the coalition has continued to meet over the years in the interest of collaborating to advance telehealth policy in the state.

I'm here today to provide some additional background regarding the intent behind the kinds of telehealth payment policies being reviewed by this committee today related to telehealth payment parity at 8744 and Medi Cal telehealth coverage policies, particularly those related to audio only under AB 32. CCHP also tracks telehealth policies across the country, so I will try to provide some context around California's telehealth landscape in the in the context in relation to other states as well.

So starting with AB 744, telehealth private payer laws generally seek to ensure that prior pay private payers do not discriminate against covering services purely because they're being provided via technology, rather than in person. Telehealth payment parity or reimbursement requirements like those added by e b seven forty four take that a step further, ensuring that the exact same service can be provided both via telehealth and in person. It should be reimbursed at the same rate.

These policies together are important in terms of ensuring that providers have the ability to offer services to patients via technology as providers may not be able to invest in and offer them otherwise.

A B 744 also updated and clarified some of California's existing telehealth definitions and requirements and included a provision to ensure that payers cover telehealth for all contracted providers, not just limit coverage to a select third party corporate telehealth provider, and that that might contract with a health plan and not be the patient's in person provider.

So, therefore, the policy, like, AB 744, seeks to offer additional access through technological means while maintaining continuity of care for patients with established providers and ensuring they remain connected to in person services as needed. The majority of states across the country now do have telehealth private payer laws. Some of them include similar protections regarding corporate telehealth providers as well, but only half the states have explicit payment parity reimbursement requirements.

So moving on to AB 321 of the main telehealth policies that we're seeing have the most growth across the country since the pandemic is related to audio only coverage under Medicaid, which is what AB 32 focused on. Medicaid audio only coverage has more than doubled since 2021 with most states now offering some coverage of the modality.

However, limitations often apply. The primary intention behind ensuring audio only availability, especially within Medicaid programs, is the lack of affordable and accessible broadband across certain areas of the country and state. Particularly in rural areas, which limits both provider and patient access to telehealth modalities, namely live video. AB 32 intended to reduce some of these policy limitations placed around audio only medical coverage when the explicit coverage was made permanent post pandemic.

In particular, it sought to ensure that providers, including safety net providers, including FQHCs and RHCs, could more readily offer audio only services by creating exceptions to the policy limiting audio only to only established patients.

AB 32 ensured that audio only could remain available to new patients as well in relation to certain sensitive services or in the event the provider patient doesn't have access to the technological means and the patient requests the modality.

While AB 32 helped to address some of these barriers related to audio only access, others remain, and there are similar asynchronous and store and forward barriers in Medi Cal, and I appreciate Assemblymember, Agua Curry, for seeking to add address some of these additional issues through other pieces of legislation these last few years.

And now I'd just like to briefly touch on some of the the main trends that we're seeing across states regard regarding telehealth payment policies as well as within the context of any potentially remaining gaps or limitations in California telehealth policy at this time.

So as you can see on the slide, next to live video, which is covered by all state Medicaid programs as well as DC, Puerto Rico, and The Virgin Islands, audio only is the second most covered telehealth modality with 46 states in DC reimbursing audio only. 41 state Medicaid programs cover remote patient monitoring, and 41 cover asynchronous restore and forward telehealth.

When it comes to FQHCs, these telehealth modality numbers are often much lower across the states with only 17 Medicaid programs covering RPM, and seven store and forward. Medi Cal does technically cover all telehealth modalities generally, at least for established patients, but Medi Cal does not cover some asynchronous billing codes such as those for e visits.

Medi Cal does cover some telehealth modalities for FQHCs and RHCs, however, that does not include remote patient monitoring and some asynchronous telehealth billing codes such as those for interprofessional consultations or econsults. Two states, New York and North Carolina, do cover all modalities for FQHCs. New York has done this through an alternative payment methodology, which we know is something that California has also been been working on.

But asynchronous telehealth does remain limited in terms of coverage in Medi Cal, although exceptions do apply and similar limitations are common for this modality across other state Medicaid programs as well. And then, in regard to the the private payer numbers, we've kinda covered those already. So I just wanted to make a note on on parity in regard to Medicaid specifically. Medicaid programs are generally required under federal requirements to reimburse telehealth services no differently than how they reimburse for in person services.

So it is common for most state Medicaid programs to reimburse telehealth modalities if they do, including store and forward and audio only at parity with in person service rates.

So as overarching policy seek to promote the use of telehealth, continue to be passed, it's when they continue to treat its uses and coverage differently than in person care rather than just recognizing it as another delivery modality best determined between the provider and patient that we find ourselves more in the nuances of that coverage, needing to navigate the potential impacts of limitations, when seeking to determine remaining policy gaps and implementation outcomes.

The concern being that the more telehealth specific policies and limitations are adopted, the more complicated it becomes to track for how and when to bill for telehealth across payers, especially if you're creating criteria for reimbursement specific to just one telehealth modality and one specific payer, which then can limit providers from offering telehealth and potentially create disparities and access across various patient populations.

So in summary, California has historically been at the forefront of other states in terms of adopting policies that ensure access to care via telehealth and even pre COVID had pretty robust coverage. Telehealth access in the state has continued to be bolstered through both AB 744, particularly to commercially insured patients and AB 32, which address addressed a gap in access to audio only services within Medi Cal.

However, gaps remain such as those noted in regard to asynchronous or store and forward coverage. Medi Cal has also created additional policies that are just specific to telehealth use such as consent and in person policies that do not similarly apply to commercial patients and providers.

And Medi Cal enrollment processes largely prevent remote only providers from being part of the program currently as well, Though Medi Cal, has created an exception for remote only mental health providers, further exceptions have have not seemed to be be viewed favorably thus far as as I know this is something else Assemblymember Agua Curry has has sought to address with their more recent bills.

Meanwhile, enrollment, processes are being updated in other state Medicaid programs more generally to address remote only providers and find additional ways to expand access to care via telehealth while keeping those necessary consumer protections and state oversight in place. So while differing telehealth policies and limitations are unfortunately common across states and payers, they can discourage provider use of telehealth and limit patient access.

Pieces of legislation like AB 744 and AB 32, however, are intended to simplify and reduce some of those barriers for both commercial and Medi Cal patients and together should better ensure that more patients are able to receive necessary, timely, and quality health care through the most appropriate and preferred modality. Thank you.

Thank you so much. We will move to any questions that we might have.

Go ahead. I'll go next.

Thank you for your presentation today. I'm a big proponent of telehealth as being an Assembly member means oftentimes our appointments are via telehealth. So wanna put

that out there. But questions around technology use and adoption in order to provide adequate telehealth. What what are the cost implications for providers for having technology, data storage, data protection versus how much they're getting reimbursed for the clinical side of the cost to provide telehealth?

I mean, I can speak a little generally. I I appreciate the question. I think it it's kind of an upfront cost to get the the technological infrastructure there, and that's where, you know, we see kind of the role of these policies trying to promote. If if we are ensured that reimbursement will be provided, it should help them invest in those those, additional things that might be needed for the technology.

Whether, you know, the the specific cost and how it might be, you know, integrated in their EHRs or, you know, when we talk about larger providers versus smaller providers, I think we're we're we're talking about the smaller ones, the safety net clinics that that don't have that infrastructure already in place and might still need it.

And then once they can get that, you know, in place and and have these services offered, I think that's that's kind of where the the big kind of crux is at this point is is those smaller providers.

And I'm sure that some of the the data safety storage infrastructure has to be there for regular patients, in person patients as well. Exactly. So some of it is just incremental or perhaps even the same.

Right. Yeah.

The audio visual component of it.

The broadband access, I think, is one of the the main components and just ensuring that they have that availability in the in the in the area and infrastructure as well.

And then a follow-up question on the the telehealth for, like, a primary care appointments. When you usually go into a primary care in person, they do height, weight, blood pressure, ear, eye checks perhaps. Those end up not getting done in a telehealth visit. So what are the guardrails or protections around that just regular clinical observation component of a telehealth visit?

So there's it it it depends. So there's something that we need to better understand is telehealth is part of our continuum of care, and so you understanding that hybrid model of care would be really instrumental in in understanding that.

There's also a lot there's been some investment into, you know, equipping patients with some of that equipment needed so that they can collect that information at the point of a telehealth visit so that that could be recorded as part of the visit even if it's not in an in person site. So I think there's been sort of that incremental, some investment and certainly could possibly use more in, in in some settings.

Especially with rural, community members who have, you know, shortages of providers that could be leaned on more and more often as their primary modality and just wanna make sure we're getting those clinical physical observations logged in. Oftentimes, they're an easy precursor to seeing what's really going on with the patient. But, wanna thank the leadership of our of our leader in bringing these bills forward and, look forward to hearing more in the next panels.

So thank you very much for the presentation. Those that know me, I'm always wanting to figure out the implementation piece, and I keep thinking about disparity and in rural communities. And so I what can this how can the state continue to ensure telehealth expands access without increasing disparities among patients who may face technology or connectivity barriers?

Thank you for the question. It you know, I think there's a lot of investment that can be made. Again, we you know, I think we both mentioned broadband access and connectivity and investing in incentivizing that investment in rural communities is essential. You know? So I think there's there's a number I I think it's just greater investment in making sure that folks have access to to broadband.

Keeping audio only is this is also very crucial. Right? That's one way in which folks who don't have access to sufficient broadband connectivity technology can access can use telehealth to access their care as well.

Yeah. I'd I'd just add, I think it's kind of speaking to the the simplifying the the billing processes to to the point that that they're easier to understand for providers, and providers will be willing to to engage in them to offer services via telehealth.

It it can be complicated, you know, as I mentioned, kind of tracking the differences and and just trying to make sure that we're we're recognizing that that balance and that fine line between how do we ensure additional protections through technology, but also not make it so cumbersome that the providers and patients are confused and and don't get to

use it as as much as they could.

So, what other investments would you see or policy that we should be doing here at the state, to ensure that all of our Californians can benefit from telehealth? What do you think is out there that

I mean, I would add, just the other modalities. I think we we typically think of live video telehealth, right, as our our go to when we think about telehealth services, but there are, you know, audio only and asynchronous modalities that that aren't being utilized, I think, to the fullest extent.

Luckily, AB 32, I think, helped with audio only, but maybe, you know, some additional, examination of those policies to see if there is a way to to keep the protections in place, but also simplify the process to make sure that those modalities can be used, especially for new patients, which might be foregoing care otherwise.

I think of it as, specialized medicine. I mean, we are just doing, I think, incredible job on telehealth. We're gonna only do better. I agree with you that we need to improve our communications and our broadband Internet connectivity, and we have a a so many members working really hard and making sure that gets up and down the state of California at a reasonable price as that's difficult.

But I really wanna make sure we can make sure specialists in our rural areas and our constituents have access to health care.

So that's a a goal I have going down the line as my many goals that I have, but I just think that we need to, as a state, is to realize that we do need to have our specialists there when we're working in rural communities. And that's all I have for now.

Thank you. And again, thank you to our majority leader for making sure that we had an opportunity to talk about this and for your presentations. I have a couple questions. The first is for our discussion around kind of the data and availability understanding the go forward opportunities for us. I think what I heard you say, miss Montano, in the first in the first couple slides was that we no longer have any data past 2022 that we're relying on.

But then you also kind of call this era that we're in post COVID as the evaluation era era. So given the fact that there are many things to still work out in terms of the disparities, barriers that we are looking forward with, what can you describe what the current state is and if you have any recommendations around what we should be doing differently inter around data collection.

Thank you for the question. We have the ability to we have we have the ability to collect data. We have been collecting data because we have the code a lot of the administrative work that went into, implementing implementing some of the build, especially in the, AB 32 and and the built in medical. However, the publicly available data dashboard that was created during COVID hasn't been updated since 2022.

And I think there's an opportunity there to maintain, you know, maintain that dataset as a way to evaluate to continue to evaluate how we're using telehealth, how people are experiencing telehealth, how and and the outcomes piece.

So, really being able to drill down into the effectiveness across, you know, we have so much data in behavioral health, and we have more in chronic care management. What else? What how how is telehealth used most effectively, and how does that evolve as we go into the future? I think being able to, have access to that data, in an easier way help create some of that transparency and evaluation going forward in sort of the for the post COVID era?

So we have the data because we collect it through our billing protocols, but we're not necessarily accessing that right now for the purpose of evaluating whether or not it's having the intended impacts. Is that

In a public way.

In a public way. So I think there we go. Thank you for that. And I've as I was reading the kind of background paper and also hearing your presentations, it's pretty clear to me that, like, there are supply issues in terms of along lines of speaking to barriers issues, like their their supply issues, like, are we set up from a reimbursement perspective to be able to have enough providers actually utilize these tools?

Are there discrepancies between if the way that smaller clinics, rural clinics, FQHCs have, you know, have the ability to have robust programs to be able to use utilize telehealth.

There are modality issues, you know, do people have access to broadband? Are there enough is there enough opportunity to have the kind of protections, privacy protections embedded in the kinds of tools that we use for that? And then there are demand issues which are, you know, why is it that, it looks like, people who are non English, speaking, patients have less ability to use this or there's an impact on elder elder patients in terms of their, likely less bill able to use that.

Can you give us a sense if you were to kind of parse out those two those three areas, supply, modality, demand, where the greatest levers for us to really increase the impact and utilization would be in either of those three categories or whether there's one that you believe is kind of more the culprit for why there isn't such a great usage?

I think I think it particularly around language access, I think there's a lot of opportunity for to to break down language barriers to care, certainly in telehealth, seamless seamless translation, or, you know, are improving our workforce and in that in the a workforce that speaks the language of the patient they're serving.

Things like that would go a long way toward breaking down barriers and improving access to telehealth and healthcare at large, I think is a is a a big, a big policy opportunity that can be that can be leveraged here.

And then I think on the reimbursement side, it's you know, it's hard to say because particularly in Medi Cal, and Medi Cal is sort of my area of expertise where reimbursement is, is is a topic across many different in different areas, and so I think it takes some some data and studying and looking at, you know, now that we have access policies in place, how does actually studying how reimbursement translates to providers offering more telehealth, or what does that look like for the landscape of telehealth utilization?

So for the purpose of this oversight review hearing for AB 32 and AB 744, which specifically focused on making sure that there was parity For different telehealth applications. Is it fair to say that a next step for us would be to better understand whether or not the reimbursement mechanisms

are

actually implemented. What what what is the question that we should be asking ourselves right now?

mean, I think you're still looking at research and definitely looking at the impact of payment parity on on utilization what does that look like in providers that are offering telehealth services? What does that look like, you know, across time? Things like that. And I don't know if you have other

I I

Yeah. I a couple of points I was I was kinda running through. One would be, I think, in terms of language access, device access, other other barriers that I think patients are facing, there are, you know, policies that promote digital navigators, community health workers. Those types of policies can could go a long way as well as as assisting the patient that might be struggling with accessing the service or having issues with technology.

So those were a couple other kind of policy areas I I just thought I'd mention.

And I know, I I know DHCS does cover community health workers, but trying to figure out, you know, how often are they being utilized in clinics and assisting patients and how is that implementation working, I I'm not sure. But I do know, you know, speaking to the data issue and DHCS having this dashboard in place, I know there was additional legislation that was signed last year that does kind of heighten DHCS's requirements on the medical telehealth data.

What I I think would be maybe another area to look into is is now can we get similar information from the private payers and kinda compare how those rates are? Like, are these specific Medi Cal policies that limit audio only? You know, technically, there's nothing in statute that says a private payer can do that.

So it's possible they might be doing something similar, but we don't have as much information to really compare these two patient populations, I think, sufficiently to make sure we don't have disparities as we're creating these policies.

And so I I I do think DHS is looking to get all of those variables in place to try to examine those outcomes, but it is a a maybe a work in progress that it it could also be helpful to bring in that private side to make sure we've got kind

of some seamlessness between the two. Thanks. Two more questions. One around the econsult component, very important, part of telehealth because it allows particularly, in rural communities or where there is less access to specialty care for there to be that consultation that happens from doctor from provider to provider. Do you have any visibility into the extent to which that particular component econsult has been elevated, has been more utilized than, yeah, in the past to any other visibility into that aspect of it.

I could speak to that a little bit. I mean, in terms of, like, the history of those codes, they're they haven't actually been around too long. They were created probably about six or seven years ago, and I think there was a lot of confusion on state Medicaid programs on how do we adopt these codes and reimburse them for different providers. And so I think state Medicaid programs are are playing catch up and they're they're getting there.

We have, I mentioned some of the numbers on on states, you know, for FQHCs.

It's it's much different. Their billing processes are much different. So we don't see as much econsult happening in FQHCs and RHCs as we do outside of them. And that I think is is just going back to, you know, looking at the way the policies have been created for billing for these particular providers and and adapting them for now, these new codes and these new telehealth services that can be offered.

And so some of the conversation, I think, in California has been around you know, there's there's two Econsult codes covered right now under Medi Cal, but those are not covered for FQHCs and RHCs.

And and my understanding is it's DHS was trying to figure out some billing aspects about how can we cover that for these particular providers, and that's where they were looking at an alternative payment methodology. And we have seen that in other states.

So I think it's it's the nature of billing, not necessarily a a reluctance to doing so, but navigating that kind of complexity of how they bill to figure out how can they also bill for these services, particularly Econsults, because that is something that they aren't currently able to do. And I know there has been legislation on that in the past.

And so it has been a conversation and and something that I I I'm not sure if there's been more work being done behind the scenes, but that's as far as I'm aware that the current status of the consult.

Legislation that has not Not passed. Been Correct. Chaptered.

Yes.

Got it.

Alright. And then my final question is around the maybe kind of unintended consequence of telehealth or perhaps lack of guardrails. This is entirely anecdotal, but I think we often start from this place. And it relates to kind of the commercial commercialization that can happen with in our telehealth services. Called I called my primary care physician the other day, you know, had to look online for the number that I needed to call.

It was a whole deal. Ten minutes into my experience, I finally get what I think is going to be a live person and instead while I'm waiting to be able to talk to that live person or even I know we're not talking about AI. They they whatever the AI bought. I get a I get a commercial about about a particular, like, service.

I I I don't even and I was like and I really had to hang up, go through the whole process again because I thought I dialed the wrong number because now I was getting a commercial.

But it was in fact the right commercial. I was calling my right phone number. I was calling my provider, but I did end up in a doom loop of trying to be sold additional care or service while I was also just trying to get a basic health care question answered. Is there anything does does this resonate at all for you? Have this has this been an experience that you've heard from other people?

And are there any guardrails in any of the legislation that we've already passed that seek to limit the exposure of patients as they are trying to participate in health in telehealth to keep them from having to be exposed to, non relevant information for the purpose of their call or their engagement.

Absolutely. Yes. You know, that that is a A Big issue and kinda push and pull regarding telehealth generally. And I think Marissa spoke a little bit about a hybrid approach to telehealth, and I think a lot of a lot of folks see that as maybe the best kind of balance where, you know, particularly the AB 744, for example, it had that provision that said, you know, you can't limit coverage just to these corporate telehealth providers, which was what had been happening previously.

People had said, well, you know, the payers aren't covering telehealth.

And I said, well, we do. We've got this contracted corporate provider. You can get your telehealth that way, but that's not their normal provider. It's not synced up with their electronic health records. They don't have that continuity of care to even sync back up with them after the visit and make sure everything went fine.

And so that was kind of the reason behind putting that in the private payer laws is ensuring that, okay, you guys you you can offer that service if you want to, but please don't only limit your telehealth coverage to them. Offer it for your other contracted provider so everybody can get an ability to see their provider instead of a corporate provider. And so we have seen that mirrored across states.

I think that is a a general concern that that folks have is kind of the larger companies and and how the protections are in place for patients in that kind of direct to consumer telehealth environment versus what I think many folks wanna see is is kind of a a hybrid approach where we've got our in person providers that now can do telehealth too, and they can make those determinations on which one is most, you know, efficient and sufficient for that particular visit.

Yeah.

I think worthy of investigation. I lied. I have one more question. Apologies. So there has been talk over the years around the need to be able to make sure that we are increasing the number of healthcare providers so that we can have greater access for people.

You know, telehealth offers the ability to have that happen increasing the number of the access to providers by increasing the available pool of providers because it it is not in person. There is some hesitation, it seems like, in this legislature to move forward with anything in the neighborhood of compacts or things that kind of extend to, health care provision outside of the state of California.

Do you have any insights into, what the next iteration really of telehealth would be and whether, you know, in order to be able to ensure adequate access to an actual provider, we need to make sure that we're kinda stepping into that space of expanding the pool of providers available to us.

Yeah. I I can speak. The CCHP does track, you know, all across state licensure policies across the country, and and that is since the pandemic, that is the main policy area we're seeing related to telehealth continue to be focused on in states. And and California is obviously, you know, it's it's it's a unique state, and I think that that's where they've kind of come from so far in terms of, you know, compacts.

I know there's a lot of concern around, you know, you've got small states that join the compact, and then you've got larger states like California.

And the the amount of providers to patient ratio as well as, you know, the the complexities that come with our particular consumer protections in California versus other states. Do we want to seed some of those? When can we seed some of those? And compacts in particular, you can't really negotiate that language. You kinda have to put it into statute as is.

And so I think that's where California has been like, well, you know, we're interested, but we wanna see how we can do it for us. That makes sense. And so outside of compacts, there are other routes to expanding cross state providers, access, and that would be creating licensure exemptions, which California does have a couple very narrow ones currently. I know legislation has been ran the last couple years to slightly expand our already narrow exemption, and that has not made it very far.

So I know there is still some reluctance on the exemption side.

The other policy area we see across states to address this issue is related to creating a registration process. Every state does that differently, though. And so it it you know, some states just say, let us know your name and information, and now you're okay to start seeing patients in our state where other states are like, no.

We want an application of fee to to all of the things you usually need to do to confirm licensure as kind of a a a registration process rather than full light full licensure process as another route of potentially opening up those additional out of state providers via telehealth.

Thank you. Assemblymember Schiavo.

Thank you so much for this information. I I wonder if you and I don't know. Maybe, miss Montano, this is more a question for you. But is there data or research? I know, you know, the kind of more ex expansive use of telehealth is a more recent thing.

And so I'm not sure how much data we have on patient outcomes when it comes to telehealth. But, you know, I worked with nurses for many years before being elected, and I heard from them how important it was to be able to see patients, to see if they're clammy or touch their skin or, you know, things that really help inform the the health and well-being of the patient and maybe what kind of, steps you need to take to care for them.

And so I know that telehealth in that way is limited. And, you know, it's an important tool, and I think it's really important especially for rural and underserved areas, areas where you can't get specialty care, all of those things. It's it's, you know, been a a godsend for a lot of people in a lot of ways.

But I also wanna make sure that we're keeping in the conversation, making sure that it's a high level of care that people are getting through that telehealth and and that, like, that it's being used appropriately. Right? If someone needs to come in, if it's the the kind of illness or issue or whatever that someone needs to be seen in person, that that's still happening, and everything isn't kind of being siphoned off to to telehealth as a a a solution that maybe doesn't fit all the needs.

Thank you for the question. The data the data that we have, outcome data is hard because it takes a long time to study outcomes. And so that I I you know, we we need more evaluation to really you know, like, where we've been able to see, improvement, through telehealth and behavioral health and some in, like, chronic care management, that there's still a lot to be done there. The data does support, though, it it not it doesn't look like it's the case that every everything is telehealth.

There is telehealth is an option, and it's an option that sometimes leads to patients getting in the door for their provider to to say we need it in person or to make that leap to driving the really long distances some folks have to drive for specialty care or, sometimes other types of care, depending on where they live.

I think one of the important pieces is that continuity. So having your, having telehealth be with your trusted provider, is and and having that continuity, is really important for catching some of the the the the the physical things you mentioned. Right? And having that rapport with with your provider, which we've we've learned from listening listening work with patients, that they very much feel that that that's how, their care is is being delivered even via telehealth.

So, you know, more all that to say, more more to come on a lot of the outcome, but it it certainly telehealth is used more than pre pandemic, but it it doesn't look like it it it's not a replacement.

It's just another tool that we have to make sure that, if someone needs to see a provider, they have the means to do it even if there's a bunch of other barriers, preventing them from from doing so.

Thank you. And, certainly, you know, even not in rural areas, Sacramento and LA where I receive health care, it can be helpful to figure out whether or not it raises to the levels of needing to bring your kid in to the doctor or something like that. And so a quick phone call can be a huge, huge help to save driving time for a lot of people in traffic Yeah. Too. So thank you so much and look forward to that further information.

Assembly Member Carrillo.

Thank you, Madam Chair. Just one quick question in the data that you are collecting. Last time I tried to schedule an appointment to see my doctor, it took four to five weeks to get scheduled. Is telehealth intended to be, readily more available, sooner than four to five weeks?

That's a great question. And I I don't know the answer to that question. I think that just varies on a lot of factors that I don't I don't personally have the data or the research to really really answer.

Yeah. I I would say, I think the intent would be, hopefully, yes, that the telehealth could provide a sooner option. I know in in my own personal anecdotal experience, I have had that happen where they said they can't get me in for a few months, but let's do a telehealth visit. Really, I think what it comes down to is provider preference and availability. If if they don't offer telehealth generally, they might not be able to do that for that particular patient.

And so it it is something that I think is very interesting to maybe examine further. But I I do think that that's a goal of telehealth.

Well, thank you so much for your commentary. Oh, we had one more question from Assemblymember Caloza.

Thank you so much, Chair. I thank you both. I'm sorry I missed your presentation earlier. And, you know, appreciate also our majority leader for for her two bills. I just wanted to ask a a question as it relates to maybe trends that you may be seeing for some of our immigrant communities who may be, using telehealth more given some of the increased ice rates.

I know for a lot of the communities that I represent in Los Angeles, a lot of our clinics and hospitals have reported a high increase in a lot of patients missing appointments, some upwards of, 70%, which is really high. And, you know, what are some of the ways in which maybe telehealth could be a solution for folks who might be scared to go out and see in person care?

Thank you for the question. It's it's, an issue that we've heard a lot about, recently and absolutely have been hearing the same things about folks, missing appointments, and telehealth is a crucial, piece to that puzzle.

Some of the ways that we can help with that, we talked a little earlier about investment in, you know, particularly for, under resourced safety net clinics or other or or mobile sites or or some other, folks that need more infrastructure to provide telehealth to larger number of people, because telehealth is especially when fear of public space is so high, telehealth might be the only way to access care or to feel safe accessing care for some folks.

And I

I would add, there, you know, as as Marissa mentioned, you know, mobile options, I know that there are, you know, pilots and initiatives in place in place in certain communities to try to to bring that care directly to the individuals. I know there was a bill that I think it was last year that was signed that was trying to do a pilot around virtual health hubs specific to farmworker communities and and folks in that area.

And so I I do think that there are some some more novel approaches and policies that they could potentially try to address that and including telehealth as well.

Thank you. And I know that's that's one of the actions, you know, Assembly Democrats took last year was making sure that a lot of our immigrant rights organizations received funding to ensure that people had and knew what their rights were. And so I think a connection piece to that if maybe your organizations aren't already connected to some of our, legal clinics, our immigrant rights organizations who, probably do know your rights trainings.

Probably in that same breath, it'd probably be good to, continue to ensure that we promote, health care access, maybe telehealth options. We know how hard so many people, especially on this committee, our chairwoman, has worked to ensure that we have more coverage and access, making sure that we fund things like our promotora programs when we were really encouraging our health for all.

And so I don't wanna lose that progress during this time when I know a lot of people are just at home scared to get help. And so we just if you haven't already been doing that, we'd we'd have a recommendation to connect with some of those organizations. And, of course, if you need our help, please let us know. Thank you.

Thanks so much. Very much appreciate, hearing from miss Montano and miss Durbin, and that concludes this panel. And we're gonna move on now to our second panel for today, which brings a range of providers who directly see the impacts of ABs seven forty four and thirty two in their ability to serve a wide range of patients. I'd like to invite up to the table doctor Steven Newman, Angela Pontus, and Jamie Gray. As with the first panel, please introduce yourself with your name, title, and organization.

You drew you drew the short straw. Go. Press the button.

Good afternoon.

Please press the button.

Okay. I think we're good. Good afternoon. I wanted to thank majority leader, Aguiar-Curry, and Chair Bonta for inviting me to help participate, in this hearing and, and my support for a B744 and AB 32 and the way it's changed my practice. My name is Stefan Newman.

I'm a family practitioner. I've been licensed to practice medicine in California since 1982. After medical school, I completed family practice residency at UCSF, San Francisco general program, and then spent four years in the National Health Service Corps, in rural Yolo County and Esparlo and Knights Landing providing care for agricultural workers and and residents of of that area, followed by twelve years at Woodland Clinic Medical Group, which is now part of Dignity, and the last twenty five years, at North Bay, Healthcare.

I've worked in their Vacaville office. So if anyone's adding, that's about forty years.

You became a doctor when you were two.

When I was two. Thank you for that. I saw lots of changes in technology. When I was starting off, CT was in its infancy. There were no MRIs, no ultrasound, no echoes, no laparoscopic surgeries, no fiber optics.

And each of those advances took time for the medical community to move forward and change patient outcome and patient experience. And one thing that we have to remember is that the cell phone has made huge changes in providing medical care. Cell phones came out about twenty five years ago, and I remember that because all of a sudden when I was on call, I didn't need to stay home or near a find a payphone to answer a a page.

It allowed us to go to little league games and and leave home when we're working nights and and weekends accepting calls. And then smartphone.

Finally, medicine is catching up to the smartphone. Smartphone is enabling us to do these visits. To give you an idea of my day, I'd I'm a part timer at this point. I have eighteen twenty minute appointments during the day, and two to four of those are reserved for virtual visits. So it's it's an important part of our practice.

Parity was very important because it allowed North Bay Healthcare to invest in the time, for staff, billing people, coding people, and for providers to be able to block, their schedules and and have these slots open for patients. We use it in my practice at this point is a lot of seniors, a lot of elder care. I don't do pediatrics anymore and can't really speak to the efficacy in pediatrics. But for people who have mobility issues, transportation issues, just don't feel well.

It's it's been a wonderful, wonderful improvement.

Also, for people who are at work and don't need to take a half day off because they can get a medical visit in their fifteen or twenty minute break time has has been also a huge advantage. Also, I know there's another speaker who's gonna talk about mental health.

You know, one third of primary care visits deal with mental health issues, and it's invaluable in following up after medication changes or if people are risk of harming themselves, you can do a very close follow-up over a period of time. Someone asked about the safety of these visits, and that's an important question. And if someone's clammy, their pulse is probably abnormal.

And with technology today, patients are calling us with their blood pressure, their pulse, their pulse oximetry. They're telling us what their oxygen level is. Some people have these smart little devices, and it it tells you if your heart isn't in a normal rhythm. So it's an amazing amount of information that we can now get from patients remotely and virtually. It's also very useful in what we call transitional care visits in Medicare.

These are visits after people have been hospitalized. Usually occurs within seven to fourteen days to help prevent readmission, and it's a review of their medications, of their hospital experience, labs, x rays. And we can do it in coordination with home health. So we can have home health nurses checking blood and urine samples and be able to give us vital signs and be with the patient sometimes when we're having that virtual visit.

I thought I'd just talk about a few patients that come to mind over the last week or two to to give you a picture of of how useful it is.

There was an 83 year old woman that was having a lot of issues in being able to live independently. A son in Chicago, a daughter in San Diego. With a couple of presses of the button, the whole family was in on the appointment.

Twenty years ago, my parents were not doing well in New York City, and I can't tell you how many red eyes that I took to New York City to accompany them to doctor's appointments and and and being a part of that of their medical decision making, I can't imagine how many dollars and hours could have been saved by using telehealth.

We also had a patient a couple of weeks ago, 55 years old, had a terrible heart attack, and the pump stopped pumping, and he went up in San Francisco with a heart transplant.

We were able to follow-up after his three month hospitalization. We're able to do testing and imaging echocardiograms for him, send it back to CPMC in the city, and they set up a follow-up, telehealth visit for him. So he's not in a car for three hours trying to get, to San Francisco. Also recently, a 75 year old woman with bad emphysema who was hospitalized for pneumonia, we're able to coordinate with home health, and have her monitored in terms of oxygen levels and her treatments and her medications.

So, it it's been really important for lots of people, and everyone has already said it reduces barriers in terms of cost, transportation, time, etcetera.

We do use audio. We don't use it specifically for Medi Cal. Medi Cal in our practice is really a partnership health plan, which is an HMO. So it's different than straight or traditional Medi Cal. We don't do it for new patients.

All of the patients that that we deal with in telehealth are established patients that we know. Someone asked about what happens, you know, if is it safe? And that's an important question, as I said, and it's clinical judgment. You have to get a sense for who you're talking to and what's going on, And it's not unusual for a virtual visit to turn into a 911 call or a visit to the office today or tomorrow, not five weeks from now.

So it all also gives people access into the system more quickly.

If you realize someone's having trouble and they're too sick for a virtual visit, you can't give them an appointment for next week. So those are all important things that people have brought up in in looking at some of the problems. I do use audio only a lot for Medicare patients. People who are older than I am have a lot of trouble with technology. They may not have Internet.

They may not have WiFi, and they have trouble just pressing the correct buttons. But they're all really comfortable on the phone, and that's that works well for a large portion proportion of people. The people that can bring you into their house, I was concerned at the beginning of of virtual visits that you'd lose sort of the human touch.

And then I found that really it's just a different human touch because people are sitting in their recliner and they've got their kitten and they're in their pajamas, and, they feel quite comfortable in in having a medical visit, in their home, kind of a a new modern home call or home visit that we used to do a hundred years ago. The importance of having systems invest, there are very few of us in private practice.

So when we talk about practitioners who may or may not benefit with parity, it it's really it's Kaiser, etcetera, it's North Bay. It's it's the big organizations that are controlling this. They control the schedules. They're the ones that put the slots in for virtual visits. So they have to feel that they're getting, parity and paid for that.

Their overhead doesn't go down. They've got the same overhead, essentially. But their incremental cost really doesn't go up with telehealth. We use a free platform called Doximity, and, any providers, can use it. It's HIPAA protected.

Those videos aren't saved anywhere in our EMR, but they're converted into a documentation note, either by a scribe or you could even use an AI scribe or someone sitting and and typing in typing and creating a a document based on that video. It's not saved in our in our EMR in in any way.

Well, I think we're at time.

And I'm sure we will get to some other questions that you might be able to respond to.

I'm sorry.

Sure. Well, thank you for your time.

Yeah. Thank you.

And certainly, both looking forward to working on this with majority leader Aviara Curry, and with Chair and committee. Thank you.

Thank you. Go ahead.

Good afternoon. Angela Pontus with Planned Parenthood Affiliates of California, representing the seven Planned Parenthood affiliates across the state that provide comprehensive sexual and reproductive health care, gender affirming care, and behavioral health services through over a 100 community health centers. I want to begin by thanking the legislature for hosting this oversight hearing and for the continued leadership on policies that expand access to telehealth.

When the COVID nineteen pandemic began six years ago, the state took quick action to allow an expanded use of telehealth to minimize disruptions in care. Planned Parenthood moved quickly to implement secure telehealth appointments for sensitive services, such as birth control, STI treatment, pregnancy counseling, PEP and PrEP follow-up, and gender affirming care.

Thanks to the leadership of the legislature and the governor, these proven successful allowances were extended permanently after the pandemic so that today, planned parenthood patients continue to have the choice to access crucial services via telehealth without having to worry about the additional time and resources necessary to travel to an in person appointment.

Regarding the purpose of today's hearing, AB 744 and AB 32 have helped to ensure that Californians can choose to see their providers, including a Planned Parenthood provider with via telehealth when clinically appropriate. These bills have led the nation in expanding access to care. First, through payment parity. Community clinics often face reimbursement and funding challenges while disproportionately serving communities that are historically underrepresented and underserved.

Telehealth payment parity authorized through AB 744 has been critical to ensuring that safety net providers like Planned Parenthood are able to serve their communities using multiple modalities for patients' access to care. Second, by establishing new patient relationships via telehealth. Planned Parenthood strongly believes that new patients should be able to access health care through telehealth. Not every health care encounter involves a patient seeing a clinician and then returning to that provider. This is particularly true for younger, healthier individuals.

For example, in the context of sexual and reproductive health care services, patients may access service one time to obtain birth control or get testing and treatment for an STI. AB 32 established flexibilities that allow a patient to see a new provider via synchronous telehealth and also allowed a provider to offer audio only synchronous telehealth when it is preferred by the patient and, again, clinically appropriate.

For individuals with lower incomes, those who face transportation, childcare, or other social barriers, an audio only visit can make the difference between seeing a provider or delaying that needed care. This is particularly important for patients who need timely access to sexual and reproductive healthcare services, such as medication abortion, birth control, or emergency contraception, all of which can be safely offered via audio only telehealth. A telehealth flexibility that is still limited is asynchronous telehealth, which allows for remote non real time communication between providers and patients.

This can reduce wait times and facilitate faster access to patient centered care. Studies have shown that rates of safety, effectiveness, and patient acceptability for asynchronous care compared to in person care, are about the same. Additionally, asynchronous care delivery can alleviate barriers like technological challenges, scheduling constraints, and privacy concerns. One survey of over 1,000 young adults revealed barriers to synchronous visits. Nearly one quarter said that it would be difficult to use phone or video visits for contraceptive services.

Asynchronous telehealth can ensure access to care for these individuals and provide an additional point of entry for people that have previously avoided health care, whether that be due to anxiety or distrust with the health care system. Through our PP Direct services, Planned Parenthood affiliates proudly offer asynchronous telehealth. However, current policies in Medi Cal prevent Planned Parenthood from providing care or establishing a new patient relationship through asynchronous telehealth to Medi Cal and family packed patients.

In close, many patients specifically choose to go to Planned Parenthood for sensitive services for reasons including their safety, comfort, and confidentiality. Planned Parenthood is uniquely situated to provide sexual and reproductive health services to its over 1,000,000 annual medical patients through both in person and telehealth modalities, restricting how medical and family pack patients access health care services, especially when those restrictions do not exist for commercial patients, only exacerbates health care disparities.

In serving a patient population that is disproportionately low income and historically underserved, Planned Parenthood strongly believes that access to and coverage of telehealth, including asynchronous telehealth, is critical to address health inequities and improve access to health care services. Thank you.

Thank you. And we'll hear from our final panelist.

Thank you. My name is Jamie Gray. I'm a licensed clinical social worker, a therapist, and the Clinical Director of integrated behavioral health at Shasta Community Health Center in Redding. And I wanna thank you for the opportunity to be here today. When I was asked to speak here to talk about the benefits of providing telehealth services for our rural behavioral health patients, I immediately reflected on my time as a clinician at the start of the COVID 19 pandemic.

When the world shut down, there were limited resources for our underserved low income population in Shasta County. If people wanted to see a therapist online, they would have had to pay hundreds of dollars out of pocket every month for the online platforms that existed at that time. We quickly pivoted to providing telephone and televideo sessions. I did the first telehealth session that the clinic offered at in 2020, and I can unequivocally say that we were able to save people by offering those services.

As the world started to open up and our office opened up to seeing clients in person again, we continue to offer telehealth services and continue to provide those services even to this day.

It was not until January 2022 that we began to see our telehealth encounters become smaller than our in person encounter count. I currently have 41 unduplicated patients that I see via telehealth. One of the things that I appreciate as a clinician about being able to offer telehealth appointments for my clients is the flexibility that it offers them. If someone needs to cancel or they aren't feeling well, I have the ability to transition their appointment from in person to a phone or video session.

I also have clients that are only seen virtually.

I have a client who lives in Boerne, which is a very small rural town about 60 miles east of Redding. When I spoke with her and asked her what her feedback was, she reminded me that it would cost about $40 round trip for her to come down the mountain to come in for an in person appointment. She's on Social Security living on about $1,200 a month.

Since Medi Cal does not allow patients to see two providers on the same day, asking them to spend over $100 a month to come see me, their psychiatrist, and other providers is simply not feasible. By being able to offer telehealth appointments, I can still work with them while they drive down to see their other providers.

We serve a low socioeconomic population in Shasta County. Most of our clients are on Medi Cal or partnership. While Medi Cal does offer some transportation services, if there's an issue with a driver getting to their house on time or if a patient is unable to schedule transportation within the parameters that partnership has, being able to work with them virtually allows them to continue to receive the Mental Health Services that they need.

Working patients are often able to see their therapist while on their lunch break because of telehealth. We have several patients who are immunocompromised, whether they're living with HIV AIDS, going through cancer treatments, and other chronic health conditions that are unable to come in person for their safety, who can come in for their who benefit from telehealth appointments.

I have a patient who's elderly and has had four surgeries in two years on their hip and femur. They're now unable to drive, and I am still able to see them every week so we can help work through the stress of recovering from these traumatic surgeries. We have several parents who are home with their kids for summer vacation when school starts and during school breaks.

And being able to be seen via telehealth allows them the opportunity to take care of themselves while also continuing to take care of their families. We also work with teen patients who sometimes have parents that don't always believe in therapy.

And having access to telehealth gives them a safe space to process the day to day trials and tribulations of being a teenager. While telehealth has been an incredible benefit to clients and staff, there are still some barriers. For many of the clients that we serve, affordability of Internet access or cell phone service can be cost prohibitive. Some of our rural patients lack broadband access and reliance on satellite Internet can make it difficult for them to be consistent with appointments.

While in person visits for the intake sessions are preferred, it can sometimes be difficult for patients because of transportation barriers or physical health issues that make it difficult for them to get into the clinic.

Overall, I'm incredibly grateful for the opportunity that telehealth allows me to best serve my patients, to help them process through trauma, learn to cope with their depression and anxiety, and have a safe space to work through the the day to day issues that life throws at them. My staff and I are thankful for the flexibility and availability that telehealth allows us to serve our underserved population in Shasta County. Thank you.

Thank you so much. Now we will move to any questions from our committee Members.

So I appreciate your comments on kind of the technology and how things are advancing. Maybe we're getting closer and closer to those Star Trek days where you just, like, get a body scan and you know all the things and figure it out and fix it really quick.

And, you know, I I think that there is there's a lot of important pieces around additional access and the cost, like, you're talking about of the out of pocket cost for travel, right, and how that adds to the cost of care. And, you know, people's time really is a barrier to access if they have to take off work or miss school or, you know, other things that have to happen.

So so there's a lot of ways I think that telehealth is kind of compounded to to make health care more accessible to folks even beyond, you know, being in rural communities or, you know, whatever the situation might be, especially for working class folks who are, you know, struggling to make ends meet.

So, you know, I guess my question is for, you know, looking to the future and where we need to go from here, what are some of the areas in which we need to focus on to support a robust and healthy, you know, telehealth system and also finding that balance between the in person care that's needed as well.

Yeah. It's a it's a difficult balance, and I think it's evolving as we all get more and more experience with it. Technology, you know, on the patient side is really important. Partnership health plan makes blood pressure machines available to to patients. You have to jump through a few hoops and not everyone knows about it.

But I think encouraging those sorts of things really helps a provider perform a safer remote visit. Especially during COVID, we were encouraging people to get pulse oximeters because they could quickly put their finger in a little device and know if they needed to go to the emergency room or not. So I I think some of that technology is really important, and making that available to people, as well as making broadband available, etcetera.

And and educating seniors on how to use a smartphone, you know, and I mean, that would be huge. We just learned of one in Balinas.

There's a Balinas senior computer class that's offered at the library they have. So things like that are really important.

Majority leader.

So I'll start with a question for the doctor. Good afternoon, sir. Just to be share fairly, doctor Newman is a family friend of mine, and I used to sit and talk to him about all what he does for rural communities and how he did it and why he did it. I said, what would your wish list? What could I do for policy?

And he said, it'd be nice to be able to have telehealth that I could help patients. And that's when this all kind of began. So I wanna thank you right now because it's changed what we're doing right here every single day and how we've changed people's lives. So thank you, doctor Newman.

Well, thank you for making it happen.

Yeah. Well, we gotta do it together. So can you just kinda walk us through when you know when it's time to call a patient in for a in person visit and the timeline, a patient faces for getting an in person appointment?

Yeah. Well, that's controlled by the provider to a large extent. So I can only talk about my practice and the practice in our office because Sure. We talk to each other and we we have certain standards that we try to agree upon and comply with. So for me, if you're too sick to have a virtual visit, you need to be seen right away.

And that might be in the office right now. It might be urgent care later. And there I can think of a few times recently where I've I've had to call 911 for someone. You know, clearly, they were struggling. It it's hard for me to describe what forty years of experience puts into assessing someone virtually or or through audio.

But I think that's part of our training, and that's that's what happens. And it's what you learn how to do vital signs are called vital signs because they're vital. So blood pressure, pulse, temperature, respiratory rate, oxygen level tells you a lot. It tells you if someone's really in danger or not. And then also their story, you know, a swollen leg, you need to go to the emergency room to make sure it's not a clot.

So there are things that you just become reflex after years and years of doing this. I don't know if does that answer Yeah. Absolutely.

For planned parenthood, miss Pontes I hate to do that to you too. So AB 32 expanded the access to the audio only telehealth, but currently, policy generally does not allow new patient relationships to be established through asynchronous care. From your perspective, would allowing patients to establish care through asynchronous visits help to improve access, particularly for our patients who there are barriers to access?

Yes. Absolutely. I think especially for sexual and reproductive health care services that can be provided safely through asynchronous health care. And I think, you know, for contraception, for example, STI testing and treatment now, we have at home test kits where you can request that. You can do your testing at home, then you can receive treatment if you need treatment for your STI.

Similarly, I think, to the doctor's point, if the conversation is for contraception, for oral contraception, and then during that conversation, whether that be through asynchronous, communication, store and forward, or through a telehealth, live visit, maybe the conversation moves towards an IUD would be better for you or a different type of contraception, and then that results in an in person visit and a follow-up.

So I think, asynchronous can be a safe foot in the door, especially for sensitive health care services where an individual actually may be more comfortable or more forthcoming with a provider when seeking sexual and reproductive health care services, and that can provide an avenue into an in person visit if that is the better modality needed.

Thank you. And for my friend up in Chester, thank you very much for traveling down here and to being part of the conversation. You know, what challenges continue or, remain using telehealth to expand behavioral health access? And what policy changes would you think would help address those challenges? I really think it'd be way out there.

And your story was fabulous, but how else can we make that better?

I think that allowing patients to have their first visit be asynchronous on the phone while as a clinician is not my preference would allow expand access for patients who don't have the ability to come into the clinic. From a policy perspective, I'm not quite sure how to answer that question. I do think that expanding broadband access for our patients, those who live way out there.

It it can be hard even with semi decent Wi Fi calls drop, and so I think we just need to expand that access for them.

We're working on that too. Thank you very much. Thank you for all three being here today.

Well, I I wanna thank you all for coming in, and thank you, majority leader, for sharing the the inspiration for your incredible legislation over time. I think the question I had was answered by miss Pontus around the kind of the importance of highlighting or creating greater access around asynchronous telehealth opportunities, and it seems like that's gonna be an area of focus for us as we move forward. So I did just wanna share.

I also sit on the communications and conveyance committee have since I started in the legislature. Digital equity and access has been a very big important part of the work that I've done as a legislator.

And we have in our Chair, who's been Chair for quite a good amount of time on the Assembly side, Assemblymember Burner, significant commitment to making sure that we are increasing digital equity, particularly in our in broadband access, particularly in our rural communities for the for this purpose as well, just making sure that we have equal access to our health care opportunities.

I also just wanted to note that it seems to me, just a reflection on all of your commentary, that the technology that, doctor Newman talked about, the wearables, the the different kinds of tools that we need, are seemingly going to be, very is moving into the area of essential as we're requiring kind of more ability for patients to do that d y d d DIY diagnostic, if you will, aided with different tools to be able to create that interface where you're hearing talking to a health care provider directly while you're also being able to report back through some of the medical devices that allow us to be able to have that that that feedback coming coming back to us.

So I just wanna note that as we continue to scale up telehealth, I think we are also going to need to make sure that we are doing so in a way that integrates that very critical aspect of, of health care.

Go ahead if you have a comment about that, either of those points.

Yeah. I'll just say that in medical training, you're taught that 80% of the information that you need to make a decision, a medical decision, is from a patient's history. So if you add in the vital signs that you can get with some of these devices, you're getting closer to 90. And, really very little is added with a stethoscope at some in in in most situations. So especially with other diagnostics that are used now.

So it it you get a lot of information

k.

From a from a history in some of these numbers.

Well, thank you. I wanna appreciate you all coming down to, Sacramento and, offering testimony and presentation on this, so that we have A Better understanding of the impacts of AB 744 and AB 32. That concludes our final panel, and really appreciate all the panelists for coming this far to be able to offer their insights into this. We're gonna move now to our public comment section for this hearing, and I wanna thank all our panelists for coming today.

We will now, make sure to, have time for everyone to share their perspective, and we encourage you to be concise.

If someone has captured your main point already, we welcome you to associate yourself with the comments of our previous speaker. I'd like to invite our first commenter to come up to share your name organization, if you have one, and your comment. You will have one minute each to be able to share public comment.

Good afternoon. Kelly Brooks on behalf of the California Association of Public Hospitals and Health Systems. Thank you so much for holding this hearing today, and a special thanks to Assembly Member Aguiar-Curry who has long prioritized telehealth issues. California's 17 public hospital systems operate over a 100 community clinics, serve 3,000,000 3,400,000 patients a year, and provide more than a third of Medi Cal and uninsured hospital care to in the state.

Public hospitals learned during the the public during the pandemic how powerful a tool telehealth has been to improve access and quality of care and the role it can play in reducing disparities of health care for California's most at risk patients.

A b 32 worked. Telehealth is not a pandemic workaround anymore. It is an essential element in how we deliver care including primary and specialty care, chronic disease management, behavioral health care, and the support of care coordinators and social workers. Thank you again for the discussion today.

Thank you.

Good afternoon, Chair Bonta and members of the committee. My name is Lonnie Riley, vice president of industry affairs at the American Telemedicine Association and ATA Action, the advocacy arm of ATA. I'm an also I'm also an occupational therapist licensed in California. Thank you for the opportunity to speak today. California has built one of the nation's strongest telehealth frameworks, making virtual care a permanent part of health care delivery.

As a result, patients have greater access to timely high quality care when and where they need it. Now is the time to build on that success. ATA action encourages the legislature to focus on four priorities.

Closing remaining Medi Cal telehealth gaps so patients can establish care using the telehealth modality that best meets their clinical needs, modernizing cross state licensure to support continuity of care, removing barriers that prevent California licensed providers located out of state from participating in Medi Cal, and creating a stable policy environment that supports continued innovation. Telehealth is essential is essential to a modern patient centered health care system.

We look forward to working with the company to ensure California remains a national leader in access, quality, and innovation. Thank you.

Thank you.

Good afternoon, Chair Bonta and members. Jennifer Robles with Health Access California. We appreciate the hearing and the opportunity to discuss how telehealth access has evolved and its impact on consumers. We support expanded telehealth, especially for behavioral health and LGBT communities and situations where confidentiality and accessibility are critical. At the same time, we want to ensure that the focus is not only on telehealth access, but also balancing and maintaining timely access to in person care for consumers.

Thank you so much.

Thank you. I think that concludes our public comments for this hearing. I will now ask any committee members if they have any final thoughts or comments.

I do.

I will turn it over to our majority leader.

First of all, I wanna thank you, Chair Bonta, for putting together in your committee. Thank you very much. We really appreciate it. I wanna thank speaker Rivas for creating the outcomes review process, giving the legislature important opportunity to evaluate impact our laws after they are enacted. And I wanna thank our panelists for sharing their experiences, for helping us better understand the impact of these policies.

I get choked up because we have changed what people are doing and how health care has changed. And I look across this room that we've all touched and done something with telehealth and how it has changed so many people's lives, particularly in the rural communities, but also as you were saying, even in your communities, how it's changed and all the things they've all been through to be able to pick up the phone or or do it by, virtually.

Our discussion today showed that telehealth has become an important part of our health care system, especially for rural communities, older adults, and patients who face barriers. I'm proud of the work you've done. You've done a great job.

I really appreciate all the support that you've done, Chair, when we were trying to work with telehealth, and we've had lot lengthy discussions to make sure that we didn't forget anybody. And I think we will continue to have some gaps that we need to fix in the future. And thank you very much as well, Assembly members. I appreciate you being here. So I'm proud of the work we've done.

We've built a strong foundation for telehealth in California, but I also recognize there's recognize there's still work to be done, ensure that every patient can benefit from these tools. So I appreciate the opportunity to work with all of you continuing to learn from patients, providers, and stakeholders about what is working here and how we're gonna do it. Thank you very much.

Thank you so much. I wanna thank everyone for participating today. Our panelists provided very valuable testimony to help us better understand the impact of our state's telehealth policies, for patients, providers, and our broader health care system. I think we were able to hit on some areas where we have opportunity for growth and continued leadership.

This review will inform any future legislative work on this topic, and I also wanna thank, of course, our majority leader, Aguiar-Curry, for her passion and her for her leadership on this issue over many years.

She's put in an immense amount of work, to push our state to be the leader in telehealth that it is today. And this will be a huge part of her legacy in this legislature. And we are very lucky to benefit from her dedication.

This maybe it made me nervous.

Keep going, lady. Keep going.

Majority leader, Aguiar-Curry, very thankful for you. And, and with that, we conclude our hearing.