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HomeMy WebLinkAboutMINUTES - 12081998 - C67 FHS #31 ' TO: BOARD OF SUPERVISORS CONTRA FROM: FAMILY&HUMAN SERVICES COMMITTEE COSTA ,,• DATE: December 8, 1998 �° --"� COUNTY SUBJECT: Managed Care Legislation SPECIFIC REQUEST(S) OR RECOMMENDATION(S) & BACKGROUND AND JUSTIFICATION RECOMMENDATION(S)': ACCEPT the attached report from the Health Services Department on managed care legislation. BACKGROUNDIREASON{S) FOR RECOMMENDATION(S): On November 23, 1398, the Family and Human Services Committee heard a report from Milt Camhi, Director of the Contra Costa Health Plan, and Bobbi Baron, Planning Director, on state managed care legislation. Mr. Camhi reported that a Managed Care Improvement Task Force appointed by the governor and legislature in 1997 issued some 100 recommendations in 12areas of managed care. Eight bills enacted in 1998 relate to the task farce recommendations and another 12 bills were enacted which may impact on the Contra Costa Health Plan (CCHP). Mr. Camhi gave an overview of the various bills. Supervisor Donna Gerber requested clarification of the impact of AB 1377 (Gallegos)on financial examinations. Ms. Baron stated that deficiencies found in current DOC fiscal examinations are not made part of the public report. AB 1377 requires both the finding of error and the correction in the report. Supervisor Gerber also asked for more information on SB 984 (Rosenthal)on provider profiling. Ms.'Baron explained that the bill was in response to charges that, if a physician uses too many services, they can be "blacklisted," and that the bill is primarily a reporting/disclosure law. If a heath plan tracks frequency or cost of provider use of service, they must so inform the provider or provider group. cownNUED ON ATTACHMENT: X YES SIGNATURE: RECOMMENDATION OF COUNTY ADMINISTRATOR—RECOMMENDATION OF BOARD COMMITTEE APPROVE —OTHER SIGNATURE(S): Donn rber Mark DeSauinier ACTION OF BOARD ON Dece-m5er 6. 1999 APPROVED AS RECOMMENDED OTHER VOTE OF SUPERVISORS I HEREBY CERTIFY THAT THIS IS A T� TRUE AND CORRECT COPY OF AN AYES:f R NOES: ACTION TAKEN AND ENTERED ABSENT, ABSTAIN: ON MINUTES OF THE BOARD OF SUPERVISORS ON THE DATE SHOWN. Contact:Sara Holtman,335-1090 ATTI sTnDecember -8, 1998 PHIL BATCHELOR,CLERK OF TIJ9 BOARD OF SUPERVISORS ADMINISTRATOR cc: CAO BY DEPUTY EMORAND November 16, 1998 TO: Supervisor Donna Gerber, Chair Supervisor Mark DeSaulnier Family and Human Services Committee of the Board of Supervisors FROM: Wile M.D. Dir , ealth Services Department SUBJECT: Managed Care Legislation r:raririrmrxr>.►ire,.vsivrirtwirfrf..rrcarirt.►irirrer,-��r.-rrr.:e,►rr..wrEiriracarrrtir;;�:inrssrxirirr..rriKsw..,►i�zr!owr.�icris:r��.w,r,w:rr!.:�-s: Last year the governor and legislature appointed a 30-member special Managed Care Improvement Task Farce which, in January 1998,issued some 100 recommendations in 12 areas of managed care. Bight bills enacted this year relate to the Task Force recommendations. There were 12 other bills enacted which may impact on Contra Costa Health Flan(CCHP). Below is a report depicting the areas of the task force recommendations and a summary of the legislation implementing these recommendations. The report also contains a summary of the other legislation signed into law in this session. Legislative Implementation of Managed Health Care Improvement Task Force Recommendations 1. Government Regulation and Oversight of Managed Health Care A. New regulatory/oversight agency • No laws enacted. B. Promote inter-departmental and private sector coordination and eliminate redundancy. '`AB 162 Alhy---Provider Audits The Department of Cor orations and the State Department of Health Services are to coordinate---to the extent feasible—audits or surveys of physicians' offices by the Knox-Keene Act and t1w Medi-Cal Act. Supervisors Gerber and DeSaulnier Family and Human Svcs. Committee of the Board of Supervisors November 16, 1998 Page 2 `'AB 1959 Gallegos Provider Audits a) Requires the Department of Corporations,with the Department of Health Services,to convene a working group to develop standards for quality audits of providers that contract with health care service plans. b) Specifies that the working group shall be comprised of representatives of health plans,consumer organizations,public and private purchasers of health care,and providers. c) Specifies the goals of the working group. d) Requires the DOC to report to the Governor,Department of Corporations,Department of Health Services,and Appropriations Committees of the Legislature by January 1,2000,on its findings and recommendations. 2. Expanding consumer choice with health plans i No laws enacted. 3. Minimizing risk avoidance strategies • No laws enacted. 4. Standardizing health insurance contracts ■ No Paws enacted. 5. New quality information development No laws enacted. 6. Improving the despute resolution process A. External consumer assistance—Ombudsperson ■ No laws enacted. B. Independent third-party services ■ No laws enacted. 7. Financial incentives for providers A. Disclosure of specific information about scope and general methods of payments to providers. vSB 750 Rosenthal—Physician Incentives ■ Has more specific language about disclosure of M.D. reimbursement than in previous legislation. The disclosure to include"the scope and general Supervisors Gerber and DeSaulnier Family and Human Svcs. Committee of the Board of Supervisors November 16, 1998 Page 3 • methods of payment made to its contracting providers of health care services and whether financial bonuses or any other incentives are used." • Allows enrollees to request additional information from the plan or the provider group. 8. Physician-Patient Relationship A. Continuation when provider is terminated "'SIS 1129 Sher—Continuity of Care • If a provider who is terminated has been providing care to an enrollee for an acute condition,serious chronic condition,or 2"dl3rd trimester pregnancy, upon request from the patient,the pian must allow patient to continue to see provider until a"safe transfer"to a plan provider can be made--usually within 90 days. B. Standing Referral to Specialist ''AB 1181 Escutia--Standing Referrals • Health plans to establish a procedure for standing referral to a specialist or specialty care center for members with a life-threatening condition, degenerative or disabling condition that requires coordination of care by a specialist instead of a primary care physician. 9. Consumer Information,Communication,Involvement *'AB 607 Scott—Disclosures in Disclosure Form:.Matrix of Information • The first page of all disclosure forms must contain a notice with specified information including plan phone number. • Individual and small group Evidence of Coverage(EOC)must contain matrix of information including the following benefit descriptions,together with the corresponding copayments or limitations in the following sequence: deductibles,lifetime maximums,professional services,outpatient services, hospitalization services,emergency services,ambulance services,prescription drug coverage,durable medical equipment,mental health services, chemical dependency services and home health services. 10. Improving Delivery of Care and Practice of Medicine A. Improve Formulary Effectiveness "AB 974 Gallegos and SB 625 Rosenthal • Listing of formulary drugs • Disclosure in EOC • Exceptions to formulary Since CCHP has an open formulary,the legislation does not affect its practices. Supervisors Gerber and ReSaulnier Family and Human Svcs. Committee of the Board of Supervisors November 16, 1998' Page 4 11. Women's Health A. Allow women direct access to"reproductive health cage providers." 1AB 12 Davis Direct unlimited access to OBIGYN services. ■ Allows women direct access(no primary care provider approval)to participating QB-GYNs or to family practice MDs in 013-GYN specialty clinics. ■ The Health..Plan can have utilization review requirements for specified procedures. 12. 'Vulnerable Populations ■ No specific legislation enacted. Other Managed Care Legislation MANDATORY BENEFITS 1. AB 7(Brown)—Mastectomy Length of Stay ■ Mastectomy and lymph node dissections length of stay to be determined by attending M.U. in consultation with the patient and consistent with sound clinical principles and processes. ■ No prior approval for mastectomy and lymph node dissection length of stay. ■ Contains requirements for follow-up care. 2. AB 1621 (Figueroa}—Reconstructive Surgery ■ Must include coverage for reconstructive surgery necessary to improve function or"create a normal appearance,to the extent possible." ■ Allows for exclusion for cosmetic surgery. ■ Refines reconstructive surgery and cosmetic surgery. • Includes Medi-Cal adults (previously only Medi-Cal children were covered). ■ Can use prior authorization to approve/deny surgery. 3. AB 2003 (Strom-Martin)—Dental Anesthesia • Bill becomes effective January 1, 2000. ■ Requires plans to pay for general anesthesia for dental procedures for specified individuals. Supervisors Gerber and DeSaulnier Family and Human Svcs. Committee of the Beard of Supervisors November 16, 1998 Page 5 4. SB 2020(Karnette)----Prostate Cancer Screening * Must cover prostate cancer screening and diagnosis including prostate-specific antigen testing and digital rectal exams when medically necessary and consistent with good medical practice. Disclosure(Effective July 1, 1999) • Requires health plans to publish toll-free number for hearing and speech impaired, plan's phone number, and DOC internet address on specified health plan documents and forms. * Modifies and clarifies what is required in standard notices to members concerning grievances and appeals. • Requires speck statements on specified documents. REGULATORY OVERSIGHT 1. AB 1377 (Gallegos}- Financial Examinations: * Deficiencies found in DOC fiscal exams,even if corrected within 30 days (current law)will be made public. • Gives plans 45 days to respond. * Requires DOC to append plan's response if requested. 1. SB 956(Rosenthal)---Anti-Fraud Unit(effective July 1, 1999) * Requires health plans to establish anti-fraud plans(including an anti-fraudunit). Plan to make annual report to DOC. 2. SB 984{Rosenthal}--Provider Profiling(effective July 1, 1999) • Plans that use `economic profiling"of physicians must file description of policies and procedures with DOC. • The bill defines"economic profiling"as an evaluation of a particular physician, provider,medical group or IPA based wholly or partly on the costs or utilization of services by the physician or provider entity. Thus, any performance measurement that touches on casts or utilization should be considered an economic profiling program subject to the requirements of the bill. • Pian must provide copy of the individual economic profiling information to individual provider or provider group. Supervisors Gerber and DeSaulnier Family and Human Svcs. Committee of the Board of Supervisors November.16, 1998 Page 6 EMERGENCY SERVICES LEGISLATION 1. AB 682 (Morrow)and SB 277(Maddy)---Amend existing law regarding emergencies. r Adds definition of"stabilized"and"stabilization"that is consistent with federal law. ■ DOC to adopt regulations by July 1, 1999,about necessary medical care after stabilization. 2. AB 984(Davis)--Emergency Transport • Plan must use reasonable person criteria in determination of emergency transport and pay for those ambulance transports. 3. AB 1560(Scott)--ER Claims ■ Requires HMOs to pay clean claims within 45 working days. • Sets up timetable for contesting,delaying,denying portions of claims. 4. AB 2103 (Gallegos)--Closing of Elis ■ health plans must notify enrollees if their hospital reduces or eliminates ER services.