Read the latest legislative news from CAFP

January 8, 2010
December 4, 2009
November 13, 2009
November 6, 2009
October 30, 2009
October 23, 2009
October 9, 2009
October 2, 2009
September 25, 2009
September 18, 2009
September 11, 2009
September 3, 2009
August 28, 2009
August 21, 2009
August 14, 2009
August 7, 2009
July 31, 2009
July 23, 2009
July 17, 2009
July 10, 2009
July 2, 2009
June 26, 2009
June 19, 2009
June 12, 2009
June 5, 2009
May 15, 2009

 

January 8, 2010

Governor Calls for Large Health Care Cuts in New Budget Proposal
On January 8, the Governor began what is sure to be a long and painful process: to bridge a General Fund budget gap of $18.9 billion for the next 18 months without decimating the State's tenuous safety net. The $6.3 billion projected deficit for 2009-10 and a the $13.6 billion gap between projected revenues and spending in 2010-11 is due to lower than expected revenue and overly optimistic revenue solutions dubbed "failed gimmicks and reductions" in an Assembly Budget analysis released earlier today. The Governor's three-part solution includes $8.5 billion in cuts ($3 billion of which are health care related), $4.5 billion in revenue transfers, and $6.9 billion in additional money the administration hopes to procure from the federal government (and a $6.9 billion fall back plan or "trigger" of additional cuts and revenue increases if the federal government does not comply).  The Governor also includes a $1 billion reserve in his proposal, which pushes the deficit to $19.9 billion.

The next few months will be critical in CAFP's advocacy efforts, and the Academy will again mount a strong defense to attempt to protect vital programs that affect you and your patients. As part of this effort, it will be crucial that family physicians reach out to the legislators and let them know the consequences that cutting or eliminating important health programs will have on patients and communities. CAFP has created an State Budget Resource Center to assist members in understanding what is at stake in this budget and how you may best be heard.

Proposed Criteria on "Meaningful Use" of HIT Released
This week, the Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC), each issued a set of regulations that, together, lay a foundation for improving the quality, efficiency and safety of the nation's health care through the use of certified EHR technology. The American Recovery and Reinvestment Act of 2009 included the Health Information Technology for Economic and Clinical Health Act, or the "HITECH Act." This Act stipulated that, in order for professionals and hospitals to be eligible to receive payments under the Medicare and Medicaid EHR incentive programs, they must be able to demonstrate "meaningful use" of a certified EHR system. Health and Human Services officials emphasized that the detailed, 700-page CMS meaningful use plan is still a proposal only. According to the announcement, the public has 60 days to comment on the regulation after it is published in the Federal Register. Subsequent revisions will be made, with the final rule expected in spring of 2010. In order to reap the financial incentives, physicians must meet three stages of progressively more demanding goals for using HIT in their practices. The initial Stage 1 set of criteria focuses on collecting data electronically, sharing information with other providers and patients, and reporting quality measures to the government. Stage 2 criteria will be proposed by the end of 2011 and focus on structured information exchange and continuous quality improvement. Stage 3 criteria will be unveiled by the end of 2013 and focus on decision support for "national high priority conditions" and population health.

Initial Set of Standards, Implementation, Specifications, and Certification Criteria for Electronic Health Record Technology
http://www.federalregister.gov/OFRUpload/OFRData/2009-31216_PI.pdf

Electronic Health Record Incentive Program Proposed Rule
http://www.federalregister.gov/OFRUpload/OFRData/2009-31217_PI.pd

CAFP Legislation to Ban Trans Fats Goes Into Effect This Week
At the end of the last legislative session in 2008, CAFP came away with some key victories. The Governor signed more than 20 CAFP-supported bills, including CAFP co-sponsored AB 97 (Mendoza), which took effect this past week. The bill has the goal of dramatically reducing diabetes and heart disease by banning artificial trans fats from being used in food storage, sale, or preparation. CAFP President Tom Bent, MD, was quoted in a recent LA Times story detailing new laws going into effect January 1st. "Consumption of trans fats greatly increases your risk of heart attack and stroke," said Laguna Beach physician Thomas C. Bent, president of the academy. "If you are going to eat fast food, it's going to be a little healthier now." To read the entire article, please click here: http://www.latimes.com/news/local/la-me-new-laws1-2010jan01,0,3437892,full.story

CAFP Attends DHCS 1115 Waiver Stakeholder Meeting
CAFP Director of Government Relations, Tom Riley, attended the first 1115 Waiver Stakeholder Committee meeting yesterday. As mentioned in previous Legislative Updates, the Administration's goal in the new 1115 waiver is to create better care coordination in public health programs for seniors, persons with disabilities, dual eligible patients (Medi-Cal and Medicare), children with special health care needs, and persons with behavioral health conditions. As part of last August's budget agreement, AB X4 6 authorizes the 1115 Waiver to seek authority to enroll beneficiaries into specific organized delivery systems, such as managed care, enhanced primary care case management, or a medical home model. CAFP will continue to be actively involved in the process to ensure that the new waiver reflects the true value of the patient centered medical home.

 

December 4, 2009

Deadline Approaching for CAFP Congress and FP-Advocacy Day at Capitol - Act Now to Register!
It's not too late to register for CAFP's 2010 Congress of Delegates, scheduled for March 6-8, 2010 at the Holiday Inn Sacramento Plaza in Sacramento. If you are looking to get involved in your community and learn about policymaking, please consider volunteering as a delegate or alternate. The Congress of Delegates is the annual policymaking meeting for CAFP and is open to all CAFP members, though only delegates and alternates are permitted to vote. This is a wonderful opportunity to meet with other family physicians, address public health and professional issues facing family medicine today, and to hear what the Academy is doing on behalf of physicians and patients. Next year's Congress will again focus on legislative and media advocacy, with trainings on talking to your legislator and working with the media.

If you are interested in this leadership opportunity, contact CAFP Membership Manager Jessica Kuo at jkuo@familydocs.org.

Analysts Predict $21 Billon Budget Gap for California in 2010-11
The state Legislative Analyst Office's (LAO) recently released economic forecast predicts the State's economy will go from bad to worse: Heading into 2010, economic analysts and government researchers predict that California will have to address a General Fund budget gap of $20.7 billion for the next 18 months. The budget problem consists of a $6.3 billion projected deficit for 2009-10 and a $14.4 billion gap between projected revenues and spending in 2010-11. The deficit is due in large part to lower than expected revenue intake and overly optimistic revenue solutions from the last budget agreement (including the failed a $1 billion partial sale of the State Compensation Insurance Fund, and the blocked $800 million the state hoped to transfer from transit money to the General Fund). Due to the significant cuts in education and health during the past budget cycles and federally required minimum spending for both, it will be very difficult for lawmakers to find savings in those areas. At a Sacramento chronic disease conference Wednesday, one former Schwarzenegger aide went so far as to say that the entire Medi-Cal program may be at risk if the economy does not improve and if federal support is not sufficient.LAO director, Mac Taylor, recommended that the state look to the federal government for further fiscal relief. He also advised  lawmakers to reintroduce the two ballot measures that failed last May: one that would have move Prop 63 mental health funds to the General Fund, and one that would transfer Prop 10 "First 5" early childhood development funds to the General Fund. The Governor will release his proposed budget solutions in early January. CAFP will again mount a strong defense to attempt to protect vital programs that affect you and your patients. As part of this effort, it will be crucial that Key Contacts (everyone who receives this email) reach out to the legislators and let them know the consequences that cutting or eliminating important health programs will have on patients and communities. Please keep and eye out for future Legislative Alerts.

To read the LAO report, click the link below: http://www.lao.ca.gov/2009/bud/fiscal_outlook/fiscal_outlook_111809.aspx

CMS Releases Final Rule on 2010 Medicare Physician Fee Schedule
On Wednesday, November 25, the Centers for Medicare and Medicaid Services (CMS) released the final rule on the 2010 Medicare physician fee schedule. CAFP was pleased to see the overall improvement in payment for primary care physician services and hopes that CMS will accelerate this trend in future years. CAFP and AAFP have some concerns, including requirements around telehealth services and CMS undervaluing the H1N1 immunization administration code (relative to the value for the corresponding CPT code). Those interested in commenting may do so either via mail or online at: http://www.regulations.gov/search/Regs/home.html#documentDetail?R=0900006480a5e991. CMS will accept comments through Tuesday, December 29.  If you have any questions, please contact CAFP's Director of Health Policy, Sandra Newman at snewman@familydocs.org. 

CAFP Works to Improve Physician Performance Initiative Process
The California Cooperative Healthcare Reporting Initiative (CCHRI) is operating a quality reporting pilot project called the California Physician Performance Initiative (CPPI). Over the past two years, CPPI has used claims data from private PPO patients from Anthem Blue Cross, Blue Shield, and United Healthcare to measure physicians on a set of quality measures. Many Academy members contacted us with serious concerns about the accuracy of their data. Academy leaders and staff have been working with the California Medical Association (CMA), CCHRI project staff, and others to delay the release of these data until a higher level of accuracy can be achieved. To date, only Blue Shield has announced plans to publicize the results. On Wednesday, CAFP Director of Health Policy, Sandra Newman, attended a meeting with Assemblymember Jared Huffman (D - San Rafael), CMA, Blue Shield and other stakeholders in order to explore alternatives.  The Academy's letter to CCHRI can be viewed here: http://www.familydocs.org/files/CPPI_LETTER.pdf.

CAFP President-Elect Meets with Assemblymember Mike Eng
CAFP President-elect Jack Chou, MD, met with Assemblymember Mike Eng (D - Monterey Park) during a Los Angeles County Medical Association (LACMA) meeting in late November.  In attendance were community physicians from the San Gabriel Valley and LACMA leadership. Dr. Chou spoke about how local physicians need to join organized medicine and how they can be empowered to make policy changes through the medical society and through their local legislator. It was a great meeting to build on the continuing good relationship between family physicians and Assemblymember Eng.

 

November 13, 2009

CAFP Endorses New House Health Care Reform Bill - HR 3962
Last Saturday, the CAFP Board of Directors voted to endorse the Affordable Health Care for America Act (also known as HR 3962), which represents input from the three House committees that oversee health care issues, and included many aspects of CAFP-endorsed HR 3200 as well as feedback provided on a number of different provisions. As with HR 3200, there are some provisions the Academy would like to see improved upon, but CAFP believes the bill is consistent with CAFP's principles of health care reform and is a necessary step to begin the long-term process of reforming U.S. health care, including re-establish primary medical care as the foundation of our health care system. As part of the reform process, CAFP has met and/or spoken with staff from California's congressional delegation to underscore the importance of eliminating the Medicare sustainable growth rate formula, expanding provisions to support family medicine education and training, including those measures that would offer loan repayment assistance, and ensuring that all patients have access to quality, affordable health care. CAFP is working to ensure that reform efforts include provisions to improve residency programs' ability to train residents in community-based settings.

The basic elements of HR 3962 are very similar to HR 3200 and the bills marked up in the Senate by the Health, Education, Labor, and Pensions (HELP) and Finance Committees. There are, however, some major differences, as pointed out by a recent Health Affairs article.

• HR 3962 insurance reforms are similar to Senate bills (prohibiting pre-existing condition exclusions; eliminating underwriting based on health status, gender or occupation; limiting out-of-pocket expenses; removing coverage caps; and mandating medical loss ratios).
• In HR 3962, all plans must cover essential benefits, cannot charge cost-sharing for preventive services, and would limit out of pocket spending to $10,000/family.  This would require revision of current law governing health savings accounts.
• HR 3962 creates a national health insurance exchange for non-group policies; insurance through the exchange would be available for small and perhaps large employers. The exchange should increase the accountability of health insurers and transparency. The Senate bills also create exchanges but at the state level.  A national plan could get underway more rapidly and have lower administrative costs.
• HR 3962 requires employers with payrolls $500,000+ to provide health insurance or pay a penalty. HR 3962 provides tax credits to small businesses that offer employees health insurance.  The Senate Finance bill has a weaker mandate.
• HR 3962 requires individuals to purchase health insurance or pay a tax of 2.5% of AGI. Each bill contains an individual mandate.
• HR 3962 includes affordability subsidies set at levels established by Blue Dog amendments in the Energy and Commerce Committee.  Subsidies are more generous than those in the Senate Finance bill but less generous than those in the HELP bill.
• HR 3962 expands Medicaid eligibility to 150% FPL and eliminates categorical eligibility requirements.  The Federal match would be 100% in 2013 91% after 2015.   The Senate Finance bill sets eligibility at 133% FPL, as did HR 3200.
• HR 3962 increases payments to PCPs who participate in Medicaid to 100% of Medicare and transfers most of the cost of increased payments to the federal government. It goes a good distance toward reducing the burden of Medicaid expansions on states.
• HR 3962 includes a public plan.  HR 3200 had a robust public plan, while the Senate HELP bill had weaker, state-based plans and the Finance bill has no public plan.  The plan, however, would have to negotiate rates with providers which will likely doom it from the start.
• HR 3962 doesn't include any changes to the sustainable growth rate (SGR) mechanism for setting Medicare's payment rates for physicians' services (these provisions are contained in a stand-alone bill).
• HR 3962 has programs and regulatory initiatives that would be noticed immediately or in the very near future.  Prior versions of both the House and Senate health reform bills waited until at least 2013 for most new programs.
• Insurers would have to justify premium increases through a rate review process. Insurers must post on a public Web site their justification for premium increases. Plans can be excluded from the Exchange if they have unjustifiable rate increases.
• The most important feature of the House Exchange is that it has the power to negotiate and contract with insurers.
• HR 3962 establishes a publicly searchable database for financial relationships (including gifts of $5+) by pharma, devices, biologics, or supplies paid for by Medicare, Medicaid to physicians, other health care professionals and researchers, patient advocacy groups, CME programs, or health care institutions. Physician ownership of hospitals and facilities would also be reportable. 
• Workforce provisions, including IME and GME for more community-based training, go into effect more quickly in HR 3962.
• HR 3962's state malpractice reform incentive program does not preempt current state malpractice laws.

 

November 6, 2009

CMS Releases Final Rule on 2010 Medicare Physician Fee Schedule
On Friday, October 30, the Centers for Medicare and Medicaid Services (CMS) released the final rule on the 2010 Medicare physician fee schedule, and will make it available for comment by all interested stakeholders on Wednesday, November 25. At that time, CAFP will provide talking points and a template comment letter, and ask for all Key Contacts to respond. To read the rule, please click here. CMS will accept comments through Tuesday, December 29.

LAC Member Testifies at Joint Hearing on Sweetened Beverages
CAFP resident member, and member of the Legislative Affairs Committee, Casey Vibbard, MD, testified on Thursday at a joint informational hearing of the Senate Select Committee on Obesity and Diabetes and the Senate Health Committee. As a representative of CAFP, Dr. Vibbard explained the link between the consumption of sugar-sweetened beverages and obesity, and informed the committee that CAFP would like to take a lead role in reducing soft drink consumption. Dr. Vibbard told the committee that one of the most heartbreaking parts of her job is to treat obese children and adolescents. She emphasized that children are suffering from diseases that their grandparents suffer from, and that without intervention, their outlook for a healthy future is bleak. She concluded by informing the committee that CAFP was instrumental in passing SB 12 (Escutia), a 2005 bill sponsored by the Academy that banned the sale of soda in public secondary schools. Dr. Vibbard also gave an on-site interview with USC TV.  

DMHC Announces Final Timely Access Regulations
This past week, the Department of Managed Health Care (DMHC) released the final version of its timely access regulations. AB 2179 (Cohn), which was signed into law in 2002 despite CAFP's strong opposition, tasked the DMHC with creating regulations regarding patient wait time limits to receive care. Many of the early iterations of the proposed regulations put the burden on already overstretched primary care physicians. CAFP urged regulators to require health plans to provide sufficient provider networks in order to ensure timely access to care, instead of requiring physicians to see more patients in less time.  With proper enforcement and provider feedback to DMHC, the Academy believes the regulations could improve contract provisions in order to build adequate physician networks.  Many, if not all of CAFP's concerns have been addressed in subsequent versions, and the final version, of the proposed regulations. 

Click here to read a summary of the changes and the final Statement of Reason: http://wpso.dmhc.ca.gov/regulations/docs/regs/20/1257296017221.pdf

Click here to read the final text of the regulations:
http://wpso.dmhc.ca.gov/regulations/docs/regs/20/1257296076228.pdf

In Home Support Services Bill Fails in Legislature
A bill that could have eased confusion for seniors and peoples with disabilities living at home was defeated this week. At a hearing on Thursday, Assembly Budget Committee Chair, Noreen Evans, underscored the magnitude of the problem by noting that it would be felt by In Home Support Services (IHSS) beneficiaries across 58 counties. This disruption to the IHSS program includes the fingerprinting of workers, background checks, and additional requirements. These changes are anticipated to delay and possibly impede care for patients who have been recently released from hospitals, as cases of re-admissions as a result of these new measures are already being reported. Governor Schwarzenegger has refused to slow down implementation despite the confusion and unnecessary disruption of service. 

Interested in attending CAFP's Congress of Delegates?
If you have interest in serving as a delegate or alternate to the CAFP Congress, you may visit http://www.familydocs.org/about-cafp/membership/chapters.php on the CAFP Web site and contact your Chapter Officer or contact Membership Manager Jessica Kuo at 415-345-8667. Names of delegates and alternates are due to CAFP no later than Thursday, December 10. Next year's Congress will again focus on legislative and media advocacy, with advocacy and media training following the regular business of the Congress, a town hall meeting on key issues of the day, and lunch with a legislative leader. Please note that resolutions for the 2010 Congress are also due to CAFP on Thursday, December 10.

 

October 30, 2009

Medical Home to Have Increased Importance in State Medicaid Efforts
This past Monday, Kevin Grumbach, MD (Chair of the UCSF Department of Family and Community Medicine; Chief of Family and Community Medicine at SF General; and Director of the UCSF Center for California Health Workforce Studies) and CAFP staff held a call with Richard Figueroa, Health Care Advisor to the Governor. The impetus for the call came out of the administration's desire to create better care coordination in public health programs for seniors, persons with disabilities, dual eligibles (Medi-Cal and Medicare), children with special health care needs, and persons with behavioral health conditions. Their goal is to coordinate that care through organized delivery systems, and specifically, the medical home model. The main vehicle through which they would make (and incentivize) this change is through the "Medicaid 1115 Waiver." Click here to read the draft Concept Paper for California's proposed section 1115 Medicaid waiver.

Background
Section 1115 of the Social Security Act provides the Secretary of Health and Human Services broad authority to authorize experimental, pilot, or demonstration projects likely to assist in promoting the objectives of the Medicaid statute. Flexibility under Section 1115 is sufficiently broad to allow states to test substantially new ideas of policy merit. These projects are intended to demonstrate and evaluate a policy or approach that has not been demonstrated on a widespread basis. Some states expand eligibility to individuals not otherwise eligible under the Medicaid program, provide services that are not typically covered, or use innovative service delivery systems.

There are two types of Medicaid authority that may be requested under Section 1115:

• Section 1115(a)(1) - allows the Secretary to waive provisions of section 1902 to operate demonstration programs, and
• Section 1115(a)(2) - allows the Secretary to provide Federal financial participation for costs that otherwise cannot be matched under Section 1903.

Projects are generally approved to operate for a five-year period, and states may submit renewal requests to continue the project for additional periods of time. Demonstrations must be "budget neutral" over the life of the project, meaning they cannot be expected to cost the Federal government more than it would cost without the waiver. Click here to read a fact sheet on California's previous 1115 Waiver agreement: http://www.kff.org/medicaid/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=14332

Signed as part of last August's budget agreement, AB X4 6 contains statutory changes to the Medi-Cal program in order to achieve long-term savings and efficiencies, and to implement the 2009 Budget Act. This bill had specific goals, including:

• Restructuring the 1115 Waiver to improve coordination between Medicare and Medi-Cal, improve integration of physical and behavioral health care, and use medical homes and specialty centers for children with significant medical needs.

• Authorize the 1115 Waiver to seek authority to enroll beneficiaries into specified organized delivery systems, such as managed care, enhanced primary care case management, or a medical home model.

Click here to read an analysis of AB x4 6: http://www.leginfo.ca.gov/pub/09-10/bill/asm/ab_0001-0050/abx4_6_cfa_20090724_153847_asm_floor.html

1115 Waiver's Potential Effect on the Medical Home
CAFP is encouraged to see that the medical home model is gaining traction within the Administration's future planning, and are pleased by the Administration's recognition of the improved care and cost-saving that the patient centered medical home offers. The Academy, however, is concerned that the Administration may not have a full understanding of the thorough transformation necessary for practices to become medical homes, as well as the financial and technical assistance needed to become an advanced medical home that will achieve the savings they are counting on. CAFP is also concerned that California has not done enough to stem the primary care physician shortage, to ensure that medical homes will be available for patients. In addition, once a practice has been transformed into a medical home, it will serve all patients, not just the high risk, heavy utilizers the Administration is trying to focus on. There is also the possibility that the Administration may try to combine this effort with the state-based multi-payer medical home demonstration project announced recently by Health and Human Services Secretary, Kathleen Sebelius (and detailed in last week's Legislative Update).

The Department of Health Care Services (DHCS) will hold a public discussion of the concept paper on Monday, November 2, 2009, from 1 to 4 PM at the DHCS auditorium at 1500 Capitol Avenue, Sacramento. Their Executive Management team will present the concept paper and respond to questions, comments, and concerns from participants. They will use stakeholder feedback to revise the concept paper before it is submitted to the federal government. The discussion is open to all interested participants, and an invitation is available at the Save the Date link. You may also send questions, comments, and concerns to their waiver renewal e-mail address at waiverrenewal@dhcs.ca.gov.

 

October 23, 2009

Governor Signs Six CAFP-supported Bills, Vetoes CAFP Workforce Bill
With his signing deadline just hours away, California Governor Arnold Schwarzenegger signed six CAFP-supported bills. Unfortunately, CAFP's co-sponsored legislation, Assembly Bill 657, authored by Assemblymember Ed Hernandez (D - Baldwin Park), was vetoed by the Governor. AB 657, co-sponsored by the Latino Coalition for a Healthy California, would have established a Health Care Workforce Taskforce to address the urgent shortage of primary care doctors and the under-representation of Latinos and African American physicians, among others.

Other CAFP priority bills the Governor signed include:

• AB 108 - Authored by Assemblymember Mary Hayashi (D - Hayward), AB 108 was one of two bills this session with the goal of ending the practice of rescission and ensuring that insurance companies cannot drop a patients' health care coverage when they need it most (and usually at the time it is most expensive to the plan). The bill gives insurance companies 24 months to review an application after accepting it. After this 24-month period, the company cannot cancel the coverage for any reason other than premium nonpayment, and it cannot cancel, limit, or raise the premiums of the policy due to any omission, misrepresentation, or inaccuracy in the application form.

• AB 119 - Authored by Assemblymember Dave Jones (D - Sacramento), this bill prohibits health insurers from charging men and women differently for health insurance, even if the charge is based on statistical and actuarial data or underwriting principles. CAFP believes the point of insurance is to pool resources and risk, share the cost of medical care, and protect individuals from financial harm due to a medical condition. Women will never need treatment for prostate cancer; men will never need treatment for cervical cancer; and childless couples will never need pediatric care. All should pay the same price for comparable coverage. CAFP received media coverage for supporting this bill in the Sacramento Bee. (http://www.sacbee.com/arnold/v-print/story/2213986.html)
• SB 606 - Authored by Senator Denise Ducheny (D - San Diego), this bill will allow osteopathic physicians (DOs) to participate in the Steven M. Thompson Physician Corps Loan Repayment Program (STLRP). STLRP provides physicians up to $105,000 in funding to be distributed over three years if they agree to practice in medically underserved areas. Just as MDs contribute $25 in their biannual license fee to support STLRP, this bill requires DOs to do the same; in return, the bill would allow them to participate in the loan program.
• SB 620 - Authored by Senator Patricia Wiggins (D - Santa Rosa), this bill helps the Office of Statewide Health Planning and Development (OSHPD) use data collected by the Osteopathic Medical Board to determine physician workforce in California. It will also help OSHPD make recommendations based on that information to help address recruitment and retention of physicians, and to identify services needed in specific regions of the state. Roughly 10 percent of CAFP members are osteopathic physicians.

Medicare PCMH Pilot Project Suspended in lieu of Health Care Reform Efforts
In 2006, congress passed the "2006 Tax Relief and Health Care Act" (TRHCA), which required the Centers for Medicare and Medicaid Services (CMS) to design a medical home demonstration project for its fee-for-service high needs Medicare population. The legislation called for a budget neutral implementation of the demonstration project in eight states. The three-year design would enroll 400 practices, 2,000 physicians and 400,000 Medicare beneficiaries. All patient enrollees would have to have at least one chronic disease (as 86 percent of Medicare beneficiaries do). For more than two years the project stalled in the planning phase, and on October 20, 2009, CMS announced that it was suspending the demonstration project. This decision was made by CMS in a recognition that current health care reform legislation could factor heavily in the project, and it was best to tailor the program to that legislation before proceeding with the current demonstration (for example, section 1302 of HR 3200 calls for repeal of the TRHCA demo and replacement with an "improved" medical home demo along with authorization of funding which addresses some concerns about budget neutrality). This decision does not, however, affect the state-based multi-payer medical home demonstration project announced recently by Health and Human Services Secretary, Kathleen Sebelius. Under this new demonstration program, CMS will solicit applications from states (the only entities that can apply). To participate, states would have to certify that they:

• Have established effective Advance Primary Care models (e.g. medical homes) in all or parts of their states that include their Medicaid program as well as private payers.
• Can demonstrate that a majority of the primary care physicians in the demonstration areas would participate.
• Have stringent requirements for designating Advance Primary Care providers, including independent accreditation and requirements for the use of health information technology.
• Have integrated public health services to emphasize wellness and prevention.
• Have secured the participation of a sufficient number of private payers.

To read more about the program, click here:  http://healthreform.gov/newsroom/factsheet/medicalhomes.html

CAFP Delegation Exceeds Expectations at CMA House of Delegates
CAFP would like to thank our delegation to the CMA (Carla Kakutani, MD; Jeffrey Luther, MD; Taejoon Ahn, MD, MPH; Steven Green, MD; Patricia Samuelson, MD; and Catherine Sonquist-Forest, MD, MPH), and all the other CAFP members attending CMA's House of Delegates this past weekend for their great efforts in making the event such a success for family medicine. Two CAFP-authored resolutions passed out of the house, and two other priority resolutions became CMA policy as well: 

CAFP Authored - Resolution 219-09 - MEDICAL HOME ADVOCACY
RESOLVED: That CMA support the definition of "patient centered medical home" in state law that is based on the "Joint Principles of the Patient Centered Medical Home"; and be it further

RESOLVED: That only a licensed physician should lead any medical home model.

CAFP Authored - Resolution 715a-09 - LESBIAN, GAY, BISEXUAL AND TRANSGENDER ADOLESCENTS
RESOLVED: That CMA work with other organizations to identify and make resources and information available to physicians to: (1) support families in developing healthy relationships with their adolescents regardless of the adolescents' sexual orientation; and (2) discuss consequences of varying levels of family acceptance and rejection of lesbian, gay, bisexual and transgender adolescents.

Resolution 615a-09 - LOAN FORGIVENESS FOR PRIMARY CARE PRACTICE
RESOLVED: That CMA reaffirm existing policy on loan forgiveness for medical education; and be it further

RESOLVED: That CMA support re-evaluating the terms of the Steven M. Thompson Loan Repayment Program to increase participation of primary care physicians and expand the geographic areas in which they may practice.

Resolution 721a-09 - SUGAR SWEETENED FOOD/BEVERAGE EDUCATION AND TAXATION
RESOLVED: That physicians should educate their patients about the health risks associated with the consumption of food and beverages containing high amounts of processed simple sugars or refined sugars such as high fructose corn syrup; and be it further

RESOLVED: That CMA support increased taxes on sodas and other relevant sugar sweetened beverages, with the revenues to be utilized for public health education efforts such as those conducted by the CMA Foundation and for other health purposes; and be it further

RESOLVED: That CMA encourage public health education campaigns on obesity prevention and treatment.

 

October 9, 2009

Veto Showdown Between Legislature and Governor - CAFP Bills Hang in the Balance
Governor Schwarzenegger has indicated that if the Legislature does not reach an agreement on legislation to fix California's water issues by midnight Sunday (his deadline to sign or veto bills) he will veto "the bulk" of bills currently on his desk. This includes several CAFP priority bills including CAFP-sponsored AB 657 (Hernandez) which would create a state health workforce "master plan", CAFP-supported AB 98 (De La Torre) which would require health insurance policies to provide coverage for maternity services,  AB 119 (Jones) which would eliminate the ability for health insurers to charge different premiums based on gender, and AB 839 (Emmerson) which would create a speedy and equitable remedy for Medi-Cal providers seeking to appeal the denial of a grievance or complaint related to Medi-Cal.

Large CAFP Contingent at Steinberg Event
Nearly a dozen CAFP members from the Sacramento area attended Wednesday's event for Senate President Pro Tempore Darrell Steinberg (D - Sacramento). The event was sponsored by Californians Allied for Patient Protection (a pro-MICRA group that has helped keep malpractice insurance premiums for physicians affordable) of which CAFP has been a long-standing member.  One CAFP member in attendance, Alisha Dyer, DO, reported that Senator Steinberg was very receptive to hearing from Family Physicians and is both informed and concerned about the plight of primary care medicine. She mentioned that the most important thing she learned in discussions with Steinberg was "how important it is for physicians like us to educate him about the current state of healthcare.  Several times he invited us to come to the capital and continue to speak on behalf of our colleagues."  

 

October 2, 2009

CAFP Delegation to the CMA Prepares for House of Delegates
This past week, the CAFP Delegation to the CMA House of Delegates determined their positions on the 138 resolutions that will be brought before the House in mid-October.  Among the 138 is a CAFP-sponsored resolution calling on the CMA to support legislation that defines the medical home if the definition is based on the Joint Principles of the Patient Centered Medical Home as written by the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association. The CAFP Delegation includes Carla Kakutani, MD; Jeffrey Luther, MD; Taejoon Ahn, MD, MPH; Steven Green, MD; Patricia Samuelson, MD; and Catherine Sonquist-Forest, MD, MPH. If you are a CMA member and plan on attending the House of Delegates, please email afrancis@familydocs.org to let us know you will be in attendance.

CAFP Meets with Statewide Screening Collaborative to Discuss Mental Health
CAFP participated in the Statewide Screening Collaborative meeting earlier this week with the goal of identifying ways that state programs can work together to ensure that children are adequately screened for developmental disabilities. The group heard a report from the Department of Mental health on poor payment for such screenings within Medi-Cal fee-for-service programs, and has developed a simpler (and more likely to be paid) protocol for such screenings. Other groups participating in the Collaborative include: the American Academy of Pediatrics (AAP-CA), the California Mental Health Task Force (MHTF), First 5 California, the Department of Health Care Services, the Arc of California, Center for Families, Children & the Courts, WestEd Center for Prevention & Early Intervention, CA Dept. of Managed Healthcare, CA Dept. of Education, and more than a dozen others. For more information on the Task Force on Mental Health and their mental health programs for children, go to: http://www.cdph.ca.gov/HealthInfo/healthyliving/childfamily/Documents/MO-StatewideScreeningCollaborativeFactSheet.doc

 

September 25, 2009

Court Continues to Block Administration Efforts To Cut Medi-Cal Rates
Despite Governor Schwarzenegger's threat to appeal to the US Supreme Court, this past Wednesday the 9th Circuit Court of Appeals declined to reconsider the federal injunction preventing payment rate cuts for Medi-Cal providers. Last year, CMA, CAFP, and a coalition of other organizations sued the state to prevent a 10 percent Medi-Cal provider payment cut to pharmacists, physicians and other health care providers on the grounds that, when the state made the decision to cut payment, they did not take into account how it would affect access to providers for Medi-Cal enrollees. The coalition asserted that, by not considering equal access to health care for the enrollees, the state was violating federal law. The court unanimously ruled in our favor, and continues to uphold the ruling.

September 18, 2009

CAFP Applauds Recent FP Health Care Leadership Graduates
CAFP's Legislative Affairs Committee Chair, Taejoon Ahn, MD, MPH, recently graduated from the California HealthCare Foundation's (CHCF) Health Care Leadership Program. The program helps talented professionals acquire the skills needed to positively influence health care policy and delivery in California. The program is a two-year fellowship that offers clinically-trained health care professionals the opportunity to gain the experience, perspective, and vision necessary for shaping a more responsive and effective health care system. Sponsored by CHCF, it is administered by The Center for the Health Professions at the University of California, San Francisco. Other graduates of this program include fellow LAC members Felix Aguilar, MD, and Mike Witte, MD. For more information or to see how you can become involved please go here: http://www.chcf.org/topics/view.cfm?itemID=19722

CAFP Goes to Dinner
CAFP Director of Government Relations, Tom Riley, co-hosted a Member Appreciation dinner this week in Claremont with Director of the Glendale Adventist Residency Program Janet Cunningham, MD, MPH, MBA. The dinner was an effort to reach out to an area of the state where CAFP has had limited direct interaction with members, and express our appreciation for their membership and support. The dinner was a great opportunity to learn about local issues facing members and their patients in Claremont, and encourage more members to get involved with advocating for family medicine, whether locally or legislatively. 

EPSDT Program Regulations Could Facilitate Payment Disputes for FPs
The Department of Mental Health (DMH) promulgated final regulations on August 24 allowing physicians to directly appeal specialty mental health services claim denial disputes to DMH under Medi-Cal's Early Prevention Screening, Diagnosis and Treatment Program (EPSDT). Previously, physicians and other "subcontractors" were required to obtain mental health plan permission to submit an appeal. The regulations stem from AB 1780 (Galgiani - Statutes of 2008) that codifies an administrative structure for the review, oversight, appeals processes, reimbursement, and claiming procedures of EPSDT.

EPSDT is a federal Medicaid requirement imposed on states as a condition of receiving federal Medicaid dollars.  Under the program, Medicaid recipients up to age 21 are eligible to receive health care services, including mental health services.  Through EPSDT, children and youth in Medi-Cal receive such services as mental health assessment, collateral contacts, therapy, rehabilitation, mental health  services, medication support services, day rehabilitation, crisis intervention and stabilization, enhanced substance abuse treatment, targeted case management, and therapeutic behavioral services. For more information about these regulations, please go to: New DMH Regs.

 

September 11, 2009

CAFP-Supported Bill on Health Care Discrepancies Signed into Law 
ACR 29, a bill authored by Asm. Dave Jones (D - Sacramento), was signed by the Governor this week. CAFP consistently advocated for and supported this bill.  The bill requests that the California Health and Human Services Agency provide leadership to ensure that departments within the agency implement programs, activities, and strategies that place a priority on preventing, reducing, and eliminating health disparities. To read the bill, visit: http://www.leginfo.ca.gov/pub/09-10/bill/asm/ab_0001-0050/acr_29_bill_20090908_chaptered.html

September 3, 2009

Bill to Prevent Health Families Cuts Moving with Bipartisan Support
After the Healthy Families Program saw its funding slashed by almost $200 million (not including the federal matching funs) in July's budget revisions, Legislators, Members of the Managed Risk Medical Insurance Board (MRMIB, which runs Healthy Families) and advocacy groups are taking several steps to combat the shortfall. The First 5 Commission has contributed $81 million in funding, MRMIB increased premiums and co-pays, and Assembly Speaker Bass (D - Los Angeles and Senate President Pro Tem Steinberg (D - Sacramento) introduced AB 1422. Senator Steinberg has also filed suit against the Governor, questioning the legality of the original cuts. AB 1422 generates funds for Health Families by reinstating a fee on insurers (a 5.5 percent fee based on their revenues) that is set to expire in October because it doesn't match new federal guidelines. This bill would instead require insurers to pay a 2.35 percent tax on gross premiums. The bill would also increase the share of cost for enrollees through increased premiums and co-pays. The following changes were made by MRMIB in an effort to save funding:

• Changed dental coverage plans to align with the approach used for state employees. Where available, subscribers would enroll in a managed care plan instead of a preferred provider plan for the first two years.  
• Increased program co-pays for health, dental and vision services from $5 to $10 for non-preventative services.
• Increased co-payment for brand-name prescription drugs from $5 to $15, and from $5 to $10 for generic drugs.  
• Increased co-pay for emergency visits from $5 to $15 unless hospitalized.
• Increased subscriber premiums for families over 150 percent of the Federal Poverty Line. Other subscribers will see premiums increase between $4 and $21 a month, depending on income and the number of children enrolled.

August 28, 2009

CAFP-Sponsored "Healthcare Workforce Task Force" Bill to Senate Floor
AB 657 by Asm. Ed Hernandez (D - Baldwin Park), passed out of the Senate Appropriations Committee and will be heard (and is expected to be passed) by the full Senate in the coming days.  We will be sending Action Alerts to key CAFP leaders urging them to ask the Governor for his signature in the coming weeks.  If signed, the bill will create a Health Care Workforce Commission to oversee the development of a workforce master plan. The Academy is co-sponsoring the bill with the Latino Coalition for a Healthy California.

Other CAFP-Supported Bills Close to Passage
Please keep an eye out for future action alerts as many CAFP-supported bills are quickly approaching the Governor's desk. Below is a list of CAFP priority bills that the Academy will be asking for your help in supporting in the coming weeks:

AB 2 (De La Torre) and AB 108 (Hayashi) would help end the practice by some insurance companies of rescinding health coverage once a patient needs it.

AB 98 (De La Torre) would require health insurance policies to provide coverage for maternity services.

AB 119 (Jones) would eliminate the ability for health insurers to charge different premiums based on gender.

AB 244 (Beall) would require health insurance policies to include the diagnosis and treatment of a mental illnesses and disorders as defined in the Diagnostic and Statistical Manual IV.
AB 611 (Fong) would require the Secretary of California Emergency Management to consider the multiple languages and needs of populations who have limited proficiency in the English language and to incorporate their needs in the curricula and scenarios related to critical emergency preparedness planning, response, and recovery training.

AB 839 (Emmerson) would create a speedy and equitable remedy for Medi-Cal providers seeking to appeal the denial of a grievance or complaint related to Medi-Cal.

ACR 29 (Jones) would request that the California Health and Human Services Agency provide leadership to ensure that, within existing resources and programs, departments within the agency implement programs, activities, and strategies that place a priority focus on preventing, reducing, and eliminating health disparities among racial and ethnic population subgroups.

Osteopathic Medical Board to Include Naturopaths Due to State Budget Deficit
One piece of the 31 bill budget packaged signed by the Governor in July contained a little-known provision which would meld the Bureau of Naturopathic Medicine into the Osteopathic Medical Board of California. Osteopathic physicians, including many CAFP members, are outraged by the move, which was denied any public hearing and done at a time when the director of the Osteopathic Medical Board was on medical leave, hence unable to provide detailed information about why this is ill conceived both in terms of implementation and resources necessary to adequately regulate both groups. Among other provisions, the new law, slated to go into effect in October, would add to naturopaths to the Osteopathic Medical Board of California. CAFP and other organizations will oppose this and will keep you posted as events develop.

CAFP Updates Fresno Chapter on Federal Health Care Reform Efforts.
CAFP's Director of Government Relations, Tom Riley, traveled to Fresno last night to attend that CAFP chapter's quarterly dinner and give a presentation on the latest twists and turns of federal health care reform efforts. Mr. Riley spent more than an hour discussing the main health care bill (HR 3200), in particular. He urged family physicians to become familiar with the major tenets of HR 3200 which he described as "one of the most beneficial pieces of legislation for primary care physicians and their patients in recent memory." Mr. Riley encouraged everyone to see CAFP's reasons for supporting HR 3200 and visit CAFP's Health Care Reform website: http://www.familydocs.org/advocacy/health-care-reform.php

 

August 21, 2009

Senate Floor Fight Anticipated Over CAFP-supported AB 2 - Your Help Needed!
AB 2 by Asm. De La Torre (D - South Gate), a bill to help end the practice by some insurance companies of rescinding health coverage once a patient needs it, is currently in the Senate Appropriations Committee and could be headed to the Senate floor shortly for a highly contested vote. CMA (the sponsor of the bill) has asked for help in ensuring its passage, so the Academy is requesting that Key Contacts to the Senators below spring into action to support this important bill. Below is the list of pivotal Senators, their phone numbers, and the area they represent. You can go here to find out if you are a constituent of one of the Senators using your work and home address. Please ask them how they are voting on AB 2 when it reaches the floor of the Senate, and encourage them to support it using the talking points contained in the Fact Sheet attached to this email.

Ron Calderon (D - Montebello) 323-890-2790
Hacienda Heights, Whittier, South El Monte, South Gate, Huntington Park

Lou Correa (D - Santa Ana) 714-558-4400
Anaheim, Fullerton, Westminster, Santa Ana

Gloria Negrete McLeod (D - Chino) 909-621-2783
Colton, San Bernardino, Fontana, Ontario, Pomona

Alex Padilla (D - Pacoima) 818-901-5588
Northridge, San Fernando, Van Nuys, North Hollywood

Curren Price (D - Los Angeles) (213)745-6656
Culver City, Hollywood, Los Angeles

Rod Wright (D - Los Angeles) 310-412-0393
Long Beach, Compton, Inglewood, San Pedro, Gardena, Hawthorne

Leland Yee (D - San Francisco/San Mateo) 650-340-8840
Belmont, Daly City, Millbrae, Pacifica, South San Francisco, Half Moon Bay

Healthy Families Program Begins to Address Consequences of Severe Budget Cuts
More than 60,000 children will lose their health insurance beginning October 1 due to the more than $190 million cuts the Healthy Families program endured in the most recent budget agreement. The program has received an $81 million contribution from the First 5 Commission to attempt to backfill the cuts made by the Governor and Legislature. While this backfill is estimated to help maintain health insurance for about 200,000 children, the money will be dedicated specifically for children up to the age of 5, leaving almost 500,000 other children to face the prospect of losing their health insurance if no other funding is contributed. The Managed Risk Medical Insurance Board anticipates that it will need to remove more than 50 percent of its 922,000 enrollees through this fiscal year, while also denying coverage to the 50,000 children currently on its waiting list.

CAFP Actively Engaged in N1H1 Prevention Efforts
CAFP has been working with the Immunization Branch of the CA Department of Public Health and other provider/medical organizations in preparation for the coming flu season in order to develop a strategy to deal with any potential difficulties in immunizing for the N1H1 flu virus. The meetings have focused on identifying vaccinators and sharing information with these providers, understanding provider concerns and questions, and identifying barriers for providers to vaccinate their populations. The Academy would like to thank Patricia Samuelson, MD, for all her work on this project. CAFP will also be participating in a joint legislative hearing of the Senate Health and Education committees regarding the impact of the H1N1 pandemic on California's public health and education systems.

CAFP Working to Improve CCS Program
Over the past two years, CAFP (spearheaded by Academy member Jeannine Rodems, MD) has been engaged in discussion with officials at the California Department of Health Care Services in an attempt to correct privileging  and access issues in the California Children's' Services program. Dr. Rodems recently took part in a stakeholder interview aimed at eliciting opinions regarding options available to address many of the systemic issues that have been identified as problems with the CCS program. Feedback gathered from the discussions with stakeholders will be used to identify options for change and the pros and cons of the options for the State's consideration.

Additional Online Resources and Loan Repayment Funds Now Available
The Office of Statewide Health Planning and Development (OSHPD), Healthcare Workforce Development Division has created a new Web page that contains online resources and additional opportunities for loan repayment for primary care, dental, and mental health clinicians. Additional funding is now available for the National Health Service Corps Loan Repayment Program. This program provides up to $50,000 to clinicians for two years of service at an approved site in a Health Professional Shortage Area. You can apply if you are already working at an approved site or seeking employment at an approved site. Applications are being accepted now through September 30, 2010 or until funds are expended. For more information, please visit: http://www.nhsc.hrsa.gov/loanrepayment/

 

August 14, 2009

Proposal to Increase Primary Care Medicare Payment Needs Your Support
As detailed in previous legislative updates, the Centers for Medicare and Medicaid Services (CMS) has proposed increasing Medicare payment to primary care physicians by as much as eight percent in 2010. Because of budget neutrality requirements, the increased payments would require reductions in other areas. Reductions would primarily affect radiation oncology, nuclear medicine, cardiology, neurology, and diagnostic testing facilities. It is anticipated that those negatively affected will muster strong opposition. Because of this, CMS must hear loudly from physicians who support increases in Medicare payment to primary care physicians. The Academy has already submitted a letter of support, as has AAFP.

The Academy prepared a sample letter of support which can be downloaded here, and submitted electronically or via postal mail. Click here to see step by step instructions on how to submit electronic comments. Comments must be received by CMS no later than August 31. If you have questions, please do not hesitate to contact CAFP.

CAFP Launches New Health Care Reform Web Page
http://www.familydocs.org/advocacy/health-care-reform.php

Because of the recent endorsement of HR 3200 (the main health care reform legislation moving through Congress) by the AAFP and CAFP Board of Directors, CAFP has created a new health care reform web page to help members learn about the bill and get involved in supporting it. You can also share your thoughts on health care reform by commenting on our page.

While not perfect, HR 3200 is a significant step in the right direction; provisions related to family medicine and your patients (e.g., access, payment, medical home, workforce) would be especially beneficial. We encourage ALL members to go to our new Legislative Meetings page where you can follow a quick, three-step list to make sure your Congressional Representative knows that you support health care reform. CAFP has developed talking points and other information to help in your meeting. Because Representatives are in their home districts for the month of August, now is the most convenient time to meet with them and/or their staffs.  Please contact Adam Francis (afrancis@familydocs.org) if you need any help, or have already scheduled or attended a meeting with your legislator.

To read HR 3200 in its entirety, click here: http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=111_cong_bills&docid=f:h3200ih.txt.pdf

Be a Resource for Accurate Health Care Reform Information for Your Patients
In an effort to combat the misinformation about HR 3200, and health care reform more generally, CAFP has prepared a "Fact v. Fiction" handout for your office. This is a patient-oriented fact sheet that dispels some of the widely-reported rumors and attacks, such as the Medicare-required death panels. Further information on the inaccuracies that both pro- and anti-reform groups have been claiming can be found at www.factcheck.org, a nonpartisan, nonprofit website that aims to reduce the level of deception and confusion in U.S. politics.

 

August 7, 2009

CAFP Endorses HR 3200 - Encourages Members to Meet With Legislators to Support Health Care Reform Efforts
After reviewing a "crosswalk" analysis of the provisions of the bill compared to CAFP principles for health care reform, the CAFP Board of Directors approved sending a letter to the entire California Congressional Delegation endorsing HR 3200, America's Affordable Health Choices Act of 2009, the main vehicle for health care reform in the House of Representatives.

Acknowledging that the bill is not perfect, CAFP noted the legislation in the House of Representatives contains numerous provisions designed to support primary care physicians, such as a bonus payment of 5 percent (10 percent if the practice is in a physician shortage area - usually rural areas). The SGR is eliminated (which is good for all physician practices), and the replacement system has higher conversion factors for E/M and preventive care services, those most provided by family physicians. In addition, primary care services in Medicaid would be paid at least at the Medicare rate, which would be a substantial increase in California. The legislation invests in a broader pilot-testing of the medical home practice model, which CAFP fully supports. Payments to departments of family medicine and to family medicine residencies are increased, and there is increased tuition assistance for medical students who choose family medicine (or other primary care specialties), actions which are sorely needed in our State. The legislation is the first major investment in primary care that the federal government has made in years. Finally, the bill is consistent with AAFP's and CAFP's long-term policy of supporting health care coverage for all.

In the letter to the California Congressional delegation, CAFP wrote that HR 3200 "provides our best opportunity to expand coverage, offer every American the opportunity to have a medical home, reform the payment system, and ensure that the primary care workforce is adequate." The Academy stressed the need for universal access and coverage, inclusion of cost management strategies that are realistic and emphasize a coherent strategy to improve our nation's health, and the need for steps to build and maintain the medical workforce needed for the 21st Century.

With a vote on HR 3200 by the full House of Representatives likely to occur in September, CAFP and AAFP are encouraging ALL members to meet with their Congressional Representatives while they are in their home districts this month. If you have any questions, or have a meeting scheduled, please contact Adam Francis at afrancis@familydocs.org.

Here are materials to help you set up and prepare for your meeting (click on any of the following):

• Find your Representative's contact information here
• Template Meeting Request Letter
• CAFP's HR 3200 Endorsement Letter
• CAFP's latest policy document on health care reform in California: Fractured

Schwarzenegger Administration Sued Over Line-Item Vetoes
Senate Pro Tem Darrel Steinberg (D-Sacramento) announced today that he will be filing suit against the Administration after the Governor cut an additional $500 million from the final budget agreement sent to him by the Legislature last week. Democratic legislative leaders and many health advocacy groups sought legal counsel about the constitutionality of additional cuts the Governor made through his line-item veto authority.

 

July 31, 2009

Governor's Line-Item Vetoes Shift Budget Cuts Squarely on Backs of the Poor
There were three main changes to the final budget agreement detailed in last week's Legislative Update, and signed by the Governor this past Tuesday. First, the Assembly rejected the provision that would have taken $1 billion in gasoline tax money from local governments. Second, the Assembly rejected a measure that would have allowed oil drilling off the Santa Barbara coast (projected to bring in $100 million). Third, by passing the budget without these two measures, the Administration believed it needed to balance the budget (based on their estimates) by using the rest of the state's reserve funds and cut roughly $500 million more. To achieve the $500 million in cuts, the Governor used his line-item veto authority to cut several health programs by dramatic amounts, including:

• An additional $50 million from the Healthy Families Program
• Nearly $7 million from Proposition 99 funds for the Tobacco Control Program for anti-tobacco media campaigns and competitive grants to local entities
• $25 million from community clinics in the Primary and Rural Health program
• More than $80 million from Public Health Local Assistance programs including:
• $52 million from various programs administered by the Office of AIDS: Education and Prevention, Therapeutic Monitoring, Counseling and Testing, Early Intervention, Home and Community-Based Care, and Housing
• $16 million from the Domestic Violence Program
• $9 million from the Adolescent Family Life Program
• $3 million from the Black Infant Health Program.

Despite the Governor's hope that philanthropic organizations and the First 5 Commission will backfill the cuts made to Health Families and other programs, many advocacy groups and legislators are gearing up for a legal fight to prevent the line-item vetoes from ever going into effect.

Line-Item Vetoes May Have Been Made Unconstitutionally
Democratic legislative leaders and many health advocacy groups have begun to seek legal counsel as to whether or not the additional cuts the Governor made through his line-item veto authority were constitutional. At issue is whether the Governor can use his line-item veto authority to further reduce funding cuts, or if he can only reduce budget bills that increase or designate specific spending.  The California Constitution states, "The Governor may reduce or eliminate one or more items of appropriation while approving other portions of a bill." The recent budget action was an addendum to the budget passed in February, and it did not include any new spending (or "appropriation"). In anticipation that the Governor would attempt to make further cuts, legislative leaders inserted "control language" in the last pages of the budget bill that said the February budget amounts were being reduced (as opposed to being appropriated). CAFP will continue to keep you updated on the legality of these cuts.

National Health Care Reform Efforts Make A Small Breakthrough
The House Energy and Commerce continued its debate on the health reform bill (HR 3200) in fits and starts as Committee Chair Rep. Henry Waxman (D-CA) and House Speaker Rep. Nancy Pelosi (D-CA) tried to bridge the divide between the concerns of the fiscally conservative Blue Dog Democrats and the liberal Progressive Caucus. After a number of false alarms, Chairman Waxman announced that he, the Blue Dogs and more liberal members had come to an agreement. The proposal will assuage Blue Dog concerns about cost, but includes the liberal Democrats' desire to allow subsidies for families to purchase insurance. Progress in the Senate remains a large hurdle. One major change that AAFP requested in the House efforts was to separate the public plan option from the Medicare payment schedule and permit Centers for Medicare and Medicaid Services (CMS) to negotiate rates from the inception of the public plan. This will assure additional bargaining leverage for providers, since they will not be locked into Medicare rates, as originally proposed, for three years. The committee's deliberations are scheduled to be completed today so that congressional members may leave for the August recess. A vote on the bill in the House likely will occur in September. 

On Thursday, July 30, AAFP Board Chair, Dr. Jim King, participated in the Senate Majority Leader's press conference to urge Congress to act on health care reform as soon as possible.  In addition, he announced the release of a health care reform video (containing several CAFP members) which encourages viewers to contact congress and ask them to pass health care reform legislation. The video can be seen at www.healhealthcarenow.org.

 

July 23, 2009

Budget Deal Reached By Legislative Leaders - Large Cuts to Health Care Services Proposed
The "Big Five" (the Governor and the two Republican and Democratic leaders from each house) reached a budget compromise Tuesday that they hope will bridge California's $26.3 billion budget gap. The proposed budget contains no tax increases and $15.6 billion in program cuts, including deep cuts to healthcare. $4.4 billion of the budget solution will be borrowed or seized from cities and counties, $4 billion of it will come through early income tax collection, and nearly $4 billion more will result from accounting maneuvers (mainly payment delays). The agreement also includes a budget reserve of $875 million. A floor vote is scheduled for tonight, but could be delayed as legislative leaders look to drum up support for their proposal from their party colleagues. Legislators that will have to pass some pieces of the budget (which contains 31 separate bills) by a super-majority vote (2/3rds of the Assembly and Senate) for it to be ratified.

Where Cuts Are Proposed:
The largest of the proposed cuts ($9 billion of the $15 billion) would come from Education. $2.2 billion would be cut from Health and Human Services. One of the largest concerns for CAFP going into the budget negotiations was the Governor's call for the elimination of the Healthy Families program. The proposal gives him half of what he wanted - a $432 million dollar cut ($124 million in state funds plus the existing $20-million shortfall in the program, plus $288 million in lost $2 to $1 federal matching funds) which officials estimate would eliminate coverage for half of the nearly one million children currently enrolled, and cause thousands of others to be put on a waiting list. Democratic leaders are hoping private foundations and possibly First 5 (Prop. 10) dollars will back fill some of the funding reductions.

Use Of Medical Homes:
Despite cuts to the Healthy Families Program (which CAFP has publically criticized), some of the proposed changes in the Medi-Cal program could offer new opportunity to family physicians and their patients. While drawing down additional federal funds through a tax on hospitals was taken off of the table (an issue discussed in last week's Legislative Update), the budget compromise includes a provision to seek a waiver from the federal government that would restructure the way Medi-Cal operates for certain beneficiaries, including utilizing managed care or other specialized delivery systems of care for vulnerable populations including seniors, people with disabilities, children with significant medical needs, and people with behavioral health problems. The goal is to better coordinated and integrated care, improve health outcomes, improve coordination between Medicare and Medi-Cal, and slow long-term growth. It also seeks to use medical homes and specialty centers for children with significant medical needs. The waiver would also allow the State to enroll beneficiaries into specified organized delivery systems, such as managed care, enhanced primary care case management, or a medical home. If passed as part of the budget, the Department of Health Care Services would convene a stakeholder advisory group to develop the waiver and consult them in the development of an implementation plan. The waiver would need to be approved by the federal government, and the State would nee to appropriate funds for the restructuring.  

Worst May Be Yet To Come
Critics believe that several billion dollars in the proposed budget may not materialize, which could leave another large budget gap at the end of the calendar year, even if the economy stabilizes. These assumed savings come from an unspecified $1.3 billion cut to the Medi-Cal program, an unspecified $1.2 billion dollar cut to the prison system, $90 million from increased fraud detection in the In Home Support Services (IHSS) program, and $1 billion if the State is able to sell the State Compensation Insurance Fund, the Orange County Fair Grounds, and 10 state-owned office buildings (none of which are guaranteed to sell before the next fiscal year).  

Below is a list of other proposed reductions that could affect your practice and your patients:

• Expand long-term care fees for an additional $18 million in revenue and reduced long-term care rates for a savings of $75.7 million General Fund.
• Reduce funding for community clinic programs by approximately 30 percent, including: Rural Health Services ($2.2 million); Seasonal Migratory Worker Program ($1.9 million); Indian Health Program ($1.5 million); and Expanded Access to Primary Care Program ($4.5 million General Fund and $3.9 million Proposition 99 funds).
• Eliminate Proposition 99 funds for County Health Services. This would be a $25.6 million cut, including: $438,000 from the Asthma Program, $3.1 from the Alzheimer's Research Centers of California, $4.9 million for the Access for Infants and Mothers (AIM) program, and $6.6 million for the MRMIP program.
• Eliminate next years funding ($18 million) for the Immunization Program.
• Cut $226 million from the In-Home Supportive Services program including eliminating care for clients who are able to do their own cooking and cleaning. The budget also proposes efforts to prevent and combat fraud in the program, including requirements of unannounced visits, fingerprinting clients, background checks of providers, making timecard changes, additional provider training, and providing additional resources to bolster fraud investigation and quality assurance efforts.
• Suspend the Children's Dental Disease Prevention Program ($2.9 million)
• Reduce funding for domestic violence shelter programs by 20 percent - from $20.4 million to $16.3 million.
• Reduce funding for the AIDS Drug Assistance Program and other Office of AIDS Programs by $35 million.
• Reduce funding for Maternal, Child and Adolescent Health (MCAH) programs, including: the Black Infant Health Program ($900,000), the Adolescent Family Life Program ($1.75 million), and Local County Maternal and Child Health Grants ($2.1 million).
• Reduce funding for the California Poison Control System by 50 percent, from $5.9 million to $2.95 million.
• Eliminate the State's portion of funding ($90 million) for the Substance Abuse and Crime Prevention Act.
• Completely eliminate the Rural Health Care Equity Program cutting $17.2 million for this year and 2010, with ongoing savings of approximately $15 million.

CAFP will continue to voice its concerns about the effect of the proposed cuts on your patients, particularly children and seniors. We will keep you apprised of the outcome of the current and upcoming votes. Please let Dr. Ahn and CAFP legislative staff know the specific consequences these cuts will have on your patients so that we may communicate this to state lawmakers.

 

July 17, 2009

Budget Deal Close, But No Cigar
This week, members of the Big 5 (the Governor and the two Republican and Democratic leaders from each house) indicated that they were very close to reaching a compromise solution to the $26 billion budget deficit facing California. Very little is known about what has been agreed to in their private meetings, but sources have said there are two main issues holding up the final agreement: Proposition 98 school funding, and welfare-to-work requirements.

Prop 98 (which amended the state constitution almost two decades ago) guarantees a minimum level of funding (roughly 40 percent of general fund revenues) for schools and community colleges. The formula to determine this minimum level is very complicated, and depends upon state revenues and economic conditions from the previous and current year, and allows for cuts below the minimum level in hard economic times. It requires that funding be repaid and restored if cuts are made below the minimum, though the timing of that repayment is ambiguous. As part of the budget negotiations, Democrats and the education lobby want the Governor to sign a bill that would ensure that last year's $9.5 billion cut will be restored eventually, and set legislative precedent to avoid any future funding disputes.  He restated his firm opposition to doing it through legislation as early as this morning, stating he believes the change should be made by voters. Also reportedly preventing the conclusion of budget negotiations is the Governor's proposal to eliminate certain grants (specifically for working parents) in the state welfare program, and increase penalties for participants who do not meet minimum federal work requirements. Legislative leaders have postponed their summer recess to keep members close to the capitol in the hope that they will all vote on a budget deal early next week.

Primary Care Physician Coalition Holds Planning Call
The Cognitive Coalition (the statewide organizations representing psychiatrists, pediatricians, internists, and family physicians) held a planning conference call yesterday night to discuss increased collaboration on legislation, health care reform, and the patient centered medical home. The group agreed that - on everything from legislation to grant pursuits - the Coalition could collaborate on multiple issues, and should make an effort to meet more than the current once or twice a year. In the coming weeks, the Coalition will determine its top priorities, set a schedule of meeting times, and develop an action plan.

 

July 10, 2009

Ninth U.S. Circuit Court Denies Review of Medi-Cal Payment Cuts
This past week, the Ninth Circuit Court of Appeals denied a review of the federal injunction that reversed the 10 percent Medi-Cal provider payment cut that took effect in July 2008. In other words, the court refused to hold a hearing on whether or not to overturn the injunction. By a decision of 3-0, the court ruled that California violated federal statute which requires states that receive Medicaid funds to set reimbursement rates at levels that allow for equal access to health care at the same rate as private payers. Last August, a federal court in Los Angeles issued a preliminary injunction that forced the State to reverse the 10 percent Medi-Cal reimbursement cut, finding that the cuts would irreparably harm access to health care for nearly 7 million Californians. The lawsuit was brought forth by a coalition of advocacy groups including CAFP, and spearheaded by the CMA. The Ninth Circuit Court upheld this ruling citing that the State implemented the cuts for financial reasons and did not sufficiently study how the reductions would affect Medi-Cal beneficiaries' access to care. This ruling has additional importance because it confirms the legal standing of California's Medi-Cal providers to challenge cuts to Medi-Cal provider payment in the future. It is estimated that this will protect more than $100 million in Medi-Cal funds.

Rule to Increase Primary Care Medicare Payment Introduced
This week the Centers for Medicare and Medicaid Services (CMS) proposed increasing Medicare payment to primary care physicians. Under the proposed rule, CMS would boost payment to family physicians by as much as eight percent in 2010. CMS recommended increasing payment for Evaluation and Management (E/M) codes while eliminating payment for nearly all consultation codes. In addition, CMS would base the practice expense component on more recent data, which is expected to yield increased payment for services typically provided in primary care settings. Other provisions in the proposal include an increase for the initial preventive physical exam ("Welcome to Medicare" visit). Because of budget neutrality requirements, increased payments require offsets in other payment areas. CMS has proposed the offsets come from CPT codes that primarily affect radiation oncology, nuclear medicine, cardiology, neurology, and diagnostic testing facilities.   

Attached is AAFP's detailed breakdown of the proposed changes. CMS will be seeking public comments on the proposal from July 13 through August 31. It is anticipated that those organizations and individuals negatively affected will strongly advocate against the proposal. Because of this, CMS must hear loudly from physicians who support increases in Medicare payment to primary care physicians. Because the comment period does not begin until July 13, the Academy will include instructions on how to submit public comments in the July 17 Legislative Update. Alternatively, you may view the CMS announcement for additional information.  It is expected the final rule will be issued on November 1, 2009. Unless otherwise specified, the new payment rates will apply to services furnished to Medicare beneficiaries on or after January 1, 2010.

CAFP Priority Bill Update
CAFP Co-Sponsored bill AB 657 (Hernandez), which creates a Health Care Workforce Commission to oversee the development of a workforce master plan, passed out of the Senate Health Committee this week despite opposition testimony from independent higher education institutions. This particular group was opposed because they believe they should have specific representation on the Commission (which already has more than 20 proposed members). They argued that independent institutions supply 35 percent of the nursing degrees and 38 percent of medical degrees in California, and therefore should have a voice on the Commission. As a solution, Senator Leno (D - San Francisco) proposed that instead of creating a new commission, the State should adopt the recommendations of the Healthcare Workforce Diversity Advisory Council, whose membership overlaps greatly with proposed Commission (health policy advocates, health professions pipeline programs, workforce investment, health student and professional associations, research, labor and industry). The Council was charged with developing recommendations to address California's health professional shortages, especially among underrepresented groups. CAFP and the other co-sponsor, the Latino Coalition for a Healthy California, will work with all stakeholders to seek a compromise. 

CAFP is also co-sponsoring a bill with the CMA, AB 526 (Fuentes). This bill would create a voluntary physician health program to assist physicians and surgeons impaired by alcohol and substance abuse or mental health disorders. AB 526 passed out of the Senate Committee on Business, Professions, and Economic Development this past week. Its passage was due in no small part to Senators Correa and Wyland who lent their support following discussions with CAFP and CMA staff. Some Senators were concerned that the bill would lead to physicians paying more during their biennial licensure in order to support the program. The bill avoids this, though, by using the same money physicians previously paid to the Medical Board for the original diversion program that ended last July. Other Senators were concerned that the program would put patients at risk by allowing physicians with substance abuse problems to continue practicing. The sponsors informed them that the program would actually help to prevent harm to patients by creating the opportunity for physicians to get treatment instead of attempting to hide their affliction and continue practicing.

Also passing out of the Committee (Senate Health) was CAFP-supported AB 2 (De La Torre), a bill sponsored by CMA that would help end the practice by some insurance companies of rescinding health coverage once a patient needs it, and a similar bill, AB 108 (Hayashi).

 

July 2, 2009

Health Programs Begin Receiving IOUs as Budget Solution Remains Elusive
As of yesterday, California does not have enough money to pay for vital health care programs and the projected budget gap has increased to more than $26 billion. After Assembly Democrats and Republicans passed bipartisan measures to avoid a cash crisis, Senate Republicans this past week chose not to vote for legislation that would have prevented issuing IOUs (i.e., "promise to pay" certificates sent to state vendors that will not be redeemable until October). The IOUs are necessary because the State faces an anticipated $2.8 billion cash shortfall in July. The shortfall could increase to $6.5 billion by September. Any vendor who receives money from the General Fund is eligible to receive IOUs, except for those protected by the federal government, the constitution, or a court ruling.

Programs that are IOU-exempt and must be paid:

• Healthy Families (subsidized children's health insurance program for low- to moderate-income families)
• Department of Health Care Services payments for Institutional and Non-Institutional Providers
• Department of Health Care Services payments for Medi-Cal County Administration and Fiscal Intermediary (claims processing, services, and support for county workers who determine eligibility)
• In-Home Supportive Services (provides services to aged, blind or disabled persons to remain in their homes)

Programs that will receive IOUs:

• Expanded Access to Primary Care
• Every Woman Counts Program
• Children's Treatment Program
• California Children's Services
• Child Health Disability Prevention Program
• Genetically Handicapped Persons Program
• Song-Brown Health Care Workforce Training Program

For family medicine residency training programs, Song-Brown funding is split between the General Fund (GF) and a special fund. The GF portion would be affected. As of this week, many residency programs currently receiving Song-Brown payments will receive an IOU for a portion of their quarterly payments. If programs have a contract starting with a 06, 07, or 08 prefix, they will be issued an IOU for any payments not yet issued for fiscal year 08/09, and possibly 1st quarter payments for fiscal year 09/10.

State Senate Postpones All Non-Budget Hearings - CAFP Workforce Bill on Hold
CAFP co-sponsored bill, AB 657 (Hernandez), which creates a Health Care Workforce Commission to oversee the development of a workforce master plan, had its Senate Health Committee hearing postponed this week; Senate President Pro Tem Darrell Steinberg (D - Sacramento) has delayed all Senate hearings until the budget crisis has been resolved.

 

June 26, 2009

Senate Republicans and Governor Reject Budget Proposals - IOUs Expected
This past week, the Governor and Senate Republicans rejected two budget proposals that would have partly addressed the $24.3 billion budget gap facing California. The first proposal was that of the Joint Conference Committee that would have ostensibly covered roughly $20 billion of the gap. The remaining $4 billion called for by the Governor and Republicans is a reserve that Democrats argue should be used to address the current crisis. Both the Governor's and Joint Conference Committee's proposals contained dubious estimates on the actual savings and revenue that would be generated by their proposals, which they privately hope would be unnecessary maneuvers when the economy improves, but has the result of just pushing structural debt into future years.

The second proposal, a package of bills focused on creating $5 billion in budget revisions (by delaying some payments to schools and local governments) to keep the State from having to issue IOUs was approved almost unanimously by the Assembly, but rejected by Senate Republicans as a "political drill" and the Governor vowed to veto the package if it have made it to his desk. The IOUs will be necessary as the State faces an anticipated $2.8-billion shortfall in July that could grow to $6.5 billion by September. In this case, that money owed is almost five times more than the amount that delayed payments this past February. The IOUs will be given to the aged, blind and disabled (who receive welfare payments that pay for their care), college students who receive state grants, other welfare recipients and developmentally disabled patients that receive treatment at regional centers. This action has only been necessary twice in California's history: in the budget crisis of 1992, and during the Great Depression.

CAFP Holds Third PCMH Meeting
This past Monday, CAFP met with stakeholders and Assembly Health Committee staff to discuss AB 1542, the Academy-sponsored bill to create a statutory definition for the "patient centered medical home" (PCMH). Among the issues discussed was allowing health facilities to qualify as PCMHs. Federal law currently allows Federally Qualified Health Centers (FQHCs) and similarly constructed clinics affiliated with public hospitals to "employ" physicians. Thus, these facilities are exempt from the bar on the "corporate practice of medicine."  CMA legal counsel has expressed concerns that including these facilities (rather than just physician practices) within the definition of the PCMH could precipitate and end-run around this bar. Conversely, the Chair of the Health Committee (in this case the Health Committee itself is the author of the bill and, therefore, the language of the bill is the Committee Chair's responsibility) has expressed concerns that if they (clinics) are not included, it would preclude the opportunity for the patients of safety net facilities to also benefit from the PCMH's improved quality of care. Adding to this controversy is the request by the Public Hospitals that we consider criteria other than the NCQA criteria for establishing a definition of PCMH. The Academy is working with the author's office and other stakeholders to do a "crosswalk" between the NCQA criteria, other nationally recognized criteria and criteria that a CA based workgroup (including the public hospitals and FQHCs) have developed. CMA has suggested a subsequent meeting between CMA's and CAFP's respective leaders to address any outstanding issues.

 

June 19, 2009

Committee Reaches Agreement on State Budget Cuts
This past week, the Joint Conference Committee tasked with bridging the $24.3 billion shortfall in the State Budget agreed on painful cuts to statewide programs. These cuts will likely be part of the final budget agreement as they have Democrat and Republican support. The Committee also voted to maintain the Healthy Families Program. Although they rejected both the Governor's proposal to eliminate the program and to reduce program eligibility from 250 to 200 percent of federal poverty, they did propose cutting funding by $70 million and adopted intent language that outside sources of funding support the program (specifically First 5). The committee also proposed measures to generate new money to offset fewer cuts. These will be more difficult to include in the final Budget as all the Republican members of the committee voted against them (since the Dems have a majority on the committee, they could include it in the report, but to get final passage they will need 2/3rds support from each house). Below is a list of the agreed upon cuts and the Democrats proposed revenue enhancements:

Department of Health Care Services

• Cut an unallocated $323.2 million from Medi-Cal and backfill the program with $1 billion in stimulus funds.

• Medi-Cal pharmacy that save approximately $109 million.

• Increase long-term care fees (saving $18 million) and reduce long-term care rates (saving $75.7).

• Reduced community clinic programs funding by 30 percent - specifically: Rural Health Services ($2.2 million); Seasonal Migratory Worker Program ($1.9 million); Indian Health Program ($1.5 million); and Expanded Access to Primary Care Program ($4.5 million General Fund and $3.9 million Proposition 99 funds).

• Enact Medi-Cal anti-fraud proposal to save $35.9 million.
• Reduce funding for Maternal, Child and Adolescent Health programs including: Black Infant Health Program ($900,000), Adolescent Family Life Program ($1.75 million), Local County Maternal and Child Health Grants ($2.1 million) and MCH state support ($3.5 million).

• Adopt reforms to Adult Day Health Care programs including a temporary 3-day cap, workgroup and minimum standards on medical necessity, on-site Treatment Authorization Requests, and anti-fraud measures for approximately $25 million in savings.

Department of Public Health

• Eliminate all $18 million in General Fund dollars for the Immunization Program on a one-time basis.

• Reduce support for domestic violence shelter programs by 20%, from $20.4 million to $16.3 million.

• Suspend the Children's Dental Disease Prevention Program to save $2.9 million.

• Eliminate Proposition 99 funds for County Health Services for a savings of $25.6 million.

• Reduce $438,000 in Proposition 99 funds from the Asthma Program.

• Reduced funding for the Alzheimer's Research Centers of California by 50%, from $6.2 million to $3.1 million.

• Reduce funding for the AIDS Drug Assistance Program and other Office of AIDS Programs by $35 million.

Emergency Medical Services Authority

• Reduced funding for the California Poison Control System by 50%, from $5.9 million to $2.95 million.

Managed Risk Medical Insurance Board

• Eliminate $2.7 million in funding for Certified Application Assistance for the Medi-Cal/Healthy Families joint application.
• Reduce $4.9 million in Proposition 99 funding for the AIM program.

• Reduce $6.6 million in Proposition 99 funding for the MRMIP program.
• Cut $250 million in the Department of Developmental Services budget to Regional Centers.

• Eliminate state support for health services other than federally required inpatient hospitalization and medication services in the Mental Health Managed Care Program ($64 million). 
• Eliminate state support ($53.4 million) for county programs developed in the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program using Mental Health Services Act funds.

• Increase fees by 18 percent for licensing and certification of Psychiatric Health Facilities and Mental Health Rehabilitation Centers. 

Human Services

• For the In-Home Supportive Services Program - increased the Share of Cost by 50 percent for all recipients receiving a state buyout, limit domestic and related services for recipients with FI rankings in these services below 4, with critical exemptions for high-need recipients, and eliminates services for those with FI scores below 2, again with critical exemptions for high-need and medically fragile recipients. 

• Reduce SSI/SSP grants for couples to the federal minimum and reduce grants for individuals by $5 per month to save $155 million on an annual basis.

• Reduce Drug Medi-Cal rates by 10 percent to save $8.8 million.

• Eliminate $90 million for the Prop 36 Substance Abuse and Crime Prevention Act. Federal funds are expected to be used to provide similar services to make up about half of the reduction that is sustained here.

• Reduce rates by 10 percent for Group Homes, Foster Family Agencies, and Seriously Emotionally Disturbed to save $26.6 million.

Revenue Enhancements

• Impose a 9.9% tax on oil extracted from California. This will increase revenues by $830 million in 2009-10 and $1.1 billion annually at current prices.

• Repeals recent corporate tax breaks. Rolls back provisions enacted with the 2008-09 budget which (a) permit net operating losses incurred on or after January 1, 2011 to be carried back to offset earnings during the two prior years; and (b) allow corporations to assign all or a portion of their unused tax credits earned on or after January 1, 2008 to an affiliated corporation that is a member of the same combined reporting group. This will increase revenue by $80 million in 2009-10 and rising annually thereafter to $850 million by 2014-15.

• Increases cigarette taxes (currently $.87 per pack) by an additional $1.50, and imposes an equivalent increase for other tobacco products. This action increases revenue by $1 billion in 2009-10 and $1.2 billion in 2010-11.

CAFP Asked to Support Medi-Cal Claims Legislation
AB 839 (Emmerson) would require Medi-Cal providers seeking to appeal the denial of a grievance or complaint related to Medi-Cal reimbursement to file a petition for a writ of mandate in superior court.  Additionally, this bill would require the prohibition on enrollment as a Medi-Cal provider to begin on the date of the providers' denial or termination of enrollment, rather than the date when the provider appeals. Some believe the current process penalizes providers when they exercise their right to appeal their denial and/or termination of enrollment in Medi-Cal.

Currently, Medi-Cal claims cases go to general civil courts on a first-come-first-served basis.  Because they lack priority, some claims cases linger on as judges resolve other higher priority cases, thus delaying the resolution of providers' claims.  The expanded time frame in resolving these cases results in an increased number of claims that are over one year old, which limits the State's ability to claim federal financial participation. According to the bill's sponsor, the Department of Health Care Services, AB 839 will benefit the state and Medi-Cal providers who sue the State by creating a speedy and equitable remedy for claims. See the bill analysis here: http://www.leginfo.ca.gov/pub/09-10/bill/asm/ab_0801-0850/ab_839_cfa_20090616_092552_sen_comm.html

 

June 12, 2009

State Budget Update - The Cuts Begin
Legislative leaders and members of a joint Conference Committee on the State Budget continued to meet this past week to vote on specific aspects of budget proposals to close California's $24 billion deficit. While CAFP was pleased to hear legislative leaders such as Assembly Speaker Karen Bass (D - Los Angeles) and Senate Pro Tem Darrell Steinberg (D - Sacramento) say that they would not follow through with Governor Schwarzenegger's proposal to eliminate the Healthy Families Program, they did indicate that it would see significant cuts. CAFP continues to urge legislators and the Governor to solve the budget deficit through means that won't put patients at risk, and so far during budget hearings, many legislators have echoed that message.

As expected, the first round of funding cuts held victories and defeats for family physicians and their patients. Fortunately, the Budget Conference Committee rejected some of the Governor's most concerning proposals including:

• Eliminating the Breast and Cervical Cancer Treatment Program for low-income women
• Eliminating postpartum care for undocumented women
• Reducing reimbursement rates for family planning services (which were increased due to CAFP co-sponsored SB 94), for which the federal government provides a $9 to $1 match

However, the Committee cut approximately $800 million from programs, including:

• $323 million cut from local assistance to Medi-Cal
• $113 million cut by eliminating mental health services other than federally required inpatient hospitalization and medication services
• $22.5 million cut from Medi-Cal reimbursements to pharmacies
• $14.3 million cut to state operations of Medi-Cal
• $2.9 million cut by suspending the dental disease program for children
• 20 percent funding reduction for domestic violence shelters

CAFP expects further cuts to health and human services, but continues to urge lawmakers to seek additional sources of revenue to avoid eliminating programs for the most vulnerable Californians. Some of the future cuts could come from the list below, which are proposals the Conference Committee has yet to act on:

• Further restrictions to services in the In-Home Supportive Services (IHSS) program such as limiting services only to recipients with Functional Index scores of 4.0 and above for an additional savings of $230.8 million
• Eliminating the CalWORKs program (California's welfare to work program) for a net General Fund savings of $1.3 billion
• Restricting Medi-Cal services for "Newly Qualified Legal Immigrants" (those here less than 5 years)
• Eliminating the Cash Assistance Program for Immigrants (CAPI) and the California Food Assistance Program for a combined General Fund savings of $120.2 million. The CAPI allows approximately 12,000 aged, blind, and disabled legal immigrants to receive cash assistance.
• Eliminating Adult Day Health Care Benefits to Medi-Cal enrollees
• Transferring $60 million in Proposition 99 funds from Expanded Access to Primary Care (EAPC) clinics to backfill Medi-Cal costs

 

June 5, 2009

CAFP Continues to Fight Proposed Budget Cuts
Legislative leaders and members of a joint committee on the State Budget met this past week to discuss the Governor's May Revise and other solutions to California's $24 billion budget gap. CAFP continues to urge legislators and the Governor (in committee testimony and letters) to solve the budget deficit through means that won't put patients at risk. The Governor's proposed budget includes a plan to eliminate all state health coverage for low to moderate income children, including saving $305 million by eliminating the Healthy Families program which provides medical, dental and vision care to almost one million children. California provides only a third of the program's funding because the federal government matches two dollars for every one dollar the State puts into the program. This is just one of many cuts that could remove health care coverage for children, including further cuts to Medi-Cal that would force 471,000 children off of the beneficiary rolls.

CAFP has also been aggressive in working to prevent the Schwarzenegger Administration from securing a waiver from the federal government to cut public health programs below federally mandated minimum levels. As part of this effort, the Academy sent a letter this week to each member of California's congressional delegation asking them to:

1. Uphold federal "Maintenance of Effort" language which preserves minimal benefit and eligibility levels for Medicaid;
2. Consider a federal loan guarantee for California; and
3. Protect the recent federal court injunction preventing cuts to Medi-Cal provider rates, ensuring California's poorest patients continue to have access to crucial health care.  

The joint budget committee will be holding session over the weekend and decisions are expected early next week.

CAFP Help May be Needed to Pass Medical Spa Bill
AB 252 (Carter), which CAFP currently has a Watch position on, attempts to create penalties for medical spas that are operated on a day-to-day basis by non-physicians. There has been recent growth in medical spas where a physician is only the titular medical director (because he or she is seldom at the facility), leaving non-physician providers to run the facility. There have been a number of cases where this has created negative consequences for patients. This bill creates a harsher penalty for physicians who knowingly allow their names to serve as a "front" for a corporation that operates a medical spa. Because of recent opposition from the Medical Board and the Department of Consumer Affairs, the bill may need our help to pass. It will be heard on June 8. Here is a link to more information about the bill:  http://www.leginfo.ca.gov/pub/09-10/bill/asm/ab_0251-0300/ab_252_cfa_20090604_133925_sen_comm.html  

CAFP Holds Informational Conference Calls on AB 1542 and the Medical Home
Over the past two weeks, the Academy has hosted and participated in meetings with stakeholder organizations interested in better understanding the patient centered medical home and CAFP's sponsored bill, AB 1542 (Assembly Health Committee) on the subject. Some of the participants included the California chapters of the American Academy of Pediatrics and American College of Physicians, the California Primary Care Association, the California Chronic Care Coalition, the California Pharmacists Association, the American College of OB-GYN, and representatives from two medical home accrediting groups - the National Committee for Quality Assurance and the Accreditation Association for Ambulatory Health Care, as well as others. These calls have been helpful in bringing stakeholders together to resolve misunderstandings about the bill and to help participant organizations to better understand the medical home model.  

 

May 15, 2009

Poor Economy Puts Three CAFP Priority Bills on Suspense File
Due to the economic hardship California is facing, legislation with financial impact is being placed on "suspense" file in both the Assembly and Senate, essentially killing the bill unless it is amended to remove its financial consequence. CAFP-supported (CMA-Sponsored) AB 2 (De La Torre), a bill to help end the practice by some insurance companies of rescinding health coverage once a patient needs it, was placed on the Assembly Appropriation Committee's Suspense File on Wednesday. Joining AB 2 are CAFP co-sponsored (with the Latino Coalition for a Healthy California) AB 657 (Hernandez), which creates a Health Care Workforce Commission that would be in charge of developing a health care workforce master plan for the State, and AB 1201 (M. Perez) co-sponsored with the CMA and American Academy of Pediatrics, Dist. IX, which would ensure adequate payment to physicians for acquiring and administering vaccines. AB 1201 is on the Suspense file because it also requires the Healthy Families program to provide adequate payment for vaccines, thereby adding costs to the State (the Department of Finance estimates the cost at $5 million). If we want the bill to have a chance at passing, we will need to remove Healthy Families from that requirement.

In other bill news this week: after testimony from CAFP Key Contact Francisco Prieto, MD, the CAFP-opposed legislation AB 1430 (Swanson) - a bill to allow only licensed nurses to administer medication to pupils in school - has become a two year bill. CAFP will continue to work with the author to find a more appropriate way to ensure children's health in schools.

CAFP's Patient-Centered Medical Home (PCMH) bill, AB 1542 (Assembly Health) that would create a statutory definition for PCMH, unanimously passed both the Assembly Health Committee (19 - 0) and the Assembly Floor (72 - 0) this week. CAFP continues to work with the author, CMA, and other stakeholders to temper the language to meet a variety of concerns and issues.

Governor's Budget "May Revise" Portends Deep Cuts to Public Programs
Yesterday, the Governor outlined two fiscal scenarios facing the state: one in which the three money-generating Propositions (1C, 1D, and 1E) on the May 19 special election ballot are approved, and one in which they fail. The difference amounts to California facing a $15.4-billion deficit versus a $21.3-billion deficit. His proposal to close the $15.4 gap includes $9 billion in cuts and $6 billion in borrowing. The state's health and human services programs would be cut by $2.1 billion (including $750 million in health-care for low-income individuals and those with disabilities; and $234 million from developmental services), and as much as $5.4 billion would come from cuts to school spending (including $1 billion from public colleges and universities). The State would borrow up to $2 billion from local governments, to be repaid within three years. The Governor proposes raising new money ($1 billion) though accelerated tax payments (a 10 percent increase for individuals and companies that pay estimated taxes) and new fees (a 2.8% property insurance surcharge (roughly $48 per homeowner) on residents and businesses, and increased state park fees). He also proposes generating revenue by selling the Los Angeles Coliseum and Sports Arena, San Quentin State Prison and other facilities (though revenue from those items wouldn't be realized for at least 2 years), consolidate state agencies, and eliminate some boards and commissions.

If Propositions 1C-1E do not pass, the Governor proposes $700 million in extra cuts to health care and an additional $2.3 billion in education cuts, including reducing the school year by 7.5 days, and proposals to raise revenue including increasing the proposed 2.8 percent property insurance surcharge to 4.8 percent, and increasing tax withholding from employee pay checks by 10 percent (generating an additional $1.7 billion to be paid back later).

Below is a detailed list of the health care cuts proposed by the Governor if the Propositions do or do not pass, listed from largest to smallest cuts. CAFP will keep you apprised of these and other proposals as they move through the legislative process in the coming weeks:

Health Care Cuts or Savings if Propositions 1C - 1E Pass:

• $750 million reduction in Medi-Cal benefits, eligibility, and provider rates - (A FEDERAL WAIVER IS REQUIRED TO MAKE THIS CUT). The most ambiguous and unknown aspect of the May Revise is whether or not the Schwarzenegger Administration will be successful in convincing the Obama Administration and California's congressional delegation to change federal laws and restrictions to allow CA to cut programs below minimum federal levels. There are three ways to cut Medi-Cal: changing eligibility rules, reducing provider rates, and cutting benefits. The state has already cut nine (of twenty) optional benefits, but provider rates are currently protected by lawsuits waged by CMA and others (in which CAFP is a participant). The Governor has proposed eligibility reductions previously and continues to believe such roll‑backs are necessary for California to manage Medi-Cal. Under the new federal requirements of the Stimulus funds, however, such reductions can not go below 2008 levels. The Governor specifically wants to limit eligibility and benefits, and cut provider rates. CA has the largest amount of Medicaid enrollees in the US (10,547,200) and more than double that of the next largest state (New York) which has 5,116,800 enrollees. CA ranks last in per enrollee spending and 47th in provider payment rates.
• Cut $120.2 million by eliminating the Cash Assistance Program for Immigrants (CAPI) and the California Food Assistance Program (CFAP). The CAPI allows approximately 12,000 aged, blind, and disabled legal immigrants, who would be eligible for the SSI/SSP program but for their immigration status, to receive cash assistance. The CFAP provides benefits to more than 22,000 low-income legal non-citizens between the ages of 18 and 65, who meet all the eligibility requirements for the federal Food Stamp program but have resided in the United States for less than five years.
• Save $132.2 million by choosing a different insurer and insurance level to lower the cost of the state employee health plan.
• Cut $125 million from Medi-Cal (excluding pregnant women) by reducing services for newly qualified legal immigrants over the age of 20 and for those permanently residing under color of law to emergency services only.
• Save $75 million in Medi‑Cal by requiring federal Drug Pricing (340b pricing) providers to dispense only drugs purchased through the program, require manufacturers of HIV/AIDS/cancer drugs to pay rebates, establish upper billing limits for drugs, and require the state to perform therapeutic category review of antipsychotic drugs to get the best price. 
• Save $47.9 million in Medi-Cal by more aggressively targeting fraud in adult day health care centers, pharmacy, physicians, durable medical equipment, and transportation.
• Save $20 million by Reduce Medi-Cal Payments to Private Hospitals by 10 percent, which matches the reduction public hospitals received in the February Budget agreement.
• Cut family planning provider rates by $6.8 million; essentially eliminating the 2008 CAFP co-sponsored law (SB 98) which increased family planning provider rates to 90 percent of Medicare.  

Additional Health Care Cuts or Savings if Propositions 1C - 1E DO NOT Pass:

• Save $108 million from the Substance Abuse Treatment and Crime Prevention Program by eliminating funding, including a 10 percent reduction in provider rates.
• Shift $60 million from the Cigarette and Tobacco Products Surtax Funds to Medi‑Cal - specifically redirect funds from county health, clinic, Breast Cancer Early Detection, Asthma, Major Risk Medical Insurance, Access for Infants and Mothers programs, rural health demonstration projects and a consumer assessment project to offset costs in the Medi‑Cal program.
• Cutting $54.5 million from the Healthy Families program by reducing eligibility to 200 percent of Federal Poverty Level (the 1999‑2000 level). Approximately 225,000 children would no longer have health coverage.
• Reducing $25.5 million from Medi‑Cal Adult Day Health Care Program.
• Cut $24.6 million from HIV Education and Prevention programs.
• A $20.4 million reduction in funding for 94 domestic violence shelter/centers providing emergency and other services to domestic violence victims and their children. Services include emergency shelter, transitional housing, legal advocacy, assisting with temporary restraining orders, counseling, and other support services.
• Cut $10 million from Maternal, Child and Adolescent Health Grants that provide services and programs to improve the health of mothers, infants, children, adolescents, and families.
• Cut $8.8 million by implementing a 10 percent rate reduction for all drug Medi‑Cal treatment modalities. This program funds substance abuse treatment services for Medi‑Cal eligible individuals.
• Save $2.9 million by suspending the Children's Dental Disease Prevention Program which serves about 300,000 preschool and elementary school children in 31 counties.