ABX1 1 (Nunez), amended 1-16-08. Comments 1-22-08 by Len Doberne, MD
ABX1 1 has changed significantly, some for the better, some for the betterment of the insurance companies, and some for the worse of Californians. This a long and far reaching bill, with long and confusing passages meant to very liberally increase health insurance coverage of people in California, especially with publicly supported plans, including government contributions to care for people with moderate financial resources. There is a special emphasis in reducing verification of financial need for public support, and hoping to increase federal contributions. Large portions of the bill relating to government sponsored coverage are cryptic, with references to government code outside of the current legislation and I have not completely summarized those portions. Several questionable portions from SB840 and other legislation have crept into the bill. The devil is in the details.
We are on the road to government sanction of practice of medicine without a (medical) license. Requirements for supervision of medical assistants will be cut substantially. Nurse practitioner scope of practice will likely greatly increase as an appointed committee's recommendations on scope of practice shall be implemented intact, if legal, without legislative or public review. We should press for legislative oversight of the nurse practitioner scope of practice changes after the Task Force on Nurse Practitioner Scope of Practice recommendations are made. The cost of scope of practice changes for nurse practitioners in this bill will be borne by doctors' and nurses' license fees. Hmm..(Historically, physician assistant scope of practice increases some time after increases in nurse practitioner scope of practice.)
Increasing scope of practice for non-physician providers is a controversial area. My own view is that there are very competent nurse practitioners and physician assistants, including many who do a better job in their field of training than done by most doctors. But their scope of practice needs to be limited to areas where they have been well trained, and they must not practice unsupervised, as often happens in practice, especially in low cost clinics. They must not assume the role of a physician when they are outside their area of expertise. A nurse practitioner who is competent in gyn health should not be giving advice regarding congestive heart failure or diabetes, and vice-versa.
"If you want to be a doctor, you should go to medical school." Okay, if nursing schools offer a comprehensive 4 year training program with rotation through all the specialties, followed by a year of supervised internship, and possibly residency and fellowship, and the same licensure examinations as required for MD's and DO's, then I have no problem with unrestricted licensure of 'Doctors of Nursing Practice'. Short of a 'DNP' degree, we need limitations in practice. There will be endless turf battles fought: some for patient safety, and some for financial gain.
My partial solution: As a minimum, at each encounter, the patient should know if they are being seen by a physician and surgeon, nurse practitioner, physician assistant, medical assistant, midwife, podiatrist, chiropracter, physical therapist, respiratory therapist, or acupuncturist. Every facility that utilizes non physician providers should have a listing available in plain English (and other languages, if appropriate for the patient population), with the types of providers at the facility, and the allowed scope of practice of each non-physician provider. This can be very broad strokes: "Nurse practitioners A and B are trained in evaluating and treating seasonal allergies and uncomplicated sinus and head congestion. Nurse practitioner C is trained in monitoring and adjusting medicines for congestive heart failure patients". This will help protect the patient and empower them to get appropriate care if they are out of the scope of practice of their non-physician provider.
There are benefits to having catastrophic coverage insurance for everyone, if the minimum coverage plan is bare-bones enough so that it is not expensive. The minimum coverage plans are not spelled out, but the text of the bill intimates that few aspects of coverage will be optional. There is no mention of high deductable plans for people with financial means, that would allow individuals with adequate resources to choose their providers on the basis of quality, cost, and convenience outside of their plan network for the bulk of their care if they so wish. A fairly priced cash-pay to the provider of choice alternative to in-network services should be encouraged; this will keep the in-network providers on their toes. (As long as in-network services are not purposely made to be hard to access, forcing people to go outside their plans for cash pay services).
I think co-pays, even minimal, should be required for all plans, from government-subsidized to high level health plans. Even as little a co-payment of $1.00 for low-income patients would help avoid over-use that would result in budget overruns, and eventually lead to pre-authorization requirements, and rationing of services. A $1.00 co-payment could be waived or reduced for the poorest recipients after a rather low out-of-pocket maximum is reached for a specified time period as short as 1-4 weeks, and then be reinstated in a subsequent time period.
I do not recall seeing any provisions for financial consequences to patients using emergency facilities inappropriately for non-emergency complaints. If everyone has healthcare, inappropriate use of emergency facilities should be greatly reduced. Avoiding inappropriate emergency room use is one of a few provisions that could save the government, and the people, money. Most doctors have seen people insisting on ambulance transportation to the emergency room for a "cold" or other similar complaint. There should be individual consequences for blatant over-use of facilities and services.
Healthcare plans should not take even 15% on all healthcare transactions for administration and profit, especially since the the definition of health care benefits has been greatly increased to include some administrative functions of the health plans, and administrative burden will be reduced: design of the 5 standard categories of health care plans will be done by the state, and guaranteed acceptance of enrollees will eliminate screening applicants. How about 90% or 95% of plan revenues to go to healthcare services?
Elimination of assets as a test for Medi-Cal eligibility is idiotic. It is an inappropriate gift of free healthcare to many people who will be able to contribute to the cost of their own care, who instead will have all their care paid for by the tax payers of California. Funds are stretched too thin to pay providers fairly for deserving patients; they should not be spent on people who can pay for their own care. Patients who have large financial (including real estate and control of companies) assets inside and outside the United States should not be getting free or subsidized care in California. There should be anonymous reporting lines for such patients, and recovery of funds expended in their care, with penalties.
I agree that healthcare costs should not prevent people to obtain very basic necessities of life. The definition of basic necessities is subject to interpretation. What about cell phones? A radio? TV? CD player? Large collection of CD's? Fashion clothes? Car? Going to movies, concerts, eating out? Gambling? Travel? I have a modest proposal: Patients who have travelled outside of the country, or made any trip on an airplane in the previous year, except for a disabled individual travelling to obtain prolonged supportive medical care from close friends or family, shall not be covered by government subsidized health care. If a person can travel and take vacations, especially to foreign countries, they can help pay for their healthcare.
The California Health Care Cost and Quality Transparency Commission will require data submission from providers without reimbursement for the cost of compiling and forwarding the data. In fact, they will charge providers of the data to submit the data. Will medical services be reimbursed at a higher level to pay for this additional work associated with gathering and submitting the data?
Pre-designation of future changes in regulations as "emergency" is a dangerous precedent (as in 12693.43(h)), and no doubt will interfere with proper scrutiny of the regulations, or safeguards for those affected by the regulations.
Tying premium costs to the age of a younger person in a marriage or domestic partnership is artificial and will likely result in sham marriages, domestic partnerships, or strange bedfellows. Premium costs should be set by the age and condition of each partner to avoid "gaming the system."
Likewise for "qualifing events" such as marriage, divorce, birth, and death triggering the ability to change healthcare coverage categories. Instead, charge an "changing up" premium if the fear is that people will get a bare bones policy until something happens medically. As proposed, allowing free changes in levels with specific qualifying events will lead to artificial qualifying events.
Okay, if a person is disenrolled in a health plan due to fraudulent use of services or deception in application, what health care plan will they be on, and what will be their cost? What costs could be recouped from previous fraudulently obtained services?
The statute creating a credit against "net tax" for persons at 2x-3xfederal poverty level for 2010-2014 is a mess. It needs to be re-written in a straightforward manner or eliminated. Try reading it yourself!
The same for the spectrum of government subsidized coverage. There is an maze of administrative patchwork to cover those under 3x the poverty level that may be needed due to federal law, but it should be simplified and include clear cut contributions/share of cost payments by the patients. The bill should be understandable by someone with a college (or even a high school) education.
Some of the provisions are pie-in-the-sky, with unreasonable expectations for benefits from analysis of data from encounter data with providers. I see a lot of pay-for-paperwork, not pay-for-performance.
-Len Doberne, MD