BILL ANALYSIS
AB 354
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Date of Hearing: April 19, 2005
ASSEMBLY COMMITTEE ON BUSINESS AND PROFESSIONS
Gloria Negrete McLeod, Chair
AB 354 (Cogdill) - As Introduced: February 10, 2005
SUBJECT : Telemedicine.
SUMMARY : Expands the definition of telemedicine to include the
use of "store and forward" technology for two applications,
teledermatology and teleophthalmology services, and allows
Medi-Cal reimbursement for these two types of services provided
by health care practitioners via telemedicine. Specifically,
this bill :
1)Defines "asynchronous store and forward teleophthalmology" or
"asynchronous store and forward teledermatology" as
transmission of a patient's medical information from an
originating site to the physician or health care practitioner
at the distant site.
2)Defines "distant site" as the location of the physician or
health care practitioner delivering the service via a
telecommunications system.
3)Defines "originating site" as the location of a patient whose
information is being transmitted via a telecommunications
system.
4)Requires a physician performing asynchronous store and forward
teleophthalmology to be certified in this state to practice in
the specialty of ophthalmology.
5)Requires a physician performing asynchronous store and forward
teledermatology to be certified in this state to practice in
the specialty of dermatology.
6)Allows a patient who receives asynchronous store and forward
teleophthalmology or teledermatology services the option to
request an interactive communication with the distant
specialist physician.
EXISTING LAW :
1)Establishes the "Telemedicine Development Act of 1996" and
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imposes several requirements governing the delivery of health
care services through "telemedicine" that is broadly defined
as the use of information technology to deliver medical
services and information from one location to another.
2)Makes several legislative findings regarding the application
and value of telemedicine in treating the medically
underserved, particularly those in rural areas; states that
telemedicine has the potential to reduce costs, improve
quality, alter conditions of practice and improve access in
medically underserved areas; and states intent that
telemedicine not replace health care providers or relegate
them to a less important role in the delivery of health care
but rather that the patient-provider relationship can be
preserved, augmented and enhanced through telemedicine.
3)Defines "telemedicine" as the practice of health care
delivery, diagnosis, consultation, treatment, transfer of
medical data, and education using "interactive" audio, video,
or data communications.
4)Specifies that neither a telephone conversation nor an
electronic mail message between a health care practitioner and
patient constitutes "telemedicine."
5)Defines "interactive" as an audio, video, or data
communication involving a real time (synchronous) or near real
time (asynchronous) two-way transfer of medical data and
formation.
6)Requires a physician, prior to providing health care service
via telemedicine, to obtain verbal and written consent of the
patient, specifies the information to be provided, and that
failure to follow the informed consent procedure would
constitute unprofessional conduct.
7)Prohibits health insurers and the Medi-Cal program from
requiring face-to-face contact between patient and a health
care provider for services appropriately provided through
telemedicine, subject to the terms of the contract.
8)Requires the Medi-Cal program to recognize the practice of
telemedicine as a legitimate means by which an individual may
receive medical services from health care providers and to
cover such services that would otherwise be covered by the
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Medi-Cal program.
FISCAL EFFECT : Unknown
COMMENTS :
Purpose of this bill . According to the sponsor, the California
Hospital Association, "telemedicine is a growing model for
health care delivery that is used to improve health care access
in rural and underserved communities. A lack of primary care
practitioners, specialty providers, and transportation continue
to be significant barriers to access to health services in
medically underserved rural and urban areas. AB 354 addresses
this problem by adding teledermatology and teleophthalmology to
the list of procedures in which physicians can utilize "store
and forward" technology and be eligible for Medi-Cal
reimbursement."
Background . Telemedicine currently utilizes two formats to
deliver medical services and information from one location to
another: "real time" and "store and forward." Real time or
synchronous telemedicine allows physicians to interact with
patients or other providers using synchronous audio or video
conferencing. "Store and forward" telemedicine utilizes
captured audio clips, video clips, still images or data that is
transmitted or received at a later time. The problem is that
under current law the definition of telemedicine is limited to
"real time" (synchronous) or "near real time" (asynchronous)
two-way transfer of medical information and excludes many
legitimate applications of telemedicine, including "store and
forward" services. This bill would expand the definition of
telemedicine to include "store and forward" teledermatology and
teleophthalmolgy services that facilitate the standard medical
consultations that are required and reimbursed under the
Medi-Cal program when in-person visits are not required.
Currently Medi-Cal reimburses "real time" telemedicine
consultations under the fee-for-service program.
Related legislation . This bill is identical to SB 1341 (Kuehl)
of 2004, which passed through both the Assembly and Senate
without a "no" vote but was vetoed by the Governor on September
24, 2004.
Governor's veto . In his veto statement the governor cited
concerns about increased Medi-Cal reimbursement levels and the
possibility of increased Medi-Cal fraud and abuse. However, the
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governor did acknowledge the importance of store and forward
technologies and agreed to work with the Legislature on a new
measure that addressed his concerns.
"Through a cross-reference to the Welfare and
Institutions Code, this bill has the effect of
authorizing a consultation level of reimbursement to
providers who are interpreting a diagnostic or lab
results without examining or interacting with the
patient. The Medi-Cal program provides reimbursement for
these interpretation services at a lower fee level which
reflects the lack of physician-patient interaction.
In addition ?this bill could also undermine important
anti-fraud measures in the Medi-Cal program. In an
effort to verify that services are being properly
provided, Medi-Cal is sending notices to beneficiaries
when services are billed and asking that the
beneficiary verify the provision of these services.
This bill, with no requirement for patient interaction
with the physician, would undermine this effort."
Requested Amendments . The California Optometric Association
(COA) is in opposition to this bill unless amended to include
qualified optometrists in the participation of asynchronous
store and forward teleophthalmology. COA contends that,
although currently they are able to practice telemedicine, as
defined, this bill will restrict the activities of store and
forward telemedicine to board certified California
ophthalmologists. "At present optometrists are fully qualified
to perform and are involved in activities within their scope of
practice, such as diabetic retinopathy evaluation, that would be
of great benefit to patients in remote locations." AB 354 in its
present form would exclude optometrists from using store and
forward telemedicine under the Telemedicine Act.
The California Medical Association (CMA) also requests
amendments to eliminate this bill's narrow application to only
those dermatologists and ophthalmologists who have been
certified by the American Board of Medical Specialties (ABMS).
While CMA indicates its support for the primary goal of this
bill to increase the use of telemedicine, CMA states: "the
limitation of the practice to board [ABMS] certified
dermatologists and ophthalmologists is in our view
counterproductive."
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The sponsor is currently working with the Department of Health
Services (DHS) to address the Governor's concerns about SB 1341,
and they indicate they are willing to incorporate the amendments
requested by COA and CMA into the discussions with DHS. The
sponsor contends it is not their intention to exclude
optometrists and has agreed to work with both COA and CMA to
address their issues.
REGISTERED SUPPORT / OPPOSITION :
Support
California Hospital Association (sponsor)
Anderson Valley Health Center
Association of California Healthcare Districts
California State Rural Health Association
Kern Regional Center
Medical Board of California
North Coast Clinics Network
Northern Sierra Rural Health Network
Redwoods Rural Health Center
Rural Health Design Network
Shasta Community Health Center
Southern Trinity Health Services, Southern Trinity Area Rescue
Opposition
California Optometric Association
Analysis Prepared by : Tracy Rhine / B. & P. / (916) 319-3301