BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: AB 2216
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|AUTHOR: |Bonta |
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|VERSION: |May 27, 2016 |
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|HEARING DATE: |June 22, 2016 | | |
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|CONSULTANT: |Melanie Moreno |
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SUBJECT : Primary care residency programs: grant program
SUMMARY :1) Creates the Teaching Health Center Primary Care Graduate
Medical Education Fund (Fund) and requires the Office of
Statewide Health Planning and Development director, subject to
appropriation by the Legislature, to award planning and
development grants and sustaining grants from the Fund to
teaching health centers for the purpose of establishing new
accredited or expanded primary care residency programs.
Existing law:
1)Establishes the California Healthcare Workforce Policy
Commission (Commission) and requires the Commission to, among
other things, identify specific areas of the state where unmet
priority needs for primary care family physicians and
registered nurses exist; establish standards for family
practice training programs, family practice residency
programs, primary care physician assistants programs, and
programs that train primary care nurse practitioners; and
review and make recommendations to Office of Statewide Health
Planning and Development (OSHPD) concerning the funding of
those programs that are submitted to the Health Professions
Development Program for participation in the state medical
contract program.
2)Establishes the Health Professions Education Foundation (HPEF)
within OSHPD. Requires the HPEF to solicit and receive funds
from Foundations and other private and public sources and to
provide financial assistance in the form of scholarships or
loans to students in the health professions who are from
underrepresented groups. Provides that HPEF governed by a
board consisting of 13 members appointed by the Governor,
Speaker of the Assembly, and Senate Rules Committee.
AB 2216 (Bonta) Page 2 of ?
3)Establishes, under the HPEF, scholarship, loan, and loan
repayment programs for registered nurses, vocational nurses,
geriatric nurse practitioners, clinical nurse specialists, and
mental health professionals who agree to practice for
specified periods of time in underserved areas and in
designated practice settings, as specified.
4)Establishes, under HPEF, the Steven M. Thompson Physician
Corps Loan Repayment Program (STPCLRP), which provides for the
repayment of educational loans for licensed physicians and
surgeons who practice in medically underserved areas of the
state, as defined. Requires HPEF, in administering the
STPCLRP, to use and develop guidelines for applicants that
give preference to applicants who are best suited to meet the
cultural and linguistic needs of patients in medically
underserved populations, as specified, and who agree to
practice in geriatric care settings. Also allows HPEF to
appoint a selection committee to provide policy direction and
guidance to the STPCLRP. Requires funds for loan repayment
under the STPCLRP to have a funding match from a Foundation or
other private source. Establishes a Medically Underserved
Account for Physicians within the Fund, the primary purpose of
which is to provide funding for the STPCLRP.
5)Establishes within OSHPD the Health Professions Education Fund
to receive funds for scholarships and loans to students from
underrepresented groups who are enrolled in or accepted to
schools of medicine, dentistry, nursing, and other health
professions. Provides that moneys in the fund are
continuously appropriated.
6)Establishes the Song-Brown Health Care Workforce Training Act
of 1973 (Song-Brown Act), administered by OSHPD to provide
financial support to family practice residency programs, nurse
practitioner and physician assistant programs, and registered
nurse education programs to increase the number of students
and residents receiving education and training in family
practice and nursing. The Song-Brown Act also encourages
universities and primary care health professionals to provide
health care in medically underserved areas.
This bill:
1)Creates the Fund within the State Treasury.
AB 2216 (Bonta) Page 3 of ?
2)Requires the OSHPD director, subject to appropriation by the
Legislature, to award planning and development grants from the
Fund to teaching health centers for the purpose of
establishing new accredited or expanded primary care residency
programs.
3)Requires grants awarded under this bill to be for a term of
not more than three years. Prohibits the maximum award to a
teaching health center from being more than $500,000.
4)Requires grants awarded under this bill be used to cover the
costs of establishing or expanding a primary care residency
training program, as specified, including costs associated
with curriculum development, recruitment, training, and
retention of residents and faculty, accreditation by the
Accreditation Council for Graduate Medical Education (ACGME),
the American Dental Association (ADA), or the American
Osteopathic Association (AOA), faculty salaries during the
development phase, and technical assistance.
5)Requires a teaching health center seeking a grant under this
bill to submit an application to OSHPD in the format it
prescribes. Requires the OSHPD director to evaluate those
applications and award grants based on criteria consistent
with a teaching health center's readiness and other factors
indicating the likelihood of success at implementing a primary
care residency program.
6)Requires the OSHPD director, subject to appropriation by the
Legislature, to award sustaining grants from the Fund to
teaching health centers operating primary care residency
programs accredited by ACGME, ADA, or AOA.
7)Requires OSHPD to determine the amount of grants awarded per
resident by taking into account the direct and indirect costs
of graduate medical education and requires grant awards amount
per resident to be updated, as appropriate, on an annual
basis.
8)Requires OSHPD to promulgate emergency regulations to
implement this bill.
9)Requires implementation of this bill to be subject to an
appropriation in the annual Budget Act for these purposes.
AB 2216 (Bonta) Page 4 of ?
FISCAL
EFFECT : According to the Assembly Appropriations Committee:
1)General Fund (GF) cost pressure, ranging from the low millions
to over $10 million, to fund primary care residency programs
as envisioned by this bill. The program could be funded at
anywhere within this range, as it would scale to the size of
the appropriation, but a program smaller in size than the low
millions would be limited in effectiveness.
2)GF costs to OSHPD to administer the new grant program. For
example, administrative costs of 5% on a $15.5 million program
would be around $750,000.
3)The California Primary Care Association (CPCA), the sponsor of
this bill, has submitted to the budget committees a related
budget request for an annual GF investment of $16.5 million GF
annually as follows: $1 million for OSHPD administration, $10
million for creating new programs, and $5.5 million to sustain
the existing six programs in Modesto, Fresno, San Bernardino,
Redding, Bakersfield, and San Diego.
4)Assembly Budget Subcommittee 1 and Senate Subcommittee 3 have
each approved $17.5 million GF to support teaching health
centers' residency programs in the 2016-17 budget, similar
what is proposed by this bill.
PRIOR
VOTES :
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|Assembly Floor: |77 - 1 |
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|Assembly Appropriations Committee: |20 - 0 |
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|Assembly Health Committee: |19 - 0 |
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COMMENTS :
1)Author's statement. According to the author, teaching health
centers are a proven model for addressing the primary care
provider shortage that six of nine California regions face.
Forty percent of graduates from teaching health centers become
AB 2216 (Bonta) Page 5 of ?
primary care providers in nonprofit, community health centers
working with underserved communities as opposed to just four
percent of traditional medical residents. California's six
teaching health centers sites are providing training to over
seventy residents that are not only committed to primary care
practice, but also to serving underserved communities and
health shortage areas. This bill will help ensure California
has a sufficient supply of health workforce professionals to
serve the needs of our diverse state.
2)Primary Care in California. California is home to the largest
number of primary care physicians and nurse practitioner in
the country. However, the state ranks 23rd in the number of
primary care physicians per resident. An August 2014 report
by the California HealthCare Foundation states that California
has only 35 to 49 primary care physicians per 100,000 Medi-Cal
enrollees. Federal guidelines call for the state to have 60
to 80 doctors per 100,000 patients. The supply of primary
care physicians also varies substantially across California's
counties. The number of primary care physicians actively
practicing in California counties is, in too many cases, at
the bottom range of, or below, the state's need. According to
2011 Health Resources and Services Administration (HRSA) data,
29 of California's 58 counties fall at the lower end, or
below, the needed supply range for primary care physicians.
In other words, half of Californians live in a community where
they do not have adequate access to the health care services
they need.
3)The Affordable Care Act (ACA). Under the ACA, about five
million Californians have enrolled in either private insurance
or Medi-Cal. There are now 12 million Medi-Cal enrollees,
about one third of California's population. The newly insured
will increase demand for health care from an already strained
system. Furthermore, the ACA will change how care is
delivered. It provides incentives for expanded and improved
primary care, which may affect demand for some health care
professionals more than others, and encourages the creation of
team-based models of service delivery. Research indicates
that health care reform will place higher skill demands on all
members of the health care workforce as systems try to improve
quality while limiting costs. The scale of change with health
care reform is unlike anything that California has previously
faced. Studies have found that persons with health insurance
use more health care services than uninsured persons,
AB 2216 (Bonta) Page 6 of ?
particularly in primary care and preventive services. This
was found in Massachusetts, which experienced a substantial
increase in demand for primary care services as a result of
its 2006 health reform. A February 2, 2015 article in the San
Jose Mercury News reported that the primary care physician
shortage combined with the millions of newly insured has
resulted in significant delays in seeing a doctor and crowded
emergency rooms. According to the Mercury News article, "?
many experts say the problems are so widespread they shouldn't
be ignored."
4)California workforce development programs. The state currently
operates a number of programs designed to increase the number
of health care professionals practicing in medically
underserved areas:
a) HPEF. Established in 1987 and housed within OSHPD,
HPEF is a non-profit foundation statutorily created to
provide financial incentives to aspiring and practicing
health professionals. The foundation offers six
scholarships and seven loan repayment programs in several
allied health professions, including nursing, mental
health, dentistry, and medicine. Scholarship programs
provide financial assistance to healthcare students who
are attending a California accredited college or
university and agree to practice in California's
underserved communities upon graduation. Loan repayment
programs are offered to working health professionals to
assist in repayment of their education debt in exchange
for a service obligation. Service obligations are
typically one to three years, and vary depending on the
program. Awards range from $4,000 to $105,000 dependent
on profession and length of service obligation. HPEF has
increased access to care in the state's underserved areas
via 6,693 awards totaling more than $60 million to health
practitioner awardees serving in 57 of the state's 58
counties;
b) California State Loan Repayment Program (SLRP).
Provides educational loan repayment assistance to primary
health care professionals who provide health care
services in federally designated Health Professional
Shortage Areas (HPSAs). Eligible health professionals
include physicians specializing in primary care fields,
nurse practitioners, certified nurse-midwives, general
practice dentists, registered dental hygienists, clinical
AB 2216 (Bonta) Page 7 of ?
or counseling psychologists, clinical social workers,
licensed counselors, pharmacists, physician assistants,
psychiatric nurse specialists, and marriage and family
therapists. Eligible health professionals must be
employed by or have accepted employment at a SLRP
Certified Eligible Site (which includes rural health
clinics, community health clinics, county facilities, and
federally qualified health centers) and must commit to
providing full-time or half-time primary care services in
a HPSA for a minimum of two years. Health professionals
may receive up to $50,000 in exchange for a two year
full-time service obligation and/or $25,000 for a two
year half-time service obligation; individuals can
receive up to $150,000 over six years at full-time and
$75,00 for half-time. SLRP award amounts are matched by
the site(s) in which the health professional is
practicing, on a dollar-for-dollar basis, in addition to
salary. The SLRP is funded through a grant from the
Health Resources and Services Administration Bureau of
Clinician Recruitment and Service, National Health
Service Corps (NHSC) and is administered by OSHPD;
c) Steven M. Thompson Physician Corps Loan Repayment
Program. This program is available for individuals who
have a valid, unrestricted license to practice medicine
in California as an allopathic or osteopathic physician
and surgeon. This program encourages recently licensed
physicians and surgeons to practice in HPSAs and Primary
Care Shortage Areas (PCSA) in California. Physicians and
surgeons pay an additional $25 fee during initial and
renewal of licensure to fund the program. The program
repays up to $105,000 in educational loans in exchange
for full-time service for a three-year commitment for
those currently employed or who have accepted employment
in an HPSA or PCSA. Priority consideration is given to
applicants who are best suited to meet the cultural and
linguistic needs and demands of patients from medically
underserved populations and who meet one or more of the
following: speak a Medi-Cal threshold language; come from
an economically disadvantaged background; have received
significant training in cultural and linguistically
appropriate service delivery; and have three years of
experience providing health care services to medically
underserved populations or in a medically underserved
area. Preference is also given to those who agree to
practice in a medically underserved area and who agree to
AB 2216 (Bonta) Page 8 of ?
serve a medically underserved population. Up to 20% of
the available funds may be awarded to program applicants
from specialties outside of the primary care specialties,
including psychiatry, anesthesiology, emergency medicine,
endocrinology and diabetes, general surgery, pediatric
emergency medicine, and child neurology;
d) Song-Brown Program. The Song-Brown Program was
established in 1973 to increase the number of family
physicians in the state and increase the number of family
medicine residency programs. Currently, Song-Brown
provides financial support to family medicine and primary
care residency (Internal Medicine, OB/GYN and Pediatric)
programs, family nurse practitioner programs, primary
care physician assistant training programs, and
registered nurse education programs. Funding is provided
to institutions that provide clinical training and
education in underserved areas, and healthcare to the
state's underserved population;
e) Mini Grants Program (Mini Grants). Provides grants
to organizations supporting underrepresented and
economically disadvantaged students in pursuit of careers
in health care. Organizations receive grants of up to
$15,000 to engage in health career conferences,
workshops, and/or career exploration activities. Since
2005, over $2.2 million has been awarded to support
organizations engaging in these activities serving nearly
56,000 students statewide. In 2014 to 2015, via partial
funding from Mental Health Services Act (MHSA) Workforce
Education and Training, the California Endowment, and the
California State Office of Rural Health, OSHPD awarded 46
Mini Grants to organizations for a sum of $603,706. This
will help support 16,555 students from demographically
underrepresented groups to pursue healthcare careers;
f) California Student/Resident Experiences and
Rotations in Community Health (CalSEARCH. Provides
grants to organizations that support student and resident
rotations from primary care and mental health disciplines
in community clinics, health centers, and public mental
health system sites which expose students, residents and
practitioners to underserved communities. Organizations
awarded receive funding to administer the program and to
provide students, residents, and preceptors and mentors a
small stipend for completing the program. In addition to
completing a rotation in an underserved area,
participants are also required to complete a community
AB 2216 (Bonta) Page 9 of ?
project. From 2009 to 2012, 150 students and residents
were supported via an American Recovery and Reinvestment
Act grant. In 2014 to2015, via funding from the MHSA
Workforce Education and Training and The California
Endowment, OSHPD granted 12 awards to organizations for a
sum of $317,000 which will help support 92 participants
statewide;
g) Licensed Mental Health Services Provider Education
Program. This program is available to individuals who are
licensed/registered mental health professionals with
either the Board of Behavioral Sciences or the Board of
Psychology. According to OSHPD, the following individuals
qualify for this program: licensed psychologist,
registered psychologist, postdoctoral psychological
fellow/trainee, LMFT, marriage and family therapist
intern, LCSW, and ACSW. These individuals pay an
additional $10 fee during initial and renewal
license/registration to fund the program. For a 24-month
service obligation at a "qualified facility," providing a
minimum of 32 hours of direct patient care, an individual
may receive up to $15,000 for loan repayment. Applicants
can only receive two awards for a total possible award of
up to $30,000 for loan repayment. "Qualified facility" is
defined as: 1) a publicly funded facility, 2) a publicly
funded or public MH facility, or 3) a nonprofit, private
MH facility that contracts with a county MH entity or
facility to provide MH services. Selection of awards is
based on the following criteria: work experience,
cultural and linguistic competence, career goals,
community service, community background, and fluency in a
language other than English. Priority is given to
individuals whose community background and commitment
indicates the likelihood of long-term employment in a
qualified facility even after the service obligation has
ended; and,
h) Mental Health Loan Assumption Program. MHLAP was
created by the MHSA, which provided funding to develop a
loan forgiveness program in order to retain qualified
professionals working within the Public Mental Health
System (PMHS). Through the Workforce Education and
Training component of the Act, $10 million is allocated
yearly to loan assumption awards. An award recipient may
receive up to $10,000 to repay educational loans in
exchange for a 12-month service obligation in a
hard-to-fill or retain position within the County PMHS.
AB 2216 (Bonta) Page 10 of ?
Counties determine which professions are eligible for
their county's hard-to-fill or retain positions. Some of
the eligible professions include, but are not limited to,
Registered or Licensed Psychologists, Registered or
Licensed Psychiatrists, Postdoctoral Psychological
Assistants, Postdoctoral Psychological Trainees,
Registered or Licensed Marriage and Family Therapists,
Registered or Licensed Clinical Social Workers, Licensed
Professional Clinical Counselors, Licensed Professional
Clinical Counselor Interns, and Registered or Licensed
Psychiatric Mental Health Nurse Practitioners in
California.Support, managerial and/or fiscal staff may be
eligible.
5)Related legislation. SB 22 (Roth), would appropriate $300
million from the General Fund to the director of OSHPD for the
purpose of funding new and existing GME physician residency
positions, and supporting training faculty. SB 22 is pending
in the Assembly Rules Committee.
SB 1471 (Hernandez) would require funds in the Managed Care
Administrative Fines and Penalties Fund to be transferred each
year to the Medically Underserved Account for Physicians in
the Health Professions Education Fund and to the Major Risk
Medical Insurance Fund, as specified. SB 1471 is pending in
the Assembly Health Committee.
AB 2048 (Gray) would require OSHPD, in its administration of
the National Health Service Corps State Loan Repayment Program
(SLRP), to include all federally qualified health centers
(FQHCs) located in California on the program's certified
eligible site list. AB 2048 is set for hearing in this
Committee on June 28, 2016.
6)Previous legislation. SB 1416 (Rubio and Hernandez of 2012),
would have created the Graduate Medical Education Trust Fund
for the purpose of funding grants to graduate medical
education residency programs in California, and would have
required OSHPD to develop criteria for distribution of
available moneys. SB 1416 was held in the Assembly
Appropriations Committee
SB 635 (Hernandez) would have required funds deposited in the
Managed Care Administrative Fines and Penalties Fund in excess
AB 2216 (Bonta) Page 11 of ?
of $1 million be transferred each year to OSHPD for the
purposes of the Song-Brown Program. SB 635 was held in the
Assembly Appropriations Committee.
AB 589 (Perea, Chapter 339, Statutes of 2012), established the
Steven M. Thompson Medical School Scholarship Program and
would provide that the program is open to persons who agree in
writing, prior to entering an accredited medical or
osteopathic school, to serve in an eligible practice setting,
as defined, for at least three years.
AB 2551 (Hernandez of 2010), would have established the Health
Workforce Development Fund, consisting of moneys received from
federal and private sources, as specified; would have
authorized the Fund to be used, upon appropriation by the
Legislature, for prescribed purposes relating to health
workforce development, and would have required the California
Workforce Investment Board and OSHPD to report specified
information to the Legislature annually, as specified. AB 2551
failed passage on the Senate Floor.
AB 657 (Hernandez of 2009), would have required OSHPD, in
collaboration with the California Workforce Investment Board,
to establish the Health Professions Workforce Task Force,
composed of specified members, to assist in the development of
a health professions workforce master plan for the state and
would have prescribed the functions and duties of the task
force in that regard. AB 657 was vetoed by the Governor, who
stated, in part, that the bill was unnecessary and duplicative
of efforts already underway.
AB 2375 (Hernandez of 2008), would have required OSHPD to
establish the Health Professions Workforce Task Force, as
specified, to assist in the development of a health
professions workforce master plan. AB 2375 was held in the
Senate Appropriations Committee on suspense.
AB 2439 (De La Torre, Chapter 640, Statutes of 2008), requires
the Medical Board of California (MBC) to assess an additional
$25 fee for the initial license and license
renewal of a physician or surgeon to support the STPCLRP.
Requires up to 15% of the funds collected from the additional
$25 fee to be dedicated to loan assistance for
physicians who agree to practice in geriatric care settings,
as specified.
AB 2216 (Bonta) Page 12 of ?
AB 327 (De La Torre, Chapter 293, Statutes of 2005), requires
the MBC to assess an applicant a $50 fee for the issuance and
renewal of a physician and surgeon's certificate. Specifies
that payment of the fee is voluntary and directs the fees to
the Medically Underserved Account for the STPCLRP.
AB 920 (Aghazarian, Chapter 317, Statutes of 2005), provides
for the transfer of the
STPCLRP and the Physician Volunteer Program from the MBC to
the California Physician Corps Program within the Foundation,
effective July 1, 2006.
AB 1403 (Nunez, Chapter 367, Statutes of 2004), renamed the
California Physician Corps Loan Repayment Program of 2002 as
the STPCLRP.
AB 982 (Firebaugh, Chapter 1131, Statutes of 2002), creates
the California Physician Corps Loan Repayment Program of 2002.
This program is administered by the Division of Licensing of
MBC for the purpose of granting loan repayment awards to
physicians and surgeons working in medically underserved
communities.
7)Support. CPCA states that this bill will help address
California's primary care provider shortage by establishing
the Fund, providing planning and development grants to THCs
for the purpose of establishing new accredited or expanded
primary care residency programs, and make available sustaining
grants to ensure the continued operation of accredited THCs.
CPCA estimates that 8,243 additional primary care physicians
will be needed in California by 2030, and notes that with
dwindling federal support for current THC sites and no federal
investment to develop new sites, California must prioritize
and demonstrate its commitment to providing access to primary
care through a greater investment in the THC model. The County
Health Executives Association of California and the California
School Employees Association support this bill, noting that,
since the passage of the ACA, the workforce of primary care
physicians in California has not kept pace, especially with
increasing enrollment in Medi-Cal, and this bill will assist
in meeting the need for physicians to serve the growing number
of newly insured and Medi-Cal patients. The Association of
California Healthcare Districts (ACHD) states, healthcare
districts located in rural and remote areas of the state have
AB 2216 (Bonta) Page 13 of ?
a difficult time recruiting health professionals to their
areas. ACHD notes that THCs are on the leading edge of
innovation educational programming dedicated to ensuring a
relevant and sufficient supply of health workforce
professionals, however due to limited and uncertain federal
funding the six programs in California are in jeopardy of
closing. ACHD concludes that this bill will support the
expansion of primary care residency programs in California.
8)Oppose. The California Right to Life Committee, Inc. opposes
this bill stating that because the definition of a California
Primary Care Residency Program includes obstetrics and
gynecology, they are assuming that Title X and family planning
education will be included in the medical education for the
residency program.
SUPPORT AND OPPOSITION :
Support: California Health+ Advocates (sponsor)
California Primary Care Association (sponsor)
AFSCME
Aids Project Los Angeles
Alameda Health Consortium
AltaMed Health Services Corporation
Ampla Health
Arroyo Vista Family Health Center
Association of California Healthcare Districts
Borrego Health
California Academy of Family Physicians
California Family Health Council
California Nurses Association
California School Employees Association
Clinica Sierra Vista
Clinicas De Salud Del Pueblo, Inc.
Coalition of Orange County Community Health Centers
Community Clinic Association of Los Angeles County
Community Clinic Consortium
County Health Executives Association of CA
Community Health Partnership
Family Health Centers of San Diego
Golden Valley Health Centers
Health Alliance of Northern CA
Health and Life Organization
Kheir Center
La Maestra Community Health Centers
Marin Community Clinics
AB 2216 (Bonta) Page 14 of ?
Medical Board of California
Mountain Valleys Health Centers
North Coast Clinics Network
North County Health Services
North East Medical Services
Northeast Valley Health Corporation
Omni Family Health
Open Door Community Health Centers
Operation Samahan
Ravenswood Family Health Center
Redwood Community Health Coalition
San Ysidro Health Center
Shasta Community Health Center
St. John's Well Child & Family Center
Tiburcio Vasquez Health Center, Inc.
Valley Community Healthcare
West County Health Centers
Western Sierra Medical Clinic
Westside Family Health Center
Oppose: California Right to Life Committee, Inc.
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