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Next Generation of Health Policy

September’s HIPC meeting began with state policy updates from CA State Senator Bill Monning, followed by a review of the Medicare Access and CHIP Reauthorization Act (MACRA), and finally a presentation by County staff on the “Next Generation” of Emergency Medical Services (EMS).

State Policy Updates

Senator Monning discussed the content and his engagement in the following legislation relevant to HIPC:

  • SB115: requires that insurance companies notify patients and providers of their right to timely access to care.

  • SB1139: requires that people utilizing services like CalFresh and Medi-Cal experience a more seamless transition when moving between counties.

  • SB253: requires judicial review and a second medical opinion to prescribe psychotropic drugs to children under 5 or children receiving two or more psychotropic drugs.

All three bills passed in legislative session and, as of this issue, were pending Governor Brown’s signature.

Senator Monning also discussed the outcomes of two health focused Assembly bills:

  • AB72: Passed the Assembly and requires insurance companies to settle billing disputes with the provider instead of the patient for “surprise billing” situations in which the patient receives care at an in-network facility, but unknowingly receives services from an out-of-network provider. Some providers are concerned about receiving payments late or that insurance companies could potentially present a take-it or leave-it approach to pricing. He acknowledged the concern over provider flight in rural areas, followed by gaps in specialty care because it is not financially viable.

  • AB1306: the midwives’ scope of practice bill, did not pass the state assembly. Other topics discussed at this meeting include:

  • When asked if there was any movement on a new sweetened beverages tax or initiative, Senator Monning replied that he has been pushing for a warning label and not a tax because taxes require a two-thirds vote as opposed to a majority vote. However, he referenced a recent junk food tax in Mexico that has shown a 10-12% decrease in consumption.

  • Prop 52: (The measure would extend the current state Medi-Cal hospital fee program, which generates over $3 billion a year in federal matching funds that pay for health care services for children, seniors and low-income families.

  • Senator Monning commented on the impending Covered California rate increases (up to a 28.6% in our region). These rate increases could push people out of coverage and out of compliance with the law. Federal subsidies will bridge some of the gaps, but not everyone is eligible for the subsidies.

In conclusion, Senator Monning stated that he supports overtime pay for farm workers, limits on the increase in costs on pharmaceutical drugs, and will be using some of this recess period looking for legislation on children’s health.


Larry DeGhetaldi, MD, Regional President of Sutter Palo Alto Medical Foundation (PAMF) presented on MACRA. As of January 2017, Medicare payments will no longer be fee-for-service. Payments will now be based on quality of care. There are two routes for payment: Alternative Payment Modalities (APMs) and Merit Incentive Payment System (MIPS). APMs begin in 2019 with payment in 2021. MIPS begins in 2017 with payment in 2019. Dr. DeGhetaldi stated that hospitals cannot opt-out of these payment methods, but solo physicians who cannot afford to produce the reports for these payment methods may stop seeing Medicare patients. He went on to say that medical groups do better in total cost of care than solo physicians, who are likely to suffer in this payment model, with the most impact for patients residing in rural areas and dual-eligible patients. The loss of Medicare providers will likely mean more patients seeking care at Safety Net Clinics. Dr. DeGhetaldi suggested that Santa Cruz would likely handle the fallout, but Monterey may struggle because they do not have large medical groups serving Medicare patients. Federally Qualified Health Centers (FQHCs) are exempt from MIPS.

The “Next Generation” of EMR

Brenda Brenner, Santa Cruz County Emergency Medical Services (EMS) Administrator, presented on the “Next Generation” EMS program. The program is based on the Triple Aim: improved health, lower costs, and better care. Their mission statement defines better care as “the right care, right patient, right time, and right place= the best outcomes.” Currently, ambulances are required to take patients to the Emergency Department (ED), however, not every patient needs to go to the ED. It is more cost-effective for patients not needing ED services to be connected with more appropriate care. Brenner shared that when the Homeless Persons Health Project noticed that a lot of their clients were calling 911 (because it was the only resource they had on hand) HPHP worked with EMS to create a pilot project to address patients’ real needs. Although the ambulance service does not get paid if they don’t actually take a patient to the ED, there was support for the pilot work because the impact was clearly improving care for patients and freeing up ambulances for appropriate use. EMS is currently conducting a stakeholders process to generate an RFP for the future EMS service provider in the County. The design of “next generation” EMS system must be acceptable to the state. Current challenges under discussion include statutes and funding limiting new approaches to EMS delivery. For more information on the EMS stakeholder process, contact Brenda Brenner at

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