The chair of the Assembly Committee on Health yesterday detailed two years’ worth of frustration and exasperation with the handling of asthma and allergy care by the Department of Health Care Services.
“This hearing is being held to see if the rules and restrictions in Medi-Cal interfere with providing quality care,” said Assembly member Richard Pan (D-Sacramento), chair of Assembly Health and a pediatrician. “There are concerns that some of the payment policies have limited patients’ access to care and that Medi-Cal has not been responsive enough to evidence of inappropriate utilization controls.”
Pan said he has tried for two years to get answers from DHCS officials, including director Toby Douglas, about why certain policies are in place that limit care of asthma and allergy patients in Medi-Cal.
“I’ve been quite disappointed and frustrated in my interactions with the Department of Health Care Services over the past two years,” Pan said. “I am concerned that many Medi-Cal patients are not able to receive quality asthma care.”
The saga began in June 2012, Pan said, when DHCS issued a bulletin saying it would only pay for skin tests, not blood tests, in allergy testing (except when some providers met a “fairly restrictive set of conditions” for blood tests, Pan said.
That meant that primary care physicians had to refer testing to an allergy specialist, rather than doing it themselves with a blood test — which, Pan said, is a practice that fits guidelines established by federal health organizations such as the National Institutes of Health.
Blood-test guidelines were not new, Pan said. They had been established in 2008.
“So I submitted a letter in September 2012 to DHCS indicating my particular concerns and attaching specific references to the guidelines and the research. … I received not a direct response, but a letter that was in response to another physician’s letter.”
So Pan set up a meeting with DHCS staff, including the medical director, and was told the decision to limit blood-testing of allergies was based on other research the department had.
“When I asked for copies or references [for that research], I never received them,” Pan said.
Pan said his staff set up yet another meeting, again including the DHCS medical director, to find out exactly “why they were not allowing primary care physicians to order a blood test so they could be in compliance with the asthma and food allergy guidelines.”
The results were identical, Pan said.
“Again reference was made to a research paper that underlay the department’s position,” Pan said. “However, once again we asked for a reference or copy and never received it.
“We also requested cost data, and again, never received it. We also requested information about their concerns about overutilization, and again, never received it. We were told the process for the laboratories was simplified; however, in our follow-up with clinical labs we found that was not the case.”
Pan said he’d had enough. He asked DHCS director Douglas to meet with him and his staff — and to bring any research with him.
“I was tired of going to meetings where evidence was referenced, and then never produced,” Pan said.
Even then, Pan said, DHCS officials did not provide evidence or data, though Douglas did propose a possible revision to the policy. That revision discussion did not really address the concerns or meet the national guidelines, Pan said — and it’s not the first exasperating subject of discussion with DHCS, he added.
“This interaction is only one example where we’ve made efforts and provided data, but the department has not been particularly responsive,” Pan said. “This hearing [has a] focus on asthma and allergies, but I think we need to look at this as being one example of potentially a larger issue that’s been going on.”
DHCS medical director Neal Kohatsu represented DHCS at yesterday’s hearing.
“It’s a balancing act, to provide the best value with the budget we have,” Kohatsu said. “Toward that end, we are familiar with and are looking at the Choosing Wisely program, and one of the things highlighted is allergy testing. Sometimes there can be indiscriminate testing.”
Choosing Wisely is a national program to promote shared decision making between patients and physicians.
Kohatsu said the department received 7,000 claims from providers that exceeded the state testing limit of 24 allergens. That shows a lack of understanding about how testing should be used, he said.
“That’s one reason why there are utilization controls,” Kohatsu said.
He added that the department is looking at some utilization controls that might present an administrative burden on providers. “Those are concerns we are sensitive to,” Kohatsu said.
“We’ve broadened the reasons blood tests can be ordered,” Kohatsu said. “We’ve expanded out the policy, and we’re committed to working on the administrative details that make a claim burdensome and we hope to get past that.”
Pan asked about the conflict between administration policy and national guidelines.
“I think we should resolve that conflict as soon as possible,” Kohatsu said. “We can and will do better to resolve conflicts in policy.”
“But how soon do we expect to resolve this?” Pan said. “It’s been two years.”
Kohatsu said it takes about three months to reprogram computers to reflect a change in policy. “It’s our intent to change the policy,” Kohatsu said, “and it’s really just the programming time.”
Pan raised the issue of unspecified research directing state policy.
“One of the concerns I’ve had is we’ve met three times face-to-face in my office. You’ve referred to papers that were used to define policies, and we have not yet received any other papers,” Pan said. “How am I supposed to believe the department’s assertions [now]? You said there was a paper in pediatrics that supported your assertions. Where is that? What is it?”
Kohatsu said he wasn’t sure what paper he might have meant, but he thought it might be the Choosing Wisely guidelines.
Pan said he agreed with the Choosing Wisely guidelines, because they limit ordering allergy tests when providers aren’t testing for something specific.
“So how does this apply to what we’ve been talking about?” Pan said. “They don’t limit blood allergy tests.”
The guidelines, Kohatsu agreed, do not specifically address allergy blood tests, but “alludes more broadly to allergy testing.”