Health — 2026-08-04 (partial)

comments she would like to make. Great. Thank you. Thank you. I want to start by thanking Chair Bonta and the committee staff for organizing today's outcomes review hearing. I also want to thank Speaker Rivas for creating the outcomes review process and giving the legislature an important tool to evaluate the impact of laws. Anyone who knows me knows that I take implementation of my bills very seriously. I often say in my office, what's the problem, how do we fix it, and how do we implement it? As legislators, we sometimes focus on passing a bill and forget that implementation is where the real work begins. Today we are looking at two bills I am especially proud of, AB 744 and AB 32. These bills share one goal, making sure Californians can access the care they need when they need it. For rural communities, farm worker families, older adults and working families, getting to a health care provider can be challenging because of distance, transportation and scheduling barriers. Telehealth helps break down those barriers by giving patients another way to connect with their providers. AB 744 was a critical step forward by establishing payment parity for telehealth services. It gave providers the certainty they need to invest in telehealth and make it sustainable part of our health care delivery. The timing of 744, AB 744, was especially important because it was enacted just before the COVID pandemic. When that pandemic hit, California was prepared to expand telehealth and maintain access to care because we had already built that foundation. The pandemic also showed the importance of ensuring telehealth works for all patients, including those who lack reliable internet or technology access. AB 32 helped address that need by expanding access to audio telehealth visits for Medi patients in appropriate circumstances Together, these bills have expanded access and given patients more options for receiving care. But I know that there's still more work to do to address barriers like broadband access, additional care, differences in telehealth use among communities. I look forward to hearing from our panelists today about their experiences implementing these policies and the impact they have had on patients and providers. I want to thank all of our witnesses today for being here and for their continued service to Californians. I appreciate the opportunity to discuss how we continue to building these policies and improving health care access across the state. Thank you.

Thank you, Madam Chair and committee members for the opportunity to speak today. If I could have the slides up on the screen. My name is Marissa Montano. I'm a senior policy officer with the California Healthcare Foundation. The foundation is an independent nonprofit philanthropy that works to improve the healthcare system for all Californians, especially those facing the greatest barriers to care. Today, I'll discuss California's health policies, how they've evolved, what we've learned from the evidence, and what it means for patients across the state. First, I'll start by defining telehealth broadly. So our Medi-Cal program defines telehealth broadly as the access information and communication technology to facilitate consultation around healthcare. I want to double-click on telehealth could be live or synchronous. where a patient interacts in real time with their provider via some sort of telecommunications, whether that be via video or audio only. Telehealth can also be asynchronous or a store-in-forward. This is when a patient or a provider consults with another provider in a different location via electronically. A popular example of this is e-consults. Remote patient monitoring is also part of telehealth. And remote patient monitoring is a collection of health and medical data from a patient in one location transmitted to a provider in another location with the goal of supporting that person's care. And then mobile health is also something that helps all of these different modalities where providers can use access to technology for education and other support for care I wanna call out that in our research, when we were talking about telehealth, we're not talking about autonomous health. So AI chatbots are part of virtual care, but not part of the definition of telehealth we used in some of our research and the data that I'll show today. Over the past nearly three decades, major policy changes in California, coupled with consumer experiences, advances in technology, and changes in the healthcare system, have greatly expanded access to telehealth for many throughout the state. While COVID-19 was certainly the catalyst for telehealth adoption, especially for Californians in the Medi-Cal program, California made key telehealth policy-related advances prior to 2020 that set the stage for tremendous progress during and after the pandemic. Coverage of telehealth began in 1996, making Medi-Cal a leader in reimbursement for telehealth in California. policy made telehealth access more lenient than in Medicare, for example, allowing telehealth outside of rural and health professional shortage areas. Prior to 2020, telehealth was primarily used clinic to clinic, for example, for specialty care access, and e-consult programs were robust, particularly within county health systems. Policy changes from 2020 onward allowed for expanded use of telehealth, initially as a result of waivers that introduced flexibility during the public health emergency, but have evolved into a permanent policy, allowing telehealth from home and other locations, ongoing payment, Medi-Cal payment, payment parity, and other supportive policies, such as those surrounding broadband access, access to community health workers, and school-based services. These policy changes also allowed for the data collection and availability of data over the past decade or more, which allows us to have more robust research and to understand how patients interact with and experience telehealth, as well as to really study the effectiveness and use of telehealth across the state. Patients say they're satisfied with telehealth and would like to continue using it. Evidence shows that patients are satisfied and experience rapport with their providers during telehealth visits, and about half of all patients found that their telehealth experience paralleled their experience with in-person care. By listening to low-income Californians, we learned, and as you can see from examples of quotes on this slide, that patients appreciate the way that telehealth removes barriers to accessing care and would forego or delay care without the telehealth options. And what about telehealth effectiveness? Telehealth is a very effective mode of care for patients, particularly for behavioral health and chronic care management. This evidence is strong across both video and audio telehealth, as well as in e-consults. More research candidly is needed to understand hybrid models of care and the extent to which telehealth serves an improved outcome for different populations. During the pandemic, we saw an incredible increase in telehealth utilization. And data up until 2022 shows that in utilization remained higher than pre-pandemic utilization rates, even once the public health emergency has ended. National data in Medicare, which has more payment restrictions than Medi-Cal, also shows that telehealth use remains steady through 2025. We've also learned that audio only is a crucial access point for maintaining care. This is especially true for patients with digital barriers to care, like lack of sufficient broadband. It is also shown to be important in the clinic setting for patients accessing primary care and behavioral health visits. The evidence for telehealth use and its availability to expand access to care centers on the way that patients experience care. Longstanding barriers to accessing care regularly, particularly for low-income Californians, like lack of transportation, inability to miss work, lack of child care, are reported to be ameliorated with the use of telehealth. Patients want to continue to access care when they can through telehealth. And for immigrant communities today, national threats for nonwhite immigrants in California have escalated, making telehealth essential for maintaining access to care when fear of public spaces is high. There are, however, still some disparities for accessing telehealth, notably for older Californians and Californians that speak a language other than English. Language access remains one of the barriers to using telehealth. And in conclusion, telehealth is a really important and effective tool for expanding access to care. It increases flexibility and allows Californians to receive the care they want and need. It's not a replacement for in-person care, but it is a crucial mode of care to maintain access for many. Telehealth, including audio only, reduces barriers to preventing patients from timely access to care, and patients really want to continue using it. And with that, thank you so much for the opportunity to speak, and my contact information is included in the slides.

Thank you, Madam Chair and members of the committee. My name is Amy Durbin, and I am here today on behalf of the Center for Connected Health Policy, or CCHP. which convenes the California Telehealth Policy Coalition. CCHP is a program underneath the Public Health Institute that was established in 2009. There we go. And since 2012, we've been acting as the federally designated National Telehealth Policy Resource Center, providing technical assistance on telehealth policy nationwide to policymakers, providers, and patients. CCHP founded the California Telehealth Policy Coalition in 2011 when engaging on AB 415, one of the bills that established the state's foundational telehealth laws. And the coalition has continued to meet over the years in the interest of collaborating to advance telehealth policy in the state. I'm here today to provide some additional background regarding the intent behind the kinds of telehealth payment policies being reviewed by this committee today related to telehealth payment parity in AB 744 and Medi telehealth coverage policies particularly those related to audio only under AB 32 CCHP also tracks telehealth policies across the country so I will try to provide some context around California's telehealth landscape in the context in relation to other states as well. So starting with AB 744, telehealth private payer laws generally seek to ensure that private payers do not discriminate against covering services purely because they're being provided via technology rather than in person. Telehealth payment parity or reimbursement requirements, like those added by AB 744, take that a step further, ensuring that the exact same service can be provided both via telehealth and in person. It should be reimbursed at the same rate. These policies together are important in terms of ensuring that providers have the ability to offer services to patients via technology, as providers may not be able to invest in and offer them otherwise. AB 744 also updated and clarified some of California's existing telehealth definitions and requirements and included a provision to ensure that payers cover telehealth for all contracted providers, not just limit coverage to a select third-party corporate telehealth provider and that might contract with a health plan and not be the patient's in-person provider. So therefore, the policy like AB 744 seeks to offer additional access through technological means while maintaining continuity of care for patients with established providers and ensuring they remain connected to in-person services as needed. The majority of states across the country now do have telehealth private payer laws. Some of them include similar protections regarding corporate telehealth providers as well, but only half the states have explicit payment parity reimbursement requirements. So moving on to AB 32, one of the main telehealth policies that we're seeing having the most growth across the country since the pandemic is related to audio-only coverage under Medicaid, which is what AB 32 focused on. Medicaid audio-only coverage has more than doubled since 2021, with most states now offering some coverage of the modality. However, limitations often apply. The primary intention behind ensuring audio-only availability, especially within Medicaid programs, is the lack of affordable and accessible broadband across certain areas of the country and state, particularly in rural areas, which limits both provider and patient access to telehealth modalities, namely live video. AB32 intended to reduce some of these policy limitations placed around audio-only Medi-Cal coverage when the explicit coverage was made permanent post-pandemic. In particular, it sought to ensure that providers, including safety net providers, including FQHCs and RHCs, could more readily offer audio-only services by creating exceptions to the policy limiting audio-only to only established patients. AB32 ensured that audio only could remain available to new patients as well in relation to certain sensitive services or in the event the provider patient doesn't have access to the technological means and the patient requests the modality. While AB32 helped to address some of these barriers related to audio only access, others remain and there are similar asynchronous and store and forward barriers in Medi-Cal and I appreciate Assemblymember Aguera-Curri for seeking to address some of these additional issues through other pieces of legislation these last few years. And now I'd just like to briefly touch on some of the main trends that we're seeing across states regarding telehealth payment policies, as well as within the context of any potentially remaining gaps or limitations in California telehealth policy at this time. So as you can see on the slide, next to live video, which is covered by all state Medicaid programs, as well as D.C., Puerto Rico, and the Virgin Islands, audio only is the second most covered telehealth modality, with 46 states and D.C. reimbursing audio only. 41 state Medicaid programs cover remote patient monitoring and 41 cover asynchronous restore and forward telehealth When it comes to FQHCs these telehealth modality numbers are often much lower across the states with only 17 Medicaid programs explicitly covering audio only eight covering RPM, and seven store and forward. Medi-Cal does technically cover all telehealth modalities generally, at least for established patients, but Medi-Cal does not cover some asynchronous billing codes, such as those for e-visits. Medi-Cal does cover some telehealth modalities for FQHCs and RHCs. However, that does not include remote patient monitoring and some asynchronous telehealth billing codes, such as those for interprofessional consultations or e-consults. Two states, New York and North Carolina, do cover all modalities for FQHCs. New York has done this through an alternative payment methodology, which we know is something that California has also been working on. But asynchronous telehealth does remain limited in terms of coverage in Medi-Cal, although exceptions do apply and similar limitations are common for this modality across other state Medicaid programs as well. And then in regard to the private payer numbers, we've kind of covered those already. So I just wanted to make a note on parity in regard to Medicaid specifically. Medicaid programs are generally required under federal requirements to reimburse telehealth services, no differently than how they reimburse for in-person services. So it is common for most state Medicaid programs to reimburse telehealth modalities if they do, including store and forward and audio only at parity with in-person service reasons. So as overarching policies seek to promote the use of telehealth continue to be passed, it's when they continue to treat its uses and coverage differently than in-person care, rather than just recognizing it as another delivery modality best determined between the provider and patient, that we find ourselves more in the nuances of that coverage, needing to navigate the potential impacts of limitations when seeking to determine remaining policy gaps and implementation outcomes. The concern being that the more telehealth-specific policies and limitations are adopted, the more complicated it becomes to track for how and when to bill for telehealth across payers, especially if you're creating criteria for reimbursements specific to just one telehealth modality and one specific payer, which then can limit providers from offering telehealth and potentially create disparities in access across various patient populations. So in summary, California has historically been at the forefront of other states in terms of adopting policies that ensure access to care via telehealth, and even pre-COVID had pretty robust coverage. Telehealth access in the state has continued to be bolstered through both AB744, particular to commercially insured patients, and AB32, which addressed a gap in access to audio-only services within Medi-Cal. However, gaps remain, such as those noted in regard to asynchronous or store-and-forward coverage. Medi-Cal has also created additional policies that are just specific to telehealth use, such as consent and in-person policies that do not similarly apply to commercial patients and providers. And Medi-Cal enrollment processes largely prevent remote-only providers from being part of the program currently as well. Though Medi-Cal has created an exception for remote-only mental health providers, Further exceptions have not seemed to be viewed favorably thus far, as I know this is something else Assemblymember Aguilar Curry has sought to address with her more recent bills. Meanwhile, enrollment processes are being updated in other state Medicaid programs more generally to address remote-only providers and find additional ways to expand access to care via telehealth while keeping those necessary consumer protections and state oversight in place. So while differing telehealth policies and limitations are unfortunately common across states and payers, they can discourage provider use of telehealth and limit patient access. Pieces of legislation like AB 744 and AB 32 however are intended to simplify and reduce some of those barriers for both commercial and Medi patients and together should better ensure that more patients are able to receive necessary timely and quality health care through the most appropriate and preferred modality Thank you Thank you so much

A big proponent of telehealth as being an assembly member means oftentimes our appointments are via telehealth. So I want to put that out there. But questions around technology use and adoption in order to provide adequate telehealth. What are the cost implications for providers for having technology, data storage, data protection versus how much they're getting reimbursed for the clinical side of the cost to provide telehealth?

infrastructure as well. And then a follow-up question on the telehealth for like primary care appointments. When you usually go into a primary care in person, they do height, weight, blood pressure, ear, eye checks, perhaps. Those end up not getting done in a telehealth visit. So what are the guardrails or protections around that just regular clinical observation component of a telehealth visit?

to hearing more in the next panels. So thank you very much for the presentation. Those that know me, I'm always wanting to figure out the implementation piece, and I keep thinking about disparity and in rural communities. So how can the state continue to ensure telehealth expands access without increasing disparities among patients who may face technology or connectivity barriers?

So what other investments would you see or policy that we should be doing here at the state to ensure that all of our Californians can benefit from telehealth? What do you think is out there?

I think of it as specialized medicine. I mean, we are just doing, I think, an incredible job on telehealth. We're going to only do better. I agree with you that we need to improve our communications and our broadband internet connectivity, and we have assembly members working really hard on making sure that gets up and down the state of California at a reasonable price, as it's difficult. But I really want to make sure we can make sure specialists in our rural areas and our constituents have access to health care. So that's a goal I have going down the line, as my many goals that I have. But I just think that we need to, as a state, is to realize that we do need to have our specialists there when we're working in rural communities. That's all I have for now. Thank you.

I have a couple questions. The first is for our discussion around kind of the data availability understanding the go opportunities for us I think what I heard you say Ms Montenegro in the first couple of slides was that we no longer have any data past 2022 that we're relying on. But then you also kind of call this era that we're in post-COVID as the evaluation era. So given the fact that there are many things to still work out in terms of the disparities, barriers that we are looking forward with, can you describe what the current state is and if you have any recommendations around what we should be doing differently around data collection?

What else? How is telehealth used most effectively? And how does that evolve as we go into the future? I think being able to have access to that data in an easier way helps create some of that transparency and evaluation going forward in sort of the post-COVID era.

In a public way. In a public way. So there we go. Thank you for that. And as I was reading the kind of background paper and also hearing your presentations, it's pretty clear to me that there are supply issues in terms of along the lines of speaking to barriers issues. Like, there are supply issues, like, are we set up from a reimbursement perspective to be able to have enough providers actually utilize these tools? Are there discrepancies between the way that smaller clinics, rural clinics, FQHCs have, you know, have the ability to have robust programs to be able to utilize telehealth? There are modality issues. You know, do people have access to broadband? And is there enough opportunity to have the kind of protections, privacy protections embedded in the kinds of tools that we use for that? And then there are demand issues, which are, you know, why is it that it looks like people who are non-English speaking patients have less ability to use this, or there's an impact on elder patients in terms of they're likely less able to use that. Can you give us a sense if you were to kind of parse out those three areas supply modality demand where the greatest levers for us to really increase the impact and utilization would be in either those three categories or whether there one that you believe is kind of more the culprit for why there isn such a great

And then I think on the reimbursement side, it's hard to say because particularly Medi-Cal, and Medi-Cal is sort of my area of expertise where reimbursement is a topic across many different areas. And so I think it takes some data and studying and looking at, you know, now that we have access policies in place, how does actually studying how reimbursement translates to providers offering more telehealth or what does that look like for the landscape of telehealth utilization? So for the purpose of this oversight review hearing for AB 32 and AB 744, which specifically focused on making sure that there was parity for different telehealth applications,

I mean, I think you're still looking at research and definitely looking at the impacts of payment parity on utilization. What does that look like in providers that are offering telehealth services? What does that look like across time, things like that? And I don't know if you have other.

But I do know, you know, speaking to the data issue and DHCS having this dashboard in place, I know there was additional legislation that was signed last year that does kind of heighten DHCS's requirements on the Medi-Cal telehealth data. What I think would be

So it's possible they might be doing something similar, but we don't have as much information to really compare these two patient populations, I think, sufficiently to make sure we don't have disparities as we're creating these policies. And so I do think DHCS is looking to get all of those variables in place to try to examine those outcomes. But it is maybe a work in progress that it could also be helpful to bring in that private side to make sure we've got some seamlessness between the two. Two more questions.

I can speak to that a little bit. I mean, in terms of like the history of those codes, they haven't actually been around too long. They were created probably about six or seven years ago, and I think there was a lot of confusion on state Medicaid programs on how do we adopt these codes and reimburse them for different providers. And so I think state Medicaid programs are playing catch up, and they're getting there. We have – I mentioned some of the numbers on states. For FQHCs, it's much different. Their billing processes are much different. So we don't see as much e-consult happening in FQHCs and RHCs. as we do outside of them. And that, I think, is just going back to, you know, looking at the way the policies have been created for billing for these particular providers and adapting them for now, these new codes and these new telehealth services that can be offered. And so some of the conversation, I think, in California has been around, you know, there's two e-consult codes covered right now under Medi-Cal, but those are not covered for FQHCs and RHCs. And my understanding is it's DHCS was trying to figure out some billing aspects about how can we cover that for these particular providers. And that's where they were looking at an alternative payment methodology. And we have seen that in other states. So I think it's the nature of billing, not necessarily a reluctance to doing so, but navigating that kind of complexity of how they bill to figure out how can they also bill for these services, particularly e-consults, because that is something that they aren't currently able to do. And I know there has been legislation on that in the past. And so it has been a conversation and something that I'm not sure if there's been more work being done behind the scenes. But that's as far as I'm aware that the current status of the consul.

Chaptered.

Absolutely, yes. That is a big issue and kind of push and pull regarding telehealth generally. And I think Marissa spoke a little bit about a hybrid approach to telehealth. And I think a lot of folks see that as maybe the best kind of balance where particularly the AB744, for example, it had that provision that said you can't limit coverage just to these corporate telehealth providers, which was what had been happening previously. people had said, well, you know, the payers aren't covering telehealth. And they said, well, we do. We've got this contracted corporate provider. You can get your telehealth that way, but that's not their normal provider. It's not synced up with their electronic health records. They don't have that continuity of care to even sync back up with them after the visit and make sure everything went fine. And so that was kind of the reason behind putting that in the private payer laws is ensuring that, okay, you guys, you can offer that service if you want to, but please don't only limit your telehealth coverage to them, offer it for your other contracted providers so everybody can get an ability to see their provider instead of a corporate provider. And so we have seen that mirrored across states. I think that is a general concern that folks have is kind of the larger companies and how the protections are in place for patients in that kind of direct-to-consumer telehealth environment versus what I think many folks want to see is it's kind of a hybrid approach where we've got our in-person providers that now can do telehealth too, and they can make those determinations on which one is most efficient and sufficient for that particular visit.

Yeah, I can speak. The CCHP does track, you know, all cross-state licensure policies across the country. And that is, since the pandemic, that is the main policy area we're seeing related to telehealth continue to be focused on in states. And California is obviously, you know, it's a unique state. And I think that that's where they've kind of come from so far in terms of, you know, compacts. I know there's a lot of concern around, you know, you've got small states that join the compact and then you've got larger states like California and the amount of providers to patient ratio as well as, you know, the complexities that come with our particular consumer protections in California versus other states. Do we want to seed some of those? When can we seed some of those? And compacts in particular, you can't really negotiate that language. You kind of have to put it into statute as is. And so I think that's where California has been like, well, you know, we're interested, but we want to see how we can do it for us. That makes sense. And so outside of compacts, there are other routes to expanding cross state providers access. And that would be creating licensure exemptions, which California does have a couple very narrow ones currently. I know legislation has been ran the last couple of years to slightly expand our already narrow exemption, and that has not made it very far. So I know there is still some reluctance on the exemption side. The other policy area we see across states to address this issue is related to creating a registration process. Every state does that differently, though. And so, you know, some states just say, let us know your name and information, and now you're okay to start seeing patients in our state. where other states are like, no, we want an application, a fee, all of the things you usually need to do to confirm licensure as kind of a registration process rather than full licensure process is another route of potentially opening up those additional out-of-state providers via telehealth.

Assemblymember Schiawa.

from them how important it was to be able to see patients, to see if they're clammy or touch their skin or, you know, things that really help inform the health and wellbeing of the patient and maybe what kind of steps you need to take to care for them. And so I know that telehealth in that way is limited And you know it an important tool and I think it really important especially for rural and underserved areas areas where you can get specialty care all of those things It it's, you know, been a godsend for a lot of people in a lot of ways. But I also want to make sure that we're keeping in the conversation, making sure that it's a high level of care that people are getting through that telehealth and that it's being used appropriately, right? If someone needs to come in, if it's the kind of illness or issue or whatever that someone needs to be seen in person, that that's still happening and everything isn't kind of being siphoned off to telehealth as a solution that maybe doesn't fit all the needs. Thank you for the question.

And certainly, you know, even not in rural areas, Sacramento and L.A., where I receive health care, it can be helpful to figure out whether or not it raises to the levels of needing to bring your kid in to the doctor or something like that. And so a quick phone call can be a huge, huge help to save driving time for a lot of people in traffic, too. So thank you so much and look forward to that further information. Assemblymember Carillo.

That a great question And I don know the answer to that question I think that just varies on a lot of factors that I don personally have the data or the research to really answer Yeah, I would say I think the intent would be hopefully yes, that telehealth could provide a sooner option. I know in my own personal anecdotal experience, I have had that happen where they said they can't get me in for a few months, but let's do a telehealth visit. Really, I think what it comes down to is provider preference and availability. If they don't offer telehealth generally, they might not be able to do that for that particular patient. And so it is something that I think is very interesting to maybe examine further. But I do think that that's a goal of telehealth. Well, thank you so much for your commentary. Oh, we had one more question

Thank you so much, Chair. Thank you both. I'm sorry I missed your presentation earlier. And, you know, appreciate also our majority leader for her two bills. I just wanted to ask a question as it relates to maybe trends that you may be seeing for some of our immigrant communities who may be using telehealth more, given some of the increased ICE rates. I know for a lot of the communities that I represent in Los Angeles, a lot of our clinics and hospitals have reported a high increase in a lot of patients missing appointments, some upwards of 70%, which is really high. And, you know, what are some of the ways in which maybe telehealth could be a solution for folks who might be scared to go out and see in-person care?

And I know that's one of the actions Assembly Democrats took last year was making sure that a lot of our immigrant rights organizations received funding to ensure that people had and knew what their rights were. And so I think a connection piece to that, if maybe your organizations aren't already connected to some of our legal clinics, our immigrant rights organizations who probably do know your rights trainings, probably in that same breath, it'd probably be good to continue to ensure that we promote health care. access, maybe telehealth options. We know how hard so many people, especially on this committee, our chairwoman has worked to ensure that we have more coverage and access, making sure that we fund things like our promotora programs when we were really encouraging our health for all. And so I don't want to lose that progress during this time when I know a lot of people are just at home scared to get help. And so I would just, if you haven't already been doing that, would have a recommendation to connect with some of those organizations. And of course, if you need our help, please let us know. Thank you.

You drew the short straw. Go. Press the button. Good afternoon.

Good afternoon. I wanted to thank Majority Leader Agriar Curry and Chair Bonta for inviting me to help participate in this hearing and my support for AB 744 and AB 32 and the way it's changed my practice. My name is Stephan Newman. I'm a family practitioner. I've been licensed to practice medicine in California since 1982. After medical school, I completed family practice residency at UCSF, San Francisco General Program, and then spent four years in the National Health Service Corps in rural Yolo County in Esparto and Knights Landing, providing care for agricultural workers and residents of that area, followed by 12 years at Woodland Clinic Medical Group, which is now part of Dignity, and the last 25 years at North Bay Healthcare. I work in their Vacaville office. So if anyone's adding, that's about 40 years. You became a doctor when you were two. When I was two. Thank you for that. I saw lots of changes in technology. When I was starting off, CT was in its infancy. There were no MRIs, no ultrasounds, no echoes, no laparoscopic surgeries, no fiber optics. And each of those advances took time for the medical community to move forward and change patient outcome and patient experience. And one thing that we have to remember is that the cell phone has made huge changes in providing medical care. Cell phones came out about 25 years ago. And I remember that because all of a sudden when I was on call, I didn't need to stay home or find a pay phone to answer a page. It allowed us to go to Little League games and leave home when we were working nights and weekends accepting calls And then the smartphone Finally medicine is catching up to the smartphone The smartphone is enabling us to do these visits To give you an idea of my day, I'm a part-timer at this point. I have 18 20-minute appointments during the day, and two to four of those are reserved for virtual visits. So it's an important part of our practice. parity was very important because it allowed North Bay Health Care to invest in the time for staff, billing people, coding people, and for providers to be able to block their schedules and have these slots open for patients. We use it, my practice at this point is a lot of seniors, a lot of elder care. I don't do pediatrics anymore and can't really speak to the efficacy in pediatrics. But for people who have mobility issues, transportation issues, just don't feel well, it's been a wonderful, wonderful improvement. Also for people who are at work and don't need to take a half day off because they can get a medical visit in their 15 or 20-minute break time has been also a huge advantage. Also, I know there's another speaker who's going to talk about mental health. One-third of primary care visits deal with mental health issues, and it's invaluable in following up after medication changes or if people are at risk of harming themselves. You can do a very close follow-up over a period of time. Someone asked about the safety of these visits, and that's an important question. And if someone's clammy, their pulse is probably abnormal. And with technology today, patients are calling us with their blood pressure, their pulse, their pulse oximetry. They're telling us what their oxygen level is. Some people have these smart little devices, and it tells you if your heart isn't in a normal rhythm. So it's an amazing amount of information that we can now get from patients remotely and virtually. It's also very useful in what we call transitional care visits in Medicare. These are visits after people have been hospitalized. Usually occurs within 7 to 14 days to help prevent readmission. And it's a review of their medications, of their hospital experience, labs, x-rays. And we can do it in coordination with home health. So we can have home health nurses checking blood and urine samples and be able to give us vital signs and be with the patient sometimes when we're having that virtual visit. I thought I'd just talk about a few patients that come to mind over the last week or two to give you a picture of how useful it is. There was an 83-year-old woman that was having a lot of issues in being able to live independently. A son in Chicago, a daughter in San Diego. With a couple of presses of the button, the whole family was in on the appointment. 20 years ago, my parents were not doing well in New York City, and I can't tell you how many red eyes that I took to New York City to accompany them to doctor's appointments and being a part of their medical decision-making. I can't imagine how many dollars and hours could have been saved by using telehealth. We also had a patient a couple of weeks ago 55 years old had a terrible heart attack and the pump stopped pumping and he wound up in San Francisco with a heart transplant We were able to follow up. After his three-month hospitalization, we were able to do testing and imaging echocardiograms for him, send it back to CPMC in the city, and they set up a follow-up telehealth visit for him. So he's not in a car for three hours trying to get to San Francisco. Also recently, a 75-year-old woman with bad emphysema who was hospitalized for pneumonia, we were able to coordinate with home health and have her monitored in terms of oxygen levels and her treatments and her medication. So it's been really important for lots of people. And everyone has already said it reduces barriers in terms of cost, transportation, time, et cetera. We do use audio. We don't use it specifically for Medi-Cal. Medi-Cal in our practice is really a partnership health plan, which is an HMO. So it's different than straight or traditional Medi-Cal. We don't do it for new patients. All of the patients that we deal with in telehealth are established patients that we know. Someone asked about what happens, you know, is it safe? And that's an important question, as I said. And it's clinical judgment. You have to get a sense for who you're talking to and what's going on. And it's not unusual for a virtual visit to turn into a 911 call or a visit to the office today or tomorrow, not five weeks from now. So it also gives people access into the system more quickly. If you realize someone's having trouble and they're too sick for a virtual visit, you can't give them an appointment for next week. So those are all important things that people have brought up in looking at some of the problems. I do use audio only a lot for Medicare patients. People who are older than I am have a lot of trouble with technology. They may not have Internet. They may not have Wi-Fi. And they have trouble just pressing the correct buttons. But they're all really comfortable on the phone. And that works well for a large proportion of people. The people that can bring you into their house, I was concerned at the beginning of virtual visits that you'd lose sort of the human touch. And then I found that really it's just a different human touch because people are sitting in their recliner and they've got their kitten and they're in their pajamas and they feel quite comfortable in having a medical visit in their home, kind of a new modern home call or home visit that we used to do 100 years ago. The importance of having systems invest. There are very few of us in private practice, So when we talk about practitioners who may or may not benefit with parity, it's really – it's Kaiser, it's Sutter, it's North Bay. It's the big organizations that are controlling this. They control the schedules. They're the ones that put the slots in for virtual visits. So they have to feel that they're getting parity and paid for that. Their overhead doesn't go down. They've got the same overhead, essentially. But their incremental cost really doesn't go up with telehealth. We use a free platform called Doximity, and any providers can use it. It HIPAA protected Those videos aren saved anywhere in our EMR but they converted into a documentation note either by a scribe or you could even use an AI scribe or someone sitting and typing and creating a document based on that video It's not saved in our EMR in any way.

I'm sorry.

Well, thank you for your time.

Thank you.

Good afternoon. Angela Pontus with Planned Parenthood Affiliates of California, representing the seven Planned Parenthood affiliates across the state that provide comprehensive sexual and reproductive health care, gender affirming care and behavioral health services through over 100 community health centers. I want to begin by thanking the legislature for hosting this oversight hearing and for the continued leadership on policies that expand access to telehealth. When the COVID-19 pandemic began six years ago, the state took quick action to allow an expanded use of telehealth to minimize disruptions in care. Planned Parenthood moved quickly to implement secure telehealth appointments for sensitive services, such as birth control, STI treatment, pregnancy counseling, PEP and PrEP follow-up, and gender-affirming care. Thanks to the leadership of the legislature and the governor, these proven successful allowances were extended permanently after the pandemic so that today Planned Parenthood patients continue to have the choice to access crucial services via telehealth without having to worry about the additional time and resources necessary to travel to an in-person appointment. Regarding the purpose of today's hearing, AB 744 and AB 32 have helped to ensure that Californians can choose to see their providers, including a Planned Parenthood provider, via telehealth when clinically appropriate. These bills have led the nation in expanding access to care, first through payment parity. Community clinics often face reimbursement and funding challenges while disproportionately serving communities that are historically underrepresented and underserved. Telehealth payment parity authorized through AB 744 has been critical to ensuring that safety net providers like Planned Parenthood are able to serve their communities using multiple modalities for patients' access to care. Second, by establishing new patient relationships via telehealth. Planned Parenthood strongly believes that new patients should be able to access healthcare through telehealth. Not every healthcare encounter involves a patient seeing a clinician and then returning to that provider. this is particularly true for younger, healthier individuals. For example, in the context of sexual and reproductive health care services, patients may access service one time to obtain birth control or get testing and treatment for an STI. AB 32 established flexibilities that allow a patient to see a new provider via synchronous telehealth and also allowed a provider to offer audio-only synchronous telehealth when it is preferred by the patient and, again, clinically appropriate. For individuals with lower incomes, those who face transportation, child care, or other social barriers, an audio-only visit can make the difference between seeing a provider or delaying that needed care. This is particularly important for patients who need timely access to sexual and reproductive health care services, such as medication abortion, birth control, or emergency contraception, all of which can be safely offered via audio-only telehealth. A telehealth flexibility that is still limited is asynchronous telehealth, which allows for remote, non-real time communication between providers and patients. This can reduce wait times and facilitate faster access to patient-centered care. Studies have shown that rates of safety effectiveness and patient acceptability for asynchronous care compared to in-person care are about the same. Additionally, asynchronous care delivery can alleviate barriers like technological challenges, scheduling constraints, and privacy concerns. One survey of over 1,000 young adults revealed barriers to synchronous visits. Nearly one quarter said that it would be difficult to use phone or video visits for contraceptive services. Asynchronous telehealth can ensure access to care for these individuals and provide an additional point of entry for people that have previously avoided healthcare, whether that be due to anxiety or distrust with the healthcare system. Through our PP Direct services, Planned Parenthood affiliates proudly offer asynchronous telehealth. However, current policies in Medi-Cal prevent Planned Parenthood from providing care or establishing a new patient relationship through asynchronous telehealth to Medi-Cal and family packed patients. In close, many patients specifically choose to go to Planned Parenthood for sensitive services for reasons including their safety, comfort, and confidentiality. Planned Parenthood is uniquely situated to provide sexual and reproductive health services to its over 1 million annual Medi-Cal patients through both in-person and telehealth modalities, restricting how Medi-Cal and Family PACT patients access healthcare services, especially when those restrictions do not exist for commercial patients, only exacerbates healthcare disparities. In serving a patient population that is disproportionately low-income and historically underserved, Planned Parenthood strongly believes that access to and coverage of telehealth, including asynchronous telehealth is critical to address health inequities and improve access to healthcare services. Thank you. Thank you and we'll hear from our final panelist.

Thank you so much. Now we will move to any questions from our committee members. So I appreciate your comments on kind of the technology and how things are advancing. Maybe we're getting closer and closer to those Star Trek days where you just like get a body scan and you know all the things and figure it out and fix it really quick. And, you know, I think that there is there's a lot of important pieces around additional access and the cost like you're talking about of the out of pocket cost for travel. Right. And how that adds to the cost of care. Um and you know people time really is a barrier to access if they have to take off work um or miss school or you know other things that have to happen So so there a lot of ways I think that telehealth is kind of compounded to to make healthcare more accessible to folks even beyond, you know, being in rural communities or, you know, whatever the situation might be, especially for working class folks who are, you know, struggling to make ends meet. So, you know, I guess my question is for, you know, looking to the future and where we need to go from here, what are some of the areas in which we need to focus on to support a robust and healthy, you know, telehealth system and also finding that balance between the in-person care that's needed as well.

Majority leader. So I'll start with a question for the doctor. Good afternoon, sir. Just to be sure, fairly. Dr. Newman is a family friend of mine, and I used to sit and talk to him about all what he does for rural communities and how he did it and why he did it. I said, what would your wish list, what could I do for policy? and he said it would be nice to be able to have telehealth, that I can help patients. And that's when this all kind of began. So I want to thank you right now because it's changed what we're doing right here every single day and how we've changed people's lives.

Yeah, well, we've got to do it together. So can you just kind of walk us through when you know when it's time to call a patient and for an in-person visit and a timeline a patient faces for getting an in-person appointment.

Absolutely. For Planned Parenthood, Ms. Pontes, I hate to do that to you too. So AB32 expanded the access to the audio-only telehealth, but currently policy generally does not allow new patient relationships to be established through asynchronous care. From your perspective, but allowing patients to establish care through asynchronous visits help to improve access, particularly for our patients who there are barriers to access?

Thank you. And for my friend up in Shasta, thank you very much for traveling down here and to being part of the conversation. You know, what challenges remain using telehealth to expand behavioral health access, and what policy changes would you think would help address those challenges? I really think you're way out there, and your story was fabulous, but how else can we make that better?

Thank you for all three being here today.

Yeah, I'll just say that in medical training You're taught that 80% Of the information that you need to make a decision A medical decision Is from a patient's history So if you add in the vital signs That you can get with some of these devices You getting closer to 90 And really very little is added With a stethoscope in most situations So especially with other diagnostics that are used now So you get a lot of information

public comment. Good afternoon. Kelly Brooks on behalf of the California Association of Public Hospitals and Health Systems. Thank you so much for holding this hearing today, and a special thanks to Assemblymember Aguirre-Curry, who has long prioritized telehealth issues. California's 17 public hospital systems operate over 100 community clinics, serve 3.4 million patients a year, and provide more than a third of Medi-Cal in uninsured hospital care in the state. Public hospitals learned during the pandemic how powerful a tool telehealth has been to improve access and quality of care and the role it can play in reducing disparities of health care for California's most at-risk patients. AB 32 worked. Telehealth is not a pandemic workaround anymore. It is an essential element in how we deliver care, including primary and specialty care, chronic disease management, behavioral health care, and the support of care coordinators and social workers. Thank you again for the discussion today.

Good afternoon, Chair Bonta and members of the committee. My name is Lonnie Riley, Vice President of Industry Affairs at the American Telemedicine Association and ATA Action, the advocacy arm of ATA. I'm also an occupational therapist licensed in California. Thank you for the opportunity to speak today. California has built one of the nation's strongest telehealth frameworks, making virtual care a permanent part of healthcare delivery As a result patients have greater access to timely high care when and where they need it Now is the time to build on that success ATA Action encourages the legislature to focus on four priorities Closing remaining Medi-Cal telehealth gaps so patients can establish care using the telehealth modality that best meets their clinical needs, modernizing cross-state licensure to support continuity of care, removing barriers that prevent California licensed providers located out of state from participating in Medi-Cal, and creating a stable policy environment that supports continued innovation. Telehealth is essential to a modern patient-centered healthcare system. We look forward to working with the committee to ensure California remains a national leader in access, quality, and innovation.

Good afternoon, Chair Bonta and members. Jennifer Robles with Health Access California. We appreciate the hearing and the opportunity to discuss how telehealth access has evolved and its impact on consumers. We support expanded telehealth, especially for behavioral health and LGBT communities and situations where confidentiality and accessibility are critical. At the same time, we want to ensure that the focus is not only on telehealth access, but also balancing and maintaining timely access to in-person care for consumers.

I do.

First of all, I want to thank you, Chair Bonta, for putting together in your committee. Thank you very much. We really appreciate it. I want to thank Speaker Rivas for creating the outcomes review process, giving the legislature an important opportunity to evaluate and impact our laws. after they are enacted. And I want to thank our panelists for sharing their experiences, for helping us better understand the impact of these policies. I get choked up because we have changed what people are doing and how health care has changed. And I look across this room that we've all touched and done something with telehealth and how it has changed so many people's lives, particularly in the rural communities, but also, as you were saying, even in your communities, how it's changed and all the things they've all been through to be able to pick up the phone or do it by virtually. Our discussion today showed that telehealth has become an important part of our health care system, especially for rural communities, older adults and patients who face barriers. I'm proud of the work you've done. You've done a great job. I really appreciate all the support that you done Chair when we were trying to work with telehealth And we had lengthy discussions to make sure that we didn forget anybody and I think we will continue to have some gaps that we need to fix in the future And thank you very much, Assembly members. I appreciate you being here.

This made me nervous. Keep going, lady. Keep going.