5023.2
. (a) In order to promote the best possible patient outcomes,
eliminate unnecessary medical and pharmacy costs, and ensure
consistency in the delivery of health care services, the department
shall maintain a statewide utilization management program that shall
include, but not be limited to, all of the following:
(1) Objective, evidence-based medical necessity criteria and
utilization guidelines.
(2) The review, approval, and oversight of referrals to specialty
medical services.
(3) The management and oversight of community hospital bed usage
and supervision of health care bed availability.
(4) Case management processes for high medical risk and high
medical cost patients.
(5) A preferred provider organization (PPO) and related contract
initiatives that improve the coverage, resource allocation, and
quality of contract medical providers and facilities.
(b) The department shall develop and implement policies and
procedures to ensure that all adult prisons employ the same statewide
utilization management program established pursuant to subdivision
(a) that supports the department's goals for cost-effective auditable
patient outcomes, access to care, an effective and accessible
specialty network, and prompt access to hospital and infirmary
resources. The department shall provide a copy of these policies and
procedures, by July 1, 2011, to the Joint Legislative Budget
Committee, the Senate Committee on Appropriations, the Senate
Committee on Budget and Fiscal Review, the Senate Committee on
Health, the Senate Committee on Public Safety, the Assembly Committee
on Appropriations, the Assembly Committee on Budget, the Assembly
Committee on Health, and the Assembly Committee on Public Safety.
(c) (1) The department shall establish annual quantitative
utilization management performance objectives to promote greater
consistency in the delivery of contract health care services, enhance
health care quality outcomes, and reduce unnecessary referrals to
contract medical services. On July 1, 2011, the department shall
report the specific quantitative utilization management performance
objectives it intends to accomplish statewide in each adult prison
during the next 12 months to the Joint Legislative Budget Committee,
the Senate Committee on Appropriations, the Senate Committee on
Budget and Fiscal Review, the Senate Committee on Health, the Senate
Committee on Public Safety, the Assembly Committee on Appropriations,
the Assembly Committee on Budget, the Assembly Committee on Health,
and the Assembly Committee on Public Safety.
(2) The requirement for submitting a report imposed under this
subdivision is inoperative on January 1, 2015, pursuant to Section
10231.5 of the Government Code.
(d) On March 1, 2012, and each March 1 thereafter, the department
shall report all of the following to the Joint Legislative Budget
Committee, the Senate Committee on Appropriations, the Senate
Committee on Budget and Fiscal Review, the Senate Committee on
Health, the Senate Committee on Public Safety, the Assembly Committee
on Appropriations, the Assembly Committee on Budget, the Assembly
Committee on Health, and the Assembly Committee on Public Safety:
(1) The extent to which the department achieved the statewide
quantitative utilization management performance objectives set forth
in the report issued the previous March as well as the most
significant reasons for achieving or not achieving those performance
objectives.
(2) A list of adult prisons that achieved and a list of adult
prisons that did not achieve their quantitative utilization
management performance objectives and the significant reasons for the
success or failure in achieving those performance objectives at each
adult state prison.
(3) The specific quantitative utilization management performance
objectives the department and each adult state prison intends to
accomplish in the next 12 months.
(4) A description of planned and implemented initiatives necessary
to accomplish the next 12 months' quantitative utilization
management performance objectives statewide and for each adult state
prison. The department shall describe initiatives that were
considered and rejected and the reasons for their rejection.
(5) The costs for inmate health care for the previous fiscal year,
both statewide and at each adult state prison, and a comparison of
costs from the fiscal year prior to the fiscal year being reported
both statewide and at each adult state prison.
(e) It is the intent of the Legislature that any activities the
department undertakes to implement the provisions of this section
shall result in no year-over-year net increase in state costs.
(f) The following definitions shall apply to this section:
(1) "Contract medical costs" mean costs associated with an
approved contractual agreement for the purposes of providing direct
and indirect specialty medical care services.
(2) "Specialty care" means medical services not delivered by
primary care providers.
(3) "Utilization management program" means a strategy designed to
ensure that health care expenditures are restricted to those that are
needed and appropriate by reviewing patient-inmate medical records
through the application of defined criteria or expert opinion, or
both. Utilization management assesses the efficiency of the health
care process and the appropriateness of decisionmaking in relation to
the site of care, its frequency, and its duration through
prospective, concurrent, and retrospective utilization reviews.
(4) "Community hospital" means an institution located within a
city, county, or city and county which is licensed under all
applicable state and local laws and regulations to provide diagnostic
and therapeutic services for the medical diagnosis, treatment, and
care of injured, disabled, or sick persons in need of acute inpatient
medical, psychiatric, or psychological care.
(g) The requirement for submitting a report imposed under
subdivision (d) is inoperative on March 1, 2016, pursuant to Section
10231.5 of the Government Code.