Submitted by: Fred Medrano, Director, Department of Health Services

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1 Office of the City Manager ACTION CALENDAR November 17, 2009 To: From: Honorable Mayor and Members of the City Council Phil Kamlarz, City Manager Submitted by: Fred Medrano, Director, Department of Health Services Subject: Fees Public Health Clinic Laboratory Services RECOMMENDATION Conduct a Public Hearing and, upon conclusion, adopt a Resolution establishing fees for two laboratory tests, effective December 1, 2009, and amending Resolution No. 64,197 N.S. FISCAL IMPACTS OF RECOMMENDATION Estimated revenue for the balance of FY 2010 (12/1/09 through 6/30/10) from the proposed fee increase and Family Planning, Access, Care and Treatment Program ( FPACT ) billing is $56,000. On an annual basis, beginning in FY 2011, estimated revenue is $96,000. The revenues collected will be deposited into Fund 055 Health (General) Fund and program costs will be expensed from the same fund. The implementation of new fees for these two laboratory tests will provide both program and fiscal stability to enable the City of Berkeley to maintain its HIV testing and counseling at the Public Health Clinic ( PHC ). In order to be in compliance with Medi-Cal and FPACT standards, the PHC must charge the same base rates to all payers, including other insurance companies and self-pay patients. By performing rapid HIV and rapid syphilis ( RPR ) tests internally, and charging Medi-Cal, the FPACT and self-pay patients for these tests and counseling visits, the PHC will generate approximately the following amounts per patient visit detailed in Table 1 and 2 below. Table 1 illustrates fees and revenues anticipated from both Medi-Cal FPACT, the cost or expenditure of each test and the projected revenue being assumed. Table 2 illustrates the Federal Poverty Level (FPL) at 250%, which is the maximum to be billed, the cost or expenditure of each test, and the projected revenue of each test. From the tables, there is total projected revenue per visit of $39.13 for Medi-Cal and FPACT beneficiaries and for those qualifying for the FPL at 250% there is total projected revenue per visit of $43.13

2 Fees Public Health Clinic Laboratory Services ACTION CALENDAR November 17, 2009 Table 1: Medi-Cal and FPACT Fees, Expenses and Projected Revenue: Potential Medi-Cal or FPACT Reimbursement per Visit: CPT Code(s): Medi-Cal Fee: FPACT Fee Cost / Expense: Projected Revenue: HIV test (rapid) $3.40 RPR Syphilis test (rapid) $3.94 Counseling visit ( mins) Z $31.79 TOTAL/VISIT: $39.13 Table 2: Federal Poverty Level (FPL) at 250% Fees, Expenses and Projected Revenue: Maximum Potential Self-Pay Reimbursement per Visit: CPT Code(s): FPL at 250% Fee Cost / Expense: Projected Revenue: HIV test (rapid) $5.75 RPR Syphilis test (rapid) $4.38 Counseling visit (30 mins) Z $33.00 TOTAL/VISIT: $43.13 Public Health estimates 2,000 visits annually. Based on a review of the current patient population, it is estimated that at least half of the patients would qualify for FPACT or MediCal. Therefore, anticipated FY 2010 revenues are estimated at $56,000 (including FPACT, Medi-Cal and self-pay), which will partly make up for the PHC s July 1, 2009 loss of State Office of AIDS ( OA ) funding. These revenues will allow continued HIV testing and counseling services in the City of Berkeley, particularly to the highest risk patients. Approval of the recommended proposed fee schedule will enable the PHC to continue providing high-quality and accessible public health services to the Berkeley community, including uninsured and self-pay patients, and to maintain a sustainable but limited reliance on the City s General Fund. CURRENT SITUATION AND ITS EFFECTS The laboratory tests subject to the proposed fee increase are the following: Rapid HIV I/II (CPT4 code 86703) and Rapid RPR syphilis (CPT4 code 86592). Through a multi-year master grant agreement, HIV testing and counseling services were previously funded by the State Office of AIDS (OA). Funding included support for the HIV I/II Rapid tests. As of July 1, 2009, OA eliminated all funding for HIV testing and counseling services provided by COB including services at the PHC. In response to this significant loss of funding, the clinic-based stand-alone HIV testing and counseling services will be moved into existing family planning and sexually

3 Fees Public Health Clinic Laboratory Services ACTION CALENDAR November 17, 2009 transmitted infection clinics at the PHC. Medi-Cal and Family PACT (FPACT) will be billed for services provided to enrolled patients. Self-pay patients will be charged a fee for HIV counseling and testing. Patients who qualify for Medi-Cal or FPACT do not pay any fees for PHC medical services that are reimbursable by MediCal or FPACT. The largest payers for PHC services are Medi-Cal and FPACT. The majority of PHC patients qualify for FPACT coverage, based on federal poverty level (FPL) guidelines (family size and income). Again, in order to be in compliance with Medi-Cal and FPACT standards, the PHC must charge the same base rates to all payers, including other insurance companies and selfpay patients. RATIONALE FOR RECOMMENDATION The proposed fee schedule change will directly affect only self-pay (private pay) patients. Self-pay patients receive a discount on all clinic fees. Self-payment for most clinic services is on a sliding fee scale based on FPL guidelines (family size and income). No one is denied services due to the inability to pay. Please refer to Appendix A for current and proposed fees for these laboratory tests. As of July 1, 2009, the City of Berkeley PHC is no longer reimbursed by OA to perform HIV testing and counseling. Therefore, so as not to interrupt HIV testing services, particularly for high-risk individuals, there is a need to purchase and perform Rapid HIV tests, bill FPACT, Medi-Cal and self-pay patients and submit grant proposals to meet expenditures and to build the Program. Patients typically wait 20 minutes for the rapid test results; therefore, if there is a conditional positive result, an immediate venipuncture can be performed and a sample sent for confirmatory testing to the off-site reference laboratory, while also counseling the patient and making an appointment for follow-up. The provision of Rapid HIV testing provides for greater opportunities for immediate follow-up with patients. Conventional HIV testing adds to the length of patient follow-up time and in our experience, some patients do not return for their results; therefore, rapid testing means we will not lose these patients to follow-up. The Rapid RPR (syphilis) test is a relatively new technology that we can now perform in our own laboratory. Historically, our RPR testing has been performed by the reference laboratory. We propose to purchase and perform the tests internally, and bill FPACT, Medi-Cal and self-pay patients. We propose introducing the Rapid RPR at the same time as the Rapid HIV test, since many of the patients who are considered high risk for HIV are also at high risk for syphilis. Also, if there is a positive RPR result from a rapid test, we can initiate treatment immediately, and not risk losing the patient to follow-up. ALTERNATIVE ACTIONS CONSIDERED An alternative action that was considered is not to add fees for these laboratory tests at this time. However, this would mean that the PHC would lose a significant amount of financial support during the current fiscal year, hampering our efforts to continue

4 Fees Public Health Clinic Laboratory Services ACTION CALENDAR November 17, 2009 providing HIV services to high risk patients. In response to fiscal challenges, this plan maintains core HIV program activities. Key components of this plan are: (1) billing Medi-Cal and FPACT; (2) charging fees to self-pay patients; and (3) submitting grant proposals to public and private funding institutions. Additionally, effective November 1, 2009 PHC was awarded $75,000 in new funding from the Alameda County Office of AIDS Administration. CONTACT PERSON Barbara Raboy, Director, Public Health Clinic, Philippa Barron, Health Services Program Specialist, Attachments: 1. Appendix A: Current & Proposed Charges--PHC Internal Labs 2. Resolution 3. Public Hearing Notice

5 Attachment 1 Appendix A: Current and Proposed Laboratory Fees Current & Proposed Charges PHC Internal Labs PHC Internal Labs Current Proposed Urine pregnancy test Hemoglobin ZS Urine dip stick ZS 6 6 Wet mount Q0111 ZS RPR -- Rapid n.a.** 5 HIV I/II -- Rapid * 15 Collect & handle venipuncture blood specimen Current & Proposed Charges PHC External Labs PHC External Labs Current Proposed CT/GC DNA 87491; CT, DNA GC, DNA CT/GC culture 87110; CT culture GC culture Herpes culture HSV types 1&2 Reflex for pos HSV RPR (+ blood draw charge) TPPA (reflex) for positive RPR** Pap, thin layer High Risk HPV HIV I/II (+ blood draw charge) * Urine culture Misc. culture, ex. GC throat; rectal GC gen probe CT gen probe Glucose (fasting) Lipid profile HTLV I/II, Western Blot HIV I/II W Blot, ImmunoBlot (x2) *The PHC does not charge for HIV testing currently; OA reimbursed testing costs until 6/30/09. **The PHC does not currently perform rapid RPR tests.

6 RESOLUTION NO. --N.S. ESTABLISHING FY 2009 FEES FOR PUBLIC HEALTH CLINIC LABORATORY SERVICES EFFECTIVE DECEMBER 1, 2009 AND AMENDING RESOLUTION NO. 64,197 N.S. WHEREAS, fee increases and adjustments were approved by City Council on September 16, 2008 and implemented on November 4, 2008 to ensure that the Public Health Clinic (PHC) could continue to offer immunization, tuberculosis testing and reproductive and sexual health services to the Berkeley community consistent with its mission since 1908; and WHEREAS, HIV testing and counseling services were previously funded by the State Office of AIDS (OA); and WHEREAS, as of July 1, 2009, OA eliminated all funding for HIV testing and counseling services provided by COB including services at the PHC; and WHEREAS, many of the patients who are considered high risk for HIV are also at high risk for syphilis; and WHEREAS, the provision of Rapid HIV testing provides for greater opportunities for immediate follow-up with patients than does conventional HIV testing; and WHEREAS, if there is a positive syphilis result from a Rapid RPR test, we can initiate treatment immediately, and not risk losing the patient to follow-up; and WHEREAS, Medi-Cal and the Family Planning, Access, Care and Treatment Program Family Program will pay for laboratory services such as HIV and RPR (syphilis) rapid testing and counseling provided to enrolled patients; and WHEREAS, the proposed fees will allow the City of Berkeley s PHC to continue to meet all Federal, State and County health, safety and regulatory requirements, while providing continued community access to high-quality, comprehensive and confidential reproductive and sexual health related services, including laboratory services. NOW THEREFORE, BE IT RESOLVED by the Council of the City of Berkeley that the following fees, detailed in the Tables 1 and 2 below, for FY 2010 are hereby fixed and established, effective December 1, 2009, for clinical laboratory services offered by the PHC of the City s Department of Health Services:

7 Table 1 Current & Proposed Charges PHC Internal Labs PHC Internal Labs Current Proposed Urine pregnancy test Hemoglobin ZS Urine dip stick ZS 6 6 Wet mount Q0111 ZS RPR -- Rapid n.a.** 5 HIV I/II -- Rapid * 15 Collect & handle venipuncture blood specimen Table 2 Current & Proposed Charges PHC External Labs PHC External Labs Current Proposed CT/GC DNA 87491; CT, DNA GC, DNA CT/GC culture 87110; CT culture GC culture Herpes culture HSV types 1&2 Reflex for pos HSV RPR (+ blood draw charge) TPPA (reflex) for positive RPR** Pap, thin layer High Risk HPV HIV I/II (+ blood draw charge) * Urine culture Misc. culture, ex. GC throat; rectal GC gen probe CT gen probe Glucose (fasting) Lipid profile HTLV I/II, Western Blot HIV I/II W Blot, ImmunoBlot (x2) *The PHC does not charge for HIV testing currently; OA reimbursed testing costs until 6/30/09. **The PHC does not currently perform rapid RPR tests.

8 NOTICE OF PUBLIC HEARING BERKELEY CITY COUNCIL PUBLIC HEALTH CLINIC LABORATORY TEST FEES Notice is hereby given by the City Council of the City of Berkeley that a public hearing will be conducted by said city council of the City of Berkeley at which time and place all persons may attend and be heard upon the following: The Department of Health Services proposes to add fees at the Public Health Clinic (PHC) for the provision of specified laboratory services, effective December 1, The Department of Health Services operates the PHC at 830 University Avenue. The PHC has offered free and low cost public health services since The PHC, according to MediCal guidelines, must charge the same rate for the same service to all payers. Self payment for services is on a sliding fee scale, which is based on federal poverty level guidelines. No one is denied services due to inability to pay. Current & Proposed Charges PHC Internal Labs Current Proposed PHC Internal Labs RPR -- Rapid n.a.** 5 HIV I/II -- Rapid * 15 Current & Proposed Charges PHC External Labs Current Proposed PHC External Labs RPR (+ blood draw charge) HIV I/II (+ blood draw charge) * *The PHC does not charge for HIV testing currently; OA reimbursed testing costs until 6/30/09. **The PHC does not currently perform rapid RPR tests. The PHC proposes to add fees for Rapid HIV and Rapid RPR (syphilis) tests, in order to continue to test patients for HIV and related diseases such as syphilis, in the absence of State Office of AIDS funding, which until July 1, 2009, paid for HIV testing and counseling at Department of Health Services locations, including the PHC. The PHC will bill MediCal, Family PACT and self-pay patients for Rapid HIV and Rapid RPR tests. The hearing will be held on November 17, 2009, at 7:00 p.m. in the City Council Chambers, 2134 Martin Luther King, Jr. Way. For further information, please contact Philippa Barron at A copy of the agenda material for this hearing will be available on the City s website at as of November 12, Milvia Street, Berkeley, CA Tel: TDD: Fax: manager@ci.berkeley.ca.us Website:

9 Written comments should be mailed or delivered directly to the City Clerk, 2180 Milvia Street, Berkeley, CA 94704, in order to ensure delivery to all Councilmembers and inclusion in the agenda packet. Comments received no later than Monday, November 9, 2009 will be included in Council agenda packets. Comments received thereafter will be submitted to Council as supplemental communications at the meeting. For further information, call Deanna Despain, CMC. City Clerk, FAX: (510) TDD: (510) If you challenge the above in court, you may be limited to raising only those issues you or someone else raised at the public hearing described in this notice, or in written correspondence delivered to the City of Berkeley at, or prior to, the public hearing. Background information concerning this proposal will be available at the City Clerk Department and posted on the City of Berkeley webpage at least 10 days prior to the public hearing. Published: November 6, 2009 and November 13, 2009 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 6

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