BILL ANALYSIS Ó
AB 137
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Date of Hearing: May 3, 2011
ASSEMBLY COMMITTEE ON HEALTH
William W. Monning, Chair
AB 137 (Portantino) - As Introduced: January 12, 2011
SUBJECT : Health care coverage: mammographies.
SUMMARY : Requires health care service plan (health plan)
contracts and health insurance policies that are issued,
amended, delivered, or renewed, on or after July 1, 2012, to
provide coverage for mammography for screening or diagnostic
purposes upon referral by a health care professional, based on
medical need, regardless of age. Specifically, this bill :
1)Requires health plan contracts and health insurance policies
that are issued, amended, delivered, or renewed to provide
coverage for mammography for screening or diagnostic purposes
upon referral of certain health care professionals, regardless
of age.
2)Exempts specialized health insurance, Medicare supplement
insurance, short-term limited duration health insurance,
CHAMPUS supplement insurance, TRI-CARE supplement insurance,
or to hospital indemnity, accident-only, or specified disease
insurance.
3)Authorizes practicing physician assistants providing care to
the patient and operating within the scope of practice
provided under existing law to refer patients to mammography
services.
4)Requires health plans and health insurers, on or after July 1,
2012 to provide subscribers and policyholders with information
regarding recommended timelines for breast cancer screening or
diagnosis through written letter, publication in a newsletter,
publication in evidence of coverage, direct telephone call,
electronic transmission, web-based portal containing various
plan and benefit information (if the enrollee or insured has
access to that portal), or by any other means that will
reasonably notify the enrollee or insured of recommended
timelines for testing.
EXISTING FEDERAL LAW :
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1)Enacts, in federal law, the Patient Protection and Affordable
Care Act (PPACA) to, among other things, make statutory
changes affecting the regulation of, and payment for, certain
types of private health insurance. Includes the definition of
essential health benefits (EHBs) that all qualified health
plans must cover, at a minimum, with some exceptions.
2)Provides that the essential health benefits EHBs package in 1)
above will be determined by the federal Department of Health
and Human Services (HHS) Secretary and must include, at a
minimum: ambulatory patient services; emergency services;
hospitalizations; mental health and substance abuse disorder
services, including behavioral health; prescription drugs;
and, rehabilitative and habilitative services and devices,
among other things.
EXISTING STATE LAW :
1)Establishes the Knox-Keene Health Care Service Plan Act of
1975 (Knox-Keene) to regulate and license health plans and
specialized health plans by the Department of Managed Health
Care and provides for the regulation of health insurers by the
California Department of Insurance.
2)Requires health plans to cover mammography for screening or
diagnostic purposes upon the referral of the patient's
physician, nurse practitioner, or certified nurse-midwife.
1)Requires health insurance policies to provide coverage for a
baseline mammogram for women age 35-39, inclusive; a mammogram
for women age 40-49, inclusive, every two years or more,
depending on a physician's recommendation; and, a mammogram
every year for women age 50 and over; for breast cancer
screening or diagnostic purposes.
FISCAL EFFECT : This bill has not yet been analyzed by a fiscal
committee.
COMMENTS :
1)PURPOSE OF THIS BILL . According to the author, this bill is
needed to remove the age based utilization of mammograms
contained in the Insurance Code. The author believes that a
woman's decision to have a mammogram should be based upon the
specific risks of the woman and in consultation with her
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physician, rather than dictated by statute based on her age.
The author points out that, scientific studies have determined
that for many high risk women, their risk of developing breast
cancer is not just age related. The author argues that they
can and often do, develop cancer at an earlier age than the
general population. The author adds that the requirement in
this bill that will have insurance companies provide
information to women on when to begin screening for breast
cancer will increase the number of women receiving mammograms,
save lives, and reduce treatment costs.
2)PREVALENCE OF BREAST CANCER . According to the American Cancer
Society's "Breast Cancer Facts & Figures 2009-2010," excluding
cancers of the skin, breast cancer is the most common cancer
among women; accounting for more than one in four cancers
diagnosed in U.S. women. It is the second leading cause of
death of women in California. According to the California
Breast Cancer Research Program, the breast cancer death rate
in California has dropped 20% since 1973 but California women
are more likely to get breast cancer today than in 1973.
While the death rate for breast cancer has dropped, the gains
have not been shared equally among all women. Minority and
low-income women are less likely than other women to be
diagnosed at early stage, receive effective treatment, and
survive the disease. The California Health Benefits Review
Program (CHBRP) reports that white women are most likely to
get the disease, followed closely by African American women,
Asian Pacific Islander women, and Hispanic women. African
American women have the highest death rate despite being less
likely than white women to get the disease.
3)NATIONAL GUIDELINES . Several organizations have adopted
evidence-based national recommendations for breast cancer
screening including the U.S. Preventive Services Task Force
(USPSTF), convened by HHS, the American Cancer Society, the
American College of Radiology, the American College of
Obstetrician-Gynecologists, and the American College of
Physicians. Generally these guidelines recommend that
mammography be performed every one to two years beginning at
age 40; or 50 for those women of average risk for breast
cancer. By and large, routine baseline mammograms in women
younger than 40 years are not recommended.
In November 2009, USPSTF issued new screening guidelines that
recommend against routine screening mammography in women ages
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40 to 49. The guidelines instead recommend screening every
other year for women ages 50 to 74. The recommendations state
that the decision to start regular, biennial screening
mammography before the age of 50 years should be an individual
one and take patient context into account, including the
patient's values regarding specific benefits and harms.
4)FEDERAL ESSENTIAL HEALTH BENEFITS . On March 30, 2010,
President Obama signed into law PPACA, which requires
qualified health plans to cover specified categories of EHBs,
including maternity services, by 2014. The HHS is tasked with
defining these benefit categories through regulation so that
they mirror those benefits offered by a "typical" employer
plan. Qualified plans are required to cover EHBs by 2014.
Federal guidance with respect to EHBs is expected later this
year and in 2012.
In a January 2011 issue brief by CHBRP focusing on the federal
requirement to cover EHBs, CHBRP notes that there is
considerable legal ambiguity over how state mandates requiring
the coverage of the treatment for a specific condition or
disease will interact with federal law. CHBRP states that
these mandates often extend across multiple benefit
categories. CHBRP cites, as an example, California's mandate
to cover breast cancer treatment, which implicitly requires
coverage for screening and testing, medically necessary
physician services, ambulatory services, prescription drugs,
hospitalization, and surgery. CHBRP writes that it is unclear
how California benefit mandates that overlap across several
EHB categories would be evaluated in relation to the EHB
package.
5)CHBRP REPORT . Pursuant to AB 1996 (Thomson), Chapter 795,
Statutes of 2002, and SB 1704 (Kuehl), Chapter 684, Statutes
of 2006, which ask the University of California to assess
legislation proposing a mandated benefit or service, or the
repeal of a mandated benefit or service, CHBRP provides an
analysis of the relevant public health, medical, and economic
impacts. CHBRP's analysis report of this bill stated the
following:
a) Medical Effectiveness . A preponderance of evidence
shows that mammography screening is medically effective for
women ages 40-49 years after 10-14 years of follow-up but
the reduction in breast cancer mortality as a result of
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screening is lower than for women who are 50 and older, and
false-positive rates are higher for women under the age of
50. For women ages 50 and older, evidence shows that the
mortality benefit is achieved after seven to nine years of
initiating screening. CHBRP concluded that false-positive
results are more likely in women under the age of 50 due to
overall lower disease prevalence and the problems of
analyzing mammography results because of the denser breast
tissue of younger women. CHBRP also found that there is a
preponderance of evidence that for women for whom national
guidelines recommend mammography screening, notification
through written notices or telephone calls increases the
percentage of eligible women screened.
b) Utilization, Cost, and Coverage Impacts . Approximately
21.9 million individuals in California are enrolled in
health plans or policies that would be subject to this
mandate. CHBRP's coverage survey of health plans and
insurers in California indicated that an estimated 100% of
health plans and insurers cover mammography as a routine
screening test when referred by a provider. CHBRP reports
that all plans and insurers are compliant with some form of
notification. Publicly funded plans such as the California
Public Employees' Retirement System, Medi-Cal Managed Care
Plans, Healthy Families Program, Access for Infants and
Mothers, and Major Risk Medical Insurance Program have
mammography coverage compliant with this bill.
CHBRP estimated that the cost of a single mammogram is about
$190, which includes the follow-up costs, other noninvasive
procedures, and office visits due to false-positive
results. CHBRP reports that AB 137 is not expected to
affect the per-unit cost of mammography or of notification
regarding timelines for breast cancer screening because an
estimated 100% of enrollees have mammography coverage and
receive notification in compliance with this bill.
Considering the diversity of notification and the
confounding effects associated to them, CHBRP determined
that it is not possible to estimate its per-unit cost.
c) Public Health Impact . In California, 84.6% of women
aged 40-64 years with health insurance had a mammogram
within the last 2 years. There is evidence that
mammography can reduce mortality from breast cancer;
however, CHBRP found that no public health impact is
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projected due to the implementation of this bill.
According to CHBRP, 99.3% of breast cancer cases occur
among women. There are approximately 4, 200 deaths each
year in California due to breast cancer, a rate of 21.4
deaths per 100,000 women. According to CHBRP, it is
estimated that for each life lost prematurely to breast
cancer, there is a loss of 22.9 life-years and a cost of
lost productivity of $272,000. Although breast cancer is
related to economic loss, CHBRP found that this bill is not
estimated to change the utilization of mammography or
result in a corresponding reduction in economic loss.
Racial and ethnic disparities exist, not only in breast
cancer prevalence, but also in early diagnosis and
mortality rates as well. The research on mammography
utilization by race/ethnicity, according to CHBRP, suggests
that some of the differences in health outcomes among
non-white women can be explained by their lower rates of
mammography utilization.
6)RELATED LEGISLATION . SB 173 (Simitian) requires, under
specified circumstances, health plan contracts and health
insurance policies to include additional benefits for
comprehensive breast cancer screening. Requires a health care
practitioner who performs a mammography exam to include
specified information on breast density in the mammography
report. SB 173 is scheduled to be heard by the Senate Health
Committee.
7)PRIOR LEGISLATION .
a) AB 113 (Portantino) of 2010 was identical to this bill.
Governor Schwarzenegger vetoed AB 113, stating, in part,
that it was unnecessary and had no practical impact on the
current state of health coverage in California.
b) AB 56 (Portantino) of 2009 contained provisions
substantially similar to those contained in this bill.
Governor Schwarzenegger vetoed AB 56, stating, in part,
"California has over 40 mandates on its health care service
plans and health insurance policies. While these mandates
are well-intentioned, the costs associated with the
cumulative effect of these mandates mean that these costs
are passed through to the purchaser and consumer."
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c) AB 2234 (Portantino) of 2008 would have required health
plans and health insurers to provide coverage for tests
necessary for screening or diagnoses of breast conditions,
in accordance with national guidelines, upon referral of a
specified health care provider and required health plans
and health insurers to notify female enrollees or
policyholders in writing of their eligibility for testing.
AB 2234 was held in the Assembly Appropriations Committee.
8)SUPPORT . The American Congress of Obstetricians and
Gynecologists (ACOG) write in support that this bill would
correct an inconsistency in the Insurance Code relative to
mammography coverage. ACOG maintains that it rectifies this
discrepancy by mirroring the language for mammography coverage
in Knox-Keene. Knox Keene regulations on HMOs, according to
ACOG, provides for mammography upon referral by a physician
subject to medical necessity standards and practice guidelines
instead of referencing explicit medical guidelines which were
current when codified but are now outdated and inaccurate.
The California National Organization for Women asserts that
while, age is one factor in determining the need for breast
cancer screening through mammography, it is not the only one,
or even the most important. Women, who are at elevated risk
for breast cancer due to family history, or membership in a
demographic group with increased risk for aggressive breast
cancer, may require earlier testing than age alone would
indicate. Planned Parenthood and its affiliates all write in
support that women should receive the services recommended by
their medical professionals and that this bill will greatly
improve access to appropriate medical care for women. The
California Academy of Physician Assistants (CAPA) writes that
physician assistants are allowed under existing law to perform
medical services in all modes of practice and medical
specialty when rendered under the supervision of a physician.
According to CAPA, this bill rightfully requires health plans
and health insurers to provide coverage for mammography
screening upon referral of a physician assistant.
9)OPPOSITION . The America's Health Insurance Plans (AHIP)
writes in opposition that health insurance plans have taken
important steps over the last decade to address the critical
issues of increasing access to innovative, quality health care
products and sot control mechanisms that would better allow
individuals and small business to obtain coverage in the
private market. AHIP argues that the 18 different health
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insurance mandates placed before the California Legislature
during the 2011 session threaten efforts to provide consumers
with meaningful health care choices and affordable coverage
options.
10)POLICY COMMENTS . This bill is one of several health mandates
introduced for legislative consideration this year. The
author may wish to address the extent to which the need for
this bill and others similar to it is premature, given that
federal regulations to define the parameters of the EHB
package have yet to be promulgated.
REGISTERED SUPPORT / OPPOSITION :
Support
American Congress of Obstetricians and Gynecologists
Association of Northern California Oncologists
California Academy of Physician Assistants
California Medical Association
California National Organization for Women
California Nurse Midwives Association
Medical Oncology Association of Southern California, Inc.
Planned Parenthood Affiliates of California
Planned Parenthood Mar Monte
Planned Parenthood Pasadena & San Gabriel Valley
Six Rivers Planned Parenthood
Opposition
America's Health Insurance Plans
Analysis Prepared by : Tanya Robinson-Taylor / HEALTH / (916)
319-2097