BILL ANALYSIS Ó
SB 255
Page 1
Date of Hearing: June 19, 2012
ASSEMBLY COMMITTEE ON HEALTH
William W. Monning, Chair
SB 255 (Pavley) - As Amended: April 25, 2011
SENATE VOTE : 27-6
SUBJECT : Health care coverage: breast cancer.
SUMMARY : Revises the definition of mastectomy, for purposes of
insurance coverage of mastectomy procedures, to specify that the
"partial removal of a breast" includes lumpectomy, which
consists of surgical removal of a tumor with clear margins.
Allows the length of a hospital stay associated with mastectomy
procedures to be determined postsurgery, consistent with sound
clinical principles and processes.
EXISTING FEDERAL LAW :
1)Defines, under the Patient Protection and Affordable Care Act
(ACA) (Public Law 111-148), as amended by the Health Care
Education and Reconciliation Act of 2010 (Public Law 111-152),
a list of essential health benefits (EHBs) which health care
service plans (health plans) and individual or group health
insurers (insurers) must provide beginning in 2014.
2)Provides protections to patients who choose to have breast
reconstruction in connection with a mastectomy under the
Women's Health and Cancer Rights Act of 1998. Requires health
plans and insurers that provide mastectomy coverage benefits
to cover reconstruction of the breast removal, surgery and
reconstruction of the other breast to achieve symmetry, any
external breast prostheses needed before or during the
reconstruction; and, any physical complications at all stages
of mastectomy, including lymphedema.
EXISTING STATE LAW :
1)Provides for the regulation of health plans by the Department
of Managed Health Care (DMHC) and insurers by the California
Department of Insurance (CDI).
2)Requires every health plan contract and health insurance
policy to provide coverage for screening, diagnosis of, and
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treatment for breast cancer, including coverage for prosthetic
devices or reconstructive surgery to restore and achieve
symmetry for the patient incidental to a mastectomy.
3)Requires every health plan and health insurance policy that
provides coverage for mastectomies and lymph node dissections
to allow the length of stay to be determined by the attending
physician and surgeon in consultation with the patient, cover
prosthetic devices or reconstructive surgery; and, cover all
complications from a mastectomy, as specified. Prohibits a
health plan or insurer from requiring a treating physician and
surgeon to receive prior approval in determining length of
hospital stay following those procedures.
4)Defines mastectomy as the removal of all or part of the breast
for medically necessary reasons, as determined by a licensed
physician and surgeon.
FISCAL EFFECT : According to the Senate Appropriations
Committee, pursuant to senate Rule 28.8, negligible state costs.
COMMENTS :
1)PURPOSE OF THIS BILL . According to the author, this bill
updates medical terminology and clarifies that the original
hospital safeguards placed in law 14 years ago apply to both
mastectomies and lumpectomies. The author maintains that the
law was intended to cover both types of surgeries by using the
definition "removal of all or part of the breast" and this
bill simply updates the law with the medical name for removing
"part of the breast" with lumpectomy. The author asserts that
current law provides that patients who undergo mastectomies
and lymph node dissections, are entitled to a hospital stay
determined by the physician and patient. Patients are also
entitled to coverage for prosthetics, reconstruction, and
surgery to address complications, if medically necessary.
However, according to the author, the law is unclear about
whether these services apply to breast conservation surgeries,
like partial mastectomies and lumpectomies. The author
maintains that while most lumpectomy patients will not need a
longer hospital stay, some patients undergoing these surgeries
may experience unexpected complications, have no support at
home and may require a longer stay to manage pain, bleeding
drains, and the risk of an infection - just like some patients
undergoing mastectomies. Patients may require different
lengths of stay to recuperate based on their health, age, and
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other factors. The author argues that this clarification is
necessary so that doctors, patients, and payers are clear
about appropriate treatment when it is medically necessary for
all breast cancer surgeries.
2)BREAST CANCER PREVALENCE . According to the California Cancer
Registry (CCR), breast cancer is the most common cancer
diagnosed in California, with nearly 24,000 new cases and more
than 4,400 deaths expected in 2012. An average newborn girl's
chance of eventually being diagnosed with invasive breast
cancer in California is approximately 12%, or one in eight.
Nearly 300,000 women are currently living with breast cancer
in California.
CCR reports that, although breast cancer is the most common
cancer found among women in California, when diagnosed early,
survival rates are high. In California, 71% of breast cancer
is diagnosed in the early stages. Among California women, the
five-year relative survival rate for breast cancer is 91%;
this rate varies with the stage at diagnosis with a 100%
five-year relative survival rate for localized breast cancer,
85% for regional breast cancer, and 26% for distant breast
cancer.
A sustained decrease in breast cancer mortality in the United
States and California during the last 20 years is attributed,
in part, to the increased use of mammography screening during
the 1980s, as well as improvements in treatments and reduction
of hormone-replacement therapy.
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.
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3)MASTECTOMY AND LUMPECTOMY . Mastectomy is performed under
general anesthesia. Most women treated with mastectomy are
hospitalized for at least one night following surgery. The
entire affected breast plus some lymph nodes are removed. (The
lymph nodes are removed to determine whether the cancer has
spread to them.) Women who have a mastectomy may choose to
have breast reconstruction at the same time or at a later
date.
Lumpectomy is performed under either local or general anesthesia
and is typically provided on an outpatient basis in a hospital
or outpatient surgical center. The area of the breast in
which the tumor is located plus a border of healthy tissue
around the tumor are removed. A second incision is often made
under the arm to remove some lymph nodes. The border of
healthy tissue around the tumor is referred to as the surgical
margin. If the surgical margin is not free of cancer, a
second surgery is performed to obtain cancer-free margins.
4)CHBRP . Pursuant to AB 1996 (Thomson), Chapter 795, Statutes
of 2002, and SB 1704 (Kuehl), Chapter 684, Statutes of 2006,
the University of California is requested to assess
legislation proposing a mandated benefit or service, or the
repeal of a mandated benefit or service, through CHBRP. CHBRP
prepares a written analysis of the public health, medical, and
economic impacts of such measures. The following are
highlights from the CHBRP analysis of this bill:
a) Medical effectiveness . According to CHBRP, there is
clear and convincing evidence from multiple randomized
controlled trials (RCTs) that rates of overall survival and
local/regional recurrence of breast cancer are equivalent
for women with stage I or II breast cancer who are treated
with mastectomy or lumpectomy plus radiation.
The CHBRP report maintains that there is clear and convincing
evidence from multiple RCTs that women with stage I or II
breast cancer who receive lumpectomy with radiation have a
lower rate of in-breast recurrence of breast cancer than
women with stage I or II cancer who receive lumpectomy
alone (i.e., without radiation). There is also a
preponderance of evidence that they also have a lower rate
of death from all causes.
CHBRP reports that there is clear and convincing evidence
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that women with ductal carcinoma in situ (DCIS) who receive
lumpectomy with radiation have lower rates of in-breast
recurrence of DCIS and invasive breast cancer than women
with DCIS who receive lumpectomy alone.
b) Impact on coverage . CHBRP indicates that DHMC-regulated
plans and CDI-regulated policies are estimated to be
currently compliant with the provision of this bill for
medically necessary lumpectomy upon provider referral and
also with the provision in this bill requiring coverage of
postsurgery consultation regarding the length of any
hospital stay. Therefore, according to CHBRP, no
measurable change in coverage for these services is
expected.
c) Impact on utilization . CHBRP estimates that no
measurable change in benefit coverage is expected as a
result of this bill (100% of female enrollees in
DMHC-regulated plans and CDI-regulated policies are
estimated to be in compliant plans) and no measurable
change in utilization is projected.
d) Impact on total health care costs . CHBRP estimates that
no measurable change in benefit coverage is expected as a
result of this bill and no measurable changes in total
premiums and total health care expenditures are expected.
As no measurable change in benefit coverage or cost is
expected, no measurable change in the number of uninsured
persons is expected.
e) Public health impact . Although lumpectomy procedures
are medically effective treatments for DCIS, stage I, and
some stage II cancers, CHBRP finds that no change in
enrollee coverage or utilization of this treatment would
occur as a result of this bill. Therefore, CHBRP
anticipates no public health impact on short- and long-term
health outcomes, possible disparities, premature death, or
economic loss related to breast cancer or its treatment
through lumpectomy procedures.
f) Potential impact of federal health care reform . EHBs
are defined to include ambulatory patient services,
hospitalization, and preventive and wellness services and
chronic disease management. In addition, the federal
Department of Health and Human Services (HHS) when
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promulgating regulations on EHBs is to ensure that the EHB
floor "is equal to the scope of benefits provided under a
typical employer plan." Virtually all employers provide
coverage for lumpectomy services. Therefore, it is highly
unlikely that there would be any impacts resulting from
this bill in the longer term, beyond the year 2014.
5)THE ACA AND EHB's . In March 2010, the federal government
passed the ACA, which includes a number of provisions that
would directly and indirectly prompt changes in health care
delivery, finance, and coverage, and that would affect
benefits covered by California health insurance products.
Specifically, the ACA includes provisions that require
coverage for new federal benefit mandates. One of these
mandates requires coverage of EHBs for most health insurance
products sold in the individual and small-group markets,
including the qualified health plans that will be sold through
state health insurance exchanges. Under federal law, EHBs
must include 10 general categories and the items and services
covered within the categories are:
a) Ambulatory patient services;
b) Emergency services;
c) Hospitalization;
d) Maternity and newborn care;
e) Mental health and substance use disorder services,
including behavioral health treatment;
f) Prescription drugs;
g) Rehabilitative and habilitative services and devices;
h) Laboratory services;
i) Preventive and wellness services and chronic disease
management; and,
j) Pediatric services, including oral and vision care.
On December 16, 2011, the HHS Center for Consumer Information
and Insurance Oversight released an EHB Bulletin outlining a
regulatory approach that HHS plans to propose to define EHBs.
In the Bulletin, HHS proposed that EHBs be defined using a
benchmark approach. States would have the flexibility to
select a benchmark plan that reflects the scope of services
offered by a "typical employer plan." EHBs would include
coverage of services and items in all 10 statutory categories
above, but states would choose one of the following benchmark
health insurance plans:
a) One of the three largest small group plans in the state
by enrollment;
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b) One of the three largest state employee health plans by
enrollment;
c) One of the three largest federal employee health plan
options by enrollment; or,
d) The largest health maintenance organization (HMO) plan
offered in the state's commercial market by enrollment.
If a state chose not to select a benchmark, HHS proposed that
the default benchmark will be the small group plan with the
largest enrollment in the state. HHS is accepting comments on
the Bulletin until January 31, 2012.
AB 1453 (Monning) and SB 951 (Ed Hernandez), currently before
the Legislature, both propose to select the Kaiser Small Group
HMO as California's benchmark plan to serve as the EHB
standard, as required by federal law. It is believed, the
provisions required under this bill are in line with the
current coverage and practices of Kaiser products including
Kaiser's Small Group HMO.
1)SUPPORT . According to the sponsor of this bill, the seven
California Affiliates of Susan G. Komen for the Cure, as more
partial mastectomies and lumpectomies are performed, it only
makes sense to provide patients undergoing these procedures
with the same standards of care received by those undergoing
full mastectomies. The sponsors maintain that by allowing a
physician or surgeon to decide, in consultation with their
patients following the procedure, what length of hospital stay
is best, breast cancer patients will be able to receive better
quality care, tailored to their own personal needs. The
sponsor further asserts that this bill will also ensure that
insurance companies cover prosthetic devices for
reconstructive surgery and all complications related to
partial mastectomies and lumpectomies. Supporters all argue
that this bill will enhance the recovery process for those
undergoing these often challenging procedures and provide that
health plans and policies follow safe minimum standards for
all breast cancer surgeries.
2)OPPOSITION . Members of the health insurance industry write in
opposition that they generally oppose all benefit mandates
because, while they sympathize with the intent to meet a need,
mandates increase the already high cost of care for everyone
and eliminate the flexibility an employer would otherwise have
to pick benefits that best address the needs of his or her
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employees' future. The organizations opposed state that
requiring all plans to include specific benefits is
counterproductive to their members' efforts to make health
insurance more affordable and available in California.
3)RELATED LEGISLATION :
a) AB 1453establishes the Kaiser Small Group HMO plan
contract as California's EHB benchmark plan. AB 1453 is
pending before the Senate Health Committee;
b) SB 95 contains the exact same language as AB 1453 and
also selects the Kaiser Small Group HMO as California's
benchmark plan to serve as the EHB standard, as required by
federal law. SB 951 is pending before the Assembly Health
Committee;
c) SB 1538 (Simitian) requires health facilities at which
mammography examinations are performed to provide a
specified notice to patients who have dense breast tissue.
4)PREVIOUS LEGISLATION . AB 7 (Brown), Chapter 789, Statutes of
1998, requires every health care service plan contract and
every policy of disability insurance that is issued, amended,
renewed, or delivered on and after January 1, 1999, that
provides coverage for mastectomies and lymph node dissections,
to allow the length of a hospital stay associated with these
procedures to be determined by the attending physician and
surgeon in consultation with the patient and consistent with
sound clinical principles and processes. Requires health
plans and insurers to cover prosthetic devices or
reconstructive surgery, and to cover all complications from a
mastectomy.
REGISTERED SUPPORT / OPPOSITION :
Support
Susan G. Komen for the Cure (sponsor)
American Cancer Society
American Congress of Obstetricians and Gynecologists, District
IX - California
American Federation of State, County and Municipal Employees,
AFL-CIO
Breast Cancer Fund
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California Communities United Institute
California Medical Association
California Teachers Association
CommuniCare Health Centers
Junior Leagues of California's State Public Affairs Committee
Michelle's Place Breast Cancer Resource Center
Planned Parenthood Affiliates of California
University of California, Davis Cancer Center
Numerous Individuals
Opposition
America's Health Insurance Plans
Association of California Life and Health Insurance Companies
California Association of Health Plans
Analysis Prepared by : Tanya Robinson-Taylor / HEALTH / (916)
319-2097