BILL ANALYSIS                                                                                                                                                                                                    Ó






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                                   THIRD READING 


          Bill No:  AB 1763
          Author:   Gipson (D) 
          Amended:  6/27/16 in Senate
          Vote:     21 

           SENATE HEALTH COMMITTEE:  7-1, 6/22/16
           AYES:  Hernandez, Hall, Mitchell, Monning, Pan, Roth, Wolk
           NOES:  Nielsen
           NO VOTE RECORDED:  Nguyen

           SENATE APPROPRIATIONS COMMITTEE:  5-2, 8/11/16
           AYES:  Lara, Beall, Hill, McGuire, Mendoza
           NOES:  Bates, Nielsen

           ASSEMBLY FLOOR:  67-5, 6/2/16 - See last page for vote

           SUBJECT:   Health care coverage:  colorectal cancer:  screening  
                     and testing


           SOURCE:    American Cancer Society Cancer Action Network 
                      California Colorectal Cancer Coalition 
          

          DIGEST:  This bill requires health plan and health insurance  
          coverage without cost sharing for specified colorectal cancer  
          screening examinations and laboratory tests for individuals at  
          average risk, and requires coverage for additional colorectal  
          cancer screening examinations without cost-sharing for  
          individuals at high risk, as specified.  Prohibits the  
          imposition of cost sharing on colonoscopies, including the  
          removal of polyps, for an enrollee who is between 50 and 75  
          years of age and has received a positive test, as specified.








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          ANALYSIS:  


          Existing federal law: 


          1)Requires, pursuant to the Affordable Care Act (ACA), coverage  
            of 10 essential health benefits and places limits on cost  
            sharing.


          2)Requires, pursuant to Section 2713 of the Public Health  
            Services Act, as added by the ACA, the preventive services  
            without cost sharing (such as copayment, coinsurance, or  
            deductible), as soon as 12 months after a recommendation  
            appears in any of the following sources:


             a)   A and B rated recommendations of the United States  
               Preventive Services Task Force (USPSTF);


             b)   Immunizations recommended by the Advisory Committee on  
               Immunization Practices of the Centers for Disease Control  
               and Prevention;


             c)   For infants, children, and adolescents,  
               evidence-informed preventive care and screenings provided  
               for in the comprehensive guidelines supported by the Health  
               Resources and Services Administration (HRSA); and,


             d)   For women, preventive care and screenings provided for  
               in comprehensive guidelines supported by HRSA.


          3)States, pursuant to federal regulation, that nothing in 2)  
            above requires a plan or insurer that has a network of  
            providers to provide benefits for the items or services  
            described in 2) above that are delivered by an out-of-network  
            provider; or precludes a plan or insurer that has a network of  







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            providers from imposing cost-sharing requirements for the  
            items or services described in 2) above that are delivered by  
            an out-of-network provider.


          Existing state law:


          1)Requires health plans to be regulated by the Department of  
            Managed Health Care (DMHC) and health insurers to be regulated  
            by the California Department of Insurance (CDI).  


          2)Mandates coverage for all generally accepted cancer screening  
            tests, subject to all terms and conditions that apply, and  
            screening for breast cancer, cervical cancer, mammography, and  
            prostate cancer. Requires coverage for breast cancer diagnosis  
            and treatment.  Establishes requirements for mastectomies and  
            lymph node dissections.  Limits copayments on orally  
            administered anticancer medications, as specified, until  
            January 1, 2019.  Mandates coverage for routine patient care  
            costs related to clinical trials for an enrollee or insured  
            diagnosed with cancer, as specified.


          This bill:


          1)Requires every health plan contract and health insurance  
            policy, except a specialized health plan contract or health  
            insurance policy, that is issued, amended, or renewed on or  
            after January 1, 2018, to provide coverage without any cost  
            sharing for all colorectal cancer screening examinations and  
            laboratory tests assigned either a grade of A or a grade of B  
            by the USPSTF for individuals at average risk. Requires if an  
            enrollee is at high risk for colorectal cancer, the plan or  
            insurer to include additional colorectal cancer screening  
            examinations as listed by the USPSTF as recommended screening  
            strategy and at least at the frequency established pursuant to  
            regulations issued by the federal Centers for Medicare and  
            Medicaid Services for the Medicare program.


          2)Prohibits, for an enrollee who is between 50 and 75 years of  







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            age, a health plan contract or insurance policy from imposing  
            cost sharing on colonoscopies, including the removal of  
            polyps, when either of the following applies:


             a)   The colonoscopy is a screening procedure not occasioned  
               by a recent positive test or procedure; or,


             b)   The colonoscopy has been scheduled because of a positive  
               result on a test or procedure, other than a colonoscopy,  
               assigned either a grade of A or a grade of B by the USPSTF.


          3)States that nothing in this bill requires a plan or insurer  
            that has a network of providers to provide benefits for items  
            or services described in this bill that are delivered by an  
            out-of-network provider or precludes a plan or insurer that  
            has a network of providers from imposing cost-sharing  
            requirements for the items or services described in this  
            section that are delivered by an out-of-network provider.




          Comments
          
          1)Author's statement.  According to the author, stool blood  
            tests are an important colorectal cancer screening option.  
            Availability is better than for colonoscopy, the cost is  
            lower, and they offer the opportunity to increase the overall  
            screening rate which would reduce incidence and mortality.  
            Some individuals, including those from low income communities  
            and communities of color may not have initial access to  
            screening colonoscopy.  Some prefer a stool blood test because  
            the procedure is simpler, there is lower risk of complications  
            and it is less invasive. Screening with stool blood tests has  
            been shown to decrease incidence and mortality in randomized  
            controlled trials, and years of life saved are essentially the  
            same as with colonoscopy screening.  However, the benefits of  
            stool blood tests as a strategy to reach more Californians,  
            especially in communities with lower access to colonoscopy  
            services are not realized when there is a cost to patients.  A  
            co-pay or cost-sharing can be a barrier, preventing some  







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            individuals with positive stool blood tests from getting a  
            follow up colonoscopy to complete the colorectal cancer  
            screening process, defeating the purpose of screening. A  
            policy that removes the cost to patients will make stool blood  
            tests a more viable screening option and will reduce costs to  
            payers.
            
          2)ACA Preventive services mandate.  The ACA requires coverage  
            for and elimination of cost-sharing on certain recommended  
            preventive health services, for policies renewing on or after  
            September 23, 2010, based on guidelines from the USPSTF.   
            There are 15 covered preventive services for adults which  
            include one-time screening for abdominal aortic aneurysm,  
            screening and counseling for alcohol misuse, aspirin, blood  
            pressure screening, cholesterol screening, depression  
            screening, screening for Type 2 Diabetes, diet counseling, HIV  
            screening, immunizations, obesity screening and counseling,  
            prevention counseling for sexually transmitted infection,  
            screening and cessation interventions for tobacco use, and  
            colorectal cancer screening for adults over 50.

          3)Colorectal cancer screening.  According to the National Cancer  
            Institute, colorectal cancer is a disease in which malignant  
            (cancer) cells form in the tissues of the colon or the rectum.  
             Colorectal cancer is the second leading cause of death from  
            cancer in the United States. For the vast majority of adults,  
            the most important risk factor for colorectal cancer is older  
            age. Most cases of colorectal cancer occur among adults older  
            than 50 years; the median age at diagnosis is 68 years. A  
            positive family history (excluding known inherited familial  
            syndromes) is thought to be linked to about 20% of cases of  
            colorectal cancer. About 3% to 10% of the population has a  
            first-degree relative with colorectal cancer. Male sex and  
            black race are also associated with higher colorectal cancer  
            incidence and mortality. Black adults have the highest  
            incidence and mortality rates compared with other  
            racial/ethnic subgroups. The final USPSTF recommendation for  
            colorectal cancer screening recommends screening with one of  
            several approved methodologies for colorectal cancer starting  
            at age 50 years and continuing until age 75 years. The  
            decision to screen for colorectal cancer in adults aged 76 to  
            85 years should be an individual one, taking into account the  
            patient's overall health and prior screening history. The  
            screening modalities and intervals are fecal occult blood test  







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            (FOBT), which has received an A or B recommendation from the  
            USPSTF and Fecal immunochemical test, which is recommended in  
            the 2016 draft updated guidelines.  Both tests are suggested  
            annually to detect cancer.  A flexible sigmoidoscopy is  
            recommended every five years to detect polyps and cancer and  
            has received an A or B recommendation from the USPSTF.  A  
            colonoscopy is recommended every 10 years to detect polyps and  
            cancer and has received an A or B recommendation.  It is also  
            recommended that a colonoscopy should be performed if test  
            results are positive.

          4)California Health Benefits Review Program (CHBRP) analysis.   
            AB 1996 (Thomson, Chapter 795, Statutes of 2002) requested the  
            University of California assess legislation proposing a  
            mandated benefit or service and prepare a written analysis  
            with relevant data on the medical, economic, and public health  
            impacts of proposed health plan and health insurance benefit  
            mandate legislation. CHBRP was created in response to AB 1996,  
            and reviewed an earlier version of this bill and issued an  
            updated letter based on the April 27, 2016 version of this  
            bill.  Key findings include that there is a preponderance of  
            evidence that USPSTF-recommended colorectal cancer screening  
            modalities are medically effective for the detection and  
            prevention of colorectal cancer screenings among average and  
            high-risk individuals.  For average-risk individuals, evidence  
            exists suggesting a small but positive impact of insurance  
            coverage for colorectal cancer screening and utilization  
            (Cokkinides, 2011), and that low socioeconomic status  
            individuals may benefit from the elimination of barriers to  
            screening utilization (Fedewa, 2015a). CHBRP projects no  
            measurable public health impact on the diagnosis or prevention  
            of colorectal cancer at the population level due to the small  
            number of enrollees who would avail themselves of the  
            additional screening.


          FISCAL EFFECT:   Appropriation:    No          Fiscal  
          Com.:YesLocal:   Yes


          According to the Senate Appropriations Committee: 

          1)No fiscal impact on the Medi-Cal program is anticipated, as  
            program beneficiaries are not subject to cost sharing.







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          2)Increased costs of $1.3 million per year to the California  
            Public Employees' Retirement System (CalPERS), due to  
            increased utilization of screening tests (various funds).  
            According to an analysis of a prior version of this bill by  
            CHBRP, prohibiting cost sharing for specified screening will  
            modestly increase utilization of screening examinations.  
            Overall, CHBRP projects that about 2,500 additional  
            individuals per year will receive colorectal screening exams  
            due to the elimination of cost sharing. The proportional  
            impact of that increased utilization on the CalPERS system is  
            $1.3 million. According to CHBRP, subsequent amendments to the  
            bill since that analysis was prepared will not substantially  
            change the projected costs.

          3)No state cost to subsidize health care coverage through  
            Covered California is anticipated. Under federal law, any new  
            mandated health benefit that exceeds the benefits in the  
            state's essential health benefits benchmark plan would be a  
            state responsibility. In other words, to the extent that the  
            state imposes a new benefit mandate that exceeds the essential  
            health benefits benchmark, the state would be responsible for  
            paying for the cost to subsidize that benefit for those  
            individuals who receive subsidized coverage through Covered  
            California. Because this bill does not mandate a new benefit,  
            but only change the terms of an existing benefit, the bill is  
            not expected to result in the state being responsible for  
            subsidizing coverage. 

          4)One-time costs of about $90,000 over the first two years and  
            ongoing costs of $25,000 per year for reviews of insurance  
            plan compliance by CDI (Insurance Fund).

          5)Ongoing costs of less than $50,000 per year for review of  
            health plan compliance by DMHC (Managed Care Fund).


          SUPPORT:   (Verified8/11/16)


          American Cancer Society Cancer Action Network (co-source)
          California Colorectal Cancer Coalition (co-source)
          American College of Gastroenterology
          American College of Surgeons







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          American Gastroenterology Association
          American Society for Gastrointestinal Endoscopy
          Association of Northern California Oncologists
          Bayer 
          California Academy of Preventive Medicine
          California Academy of Physician Assistants
          California Black Health Network
          California Chapters of the American College of Physicians
          California Immigrant Policy Center
          California Life Sciences Association
          California Primary Care Association
          Fresno Center for New Americans
          Fresno Interdenominational Refugee Ministries
          Health Officers Association of California 
          Medical Oncology Association of Southern California
          Southeast Asia Resource Action Center
          The Cambodian Family Community Center
          Several individuals


          OPPOSITION:   (Verified8/11/16)


          America's Health Insurance Plans
          Blue Shield of California
          California Chamber of Commerce
          Department of Managed Health Care

          ARGUMENTS IN SUPPORT:   The American Cancer Society Action  
          Network writes that colorectal cancer is the second leading  
          cause of cancer deaths in the United States but is the most  
          preventable with screening and early detection. Timely and  
          appropriate screening can decrease colorectal cancer incidence  
          and mortality by 30% to 60%.  High-sensitivity FOBT tests are  
          effective, non-invasive, easily accessible and safe screening  
          tests that are more cost efficient than colonoscopies. However,  
          a positive test result requires that a follow-up colonoscopy be  
          provided.  Multiple studies have shown that individuals are less  
          likely to seek additional health services, including preventive  
          screenings, when they are required to pay out-of-pocket.   
          Additionally, research has shown that limiting colorectal cancer  
          screening choices to only colonoscopy can result in a lower  
          colorectal cancer screening completion rate compared to  
          providing a choice between colonoscopy and a stool-based test,  







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          particularly among racial and ethnic minorities.  The California  
          Colorectal Cancer Coalition writes that many health insurers  
          apply cost-sharing to colonoscopies that follow a positive stool  
          blood test because they consider it a diagnostic procedure  
          rather than a screening test.  Patient cost can be more than  
          $300 when a polyp or abnormal growth is removed during the  
          screening colonoscopy.  This charge is generally received  
          unexpectedly after having a screening and can act as a  
          disincentive for future screening for colon cancer.  Finding an  
          adenomatous polyp during a screening colonoscopy can be found in  
          at least 50% of good quality colonoscopy exams.  This bill  
          eliminates this unexpected cost, and removes the financial  
          disincentives, which prevent people from getting their colon  
          cancer screening.
          
          ARGUMENTS IN OPPOSITION:America's Health Insurance Plans (AHIP)  
          write that this bill creates a new mandate for health plans and  
          insurers to cover costly services for diagnostic purposes  
          without cost-sharing, which threatens the efforts of all health  
          care stakeholders to provide consumers with meaningful health  
          care choices and affordable coverage options.  This bill will  
          increase annual expenditures by $5.63 million for enrollees with  
          DMHC-regulated plans and CDI-regulated policies.  The state  
          should be looking for ways to bring down health care costs for  
          consumers, not drive them up.  Extending the elimination of  
          cost-sharing to diagnostic care in this instance creates a  
          slippery slope to eliminating cost-sharing for other similar  
          types of diagnostic care.  As currently amended, this bill fails  
          to follow the federal standard by not recognizing the value of  
          in-network benefits - and results in increased costs in premiums  
          if cost-sharing on out-of-network benefits was not permitted.  A  
          recent study conducted by AHIP found that in California the  
          average billed charge for colonoscopies and biopsies was 252.7%  
          of the Medicare rate.  Requiring plans to cover such services  
          and pay full billed charges would allow those providers to set  
          charges at any level that they wish.  According to DMHC, this  
          bill imposes a zero cost sharing requirement on colorectal  
          cancer services above and beyond the zero cost-sharing mandate  
          for preventive services under the Affordable Care Act. This type  
          of disease specific statute creates disparities and inequities  
          for individuals that suffer from other diseases.

          ASSEMBLY FLOOR:  67-5, 6/2/16
          AYES:  Achadjian, Alejo, Arambula, Atkins, Baker, Bloom,  







                                                                    AB 1763  
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            Bonilla, Bonta, Brown, Burke, Calderon, Campos, Chau, Chávez,  
            Chiu, Chu, Cooley, Cooper, Dababneh, Daly, Dodd, Eggman,  
            Frazier, Cristina Garcia, Eduardo Garcia, Gatto, Gipson,  
            Gomez, Gonzalez, Gordon, Gray, Grove, Hadley, Harper, Roger  
            Hernández, Holden, Irwin, Jones, Jones-Sawyer, Lackey, Levine,  
            Linder, Lopez, Low, Maienschein, Mathis, McCarty, Medina,  
            Mullin, Nazarian, O'Donnell, Olsen, Quirk, Ridley-Thomas,  
            Rodriguez, Salas, Santiago, Steinorth, Mark Stone, Thurmond,  
            Ting, Wagner, Weber, Wilk, Williams, Wood, Rendon
          NOES:  Travis Allen, Brough, Melendez, Obernolte, Patterson
          NO VOTE RECORDED:  Bigelow, Chang, Dahle, Beth Gaines,  
            Gallagher, Kim, Mayes, Waldron

          Prepared by:Teri Boughton / HEALTH / (916) 651-4111
          8/15/16 20:17:19


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