BILL ANALYSIS Ó ----------------------------------------------------------------- |SENATE RULES COMMITTEE | AB 1763| |Office of Senate Floor Analyses | | |(916) 651-1520 Fax: (916) | | |327-4478 | | ----------------------------------------------------------------- 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. AB 1763 Page 2 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 AB 1763 Page 3 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 AB 1763 Page 4 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 AB 1763 Page 5 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 AB 1763 Page 6 (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. AB 1763 Page 7 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 AB 1763 Page 8 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, AB 1763 Page 9 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 Page 10 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 **** END ****