BILL ANALYSIS
AB 56
Page 1
Date of Hearing: March 31, 2009
ASSEMBLY COMMITTEE ON HEALTH
Dave Jones, Chair
AB 56 (Portantino) - As Introduced: December 5, 2008
SUBJECT : Health care coverage: mammographies.
SUMMARY : Requires, on or after July 1, 2010, disability
insurers selling health insurance (health insurers) to provide
coverage for mammography for screening or diagnostic purposes
upon referral of a specified health care provider and requires
health care service plans (health plans) and health insurers to
notify female enrollees or insureds in writing of their
eligibility for testing. Specifically, this bill :
1)Requires every individual or group policy of health insurance
or self-insured employee welfare benefit plan issued, amended,
delivered, or renewed on or after July 1, 2010, to provide
coverage for mammography for screening or diagnostic purposes
upon referral of a participating physician, nurse
practitioner, or certified nurse-midwife.
2)Requires health plans and health insurers to send female
enrollees or insureds a written notice, during the calendar
year in which national guidelines indicate they should start
undergoing tests for screening or diagnosis of breast cancer,
advising that they are eligible for testing.
3)Exempts from the provisions of this bill Medicare supplement,
vision-only, dental-only, and Civilian Health and Medical
Program of the Uniformed Services (CHAMPUS)-supplement
insurance; and, hospital indemnity, accident-only, and
specified disease insurance that does not pay benefits on a
fixed-benefit, cash-payment-only basis.
4)States legislative intent to ensure that all women have access
to medically appropriate breast cancer screening and
diagnostic tests, especially those women who have certain
specified risk factors.
EXISTING LAW :
1)Provides for the regulation of health plans by the Department
of Managed Health Care (DMHC) and health insurers by the
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California Department of Insurance (CDI).
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.
3)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
physician, rather than dictated based on her age. The author
points out that, for many high risk women, their risk of
developing breast cancer is not solely related to their age,
and high risk women can, and often do, develop cancer at an
earlier age than the general population. Additionally, the
author states that existing law requiring insurance companies
to pay for a baseline mammogram at 35 years of age, a
mammogram every other year at age 40 and then every year
starting at age 50 was enacted 20 years ago and needs to be
updated to reflect national screening guidelines that
generally call for mammography to begin at age 40 for most
women. The author adds that the notification requirement in
this bill will increase the number of women receiving
mammograms, save lives, and reduce treatment costs.
2)PREVALENCE OF BREAST CANCER . One in nine women in California
has a chance of being diagnosed with breast cancer in her
lifetime. It is the second leading cause of death in 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
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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 University of California (UC) 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 the U.S. Department of Health and Human
Services, the American Cancer Society (ACS), 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 1-2 years beginning at age 40
or 50 for those women of average risk for breast cancer, but
no longer suggest routine baseline mammograms in women younger
than 40 years. However, the most widely accepted guidelines,
those developed by USPSTF and ACS, recommend breast cancer
screening for women starting at age 30 if they have certain
high risk factors, including specific genetic mutations, a
personal or family history of breast cancer, prior exposure to
chest radiation, or extremely dense breast tissue.
4)CALIFORNIA HEALTH BENEFITS REVIEW PROGRAM . AB 1996 (Thomson),
Chapter 795, Statutes of 2002, requests the UC to assess
legislation proposing a mandated benefit or service, and
prepare a written analysis with relevant data on the public
health, medical, and economic impact of proposed health plan
and health insurance benefit mandate legislation. CHBRP was
created in response to AB 1996 and extended for four
additional years in SB 1704 (Kuehl), Chapter 684, Statutes of
2006.
In reviewing AB 56, CHBRP focused its analysis on screening
instead of diagnosis, based on the broad agreement between the
multiple national organizations referenced in 3) above that
breast cancer screening should begin as early as age 40 for
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women of average risk for breast cancer, and assumed the
written notification requirement in this bill would be met
through a one-time generic letter sent to each covered woman
during the calendar year she reaches age 40. In its analysis
of this bill, CHBRP reported:
a) Medical Effectiveness . According to CHBRP, 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 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 a preponderance of
evidence showing that patient reminders for mammography
screening increase the number of women completing
mammography and increase the overall mammography screening
rate by about one-third.
b) Utilization, Cost, and Coverage Impacts . According to
CHBRP, approximately 21.3 million individuals in California
are enrolled in health plans or policies that would be
subject to the mandate in this bill. 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. Currently, about 51% of women receive a
mammogram during their 40th year - the age at which annual
screening is recommended to begin. CHBRP's coverage survey
also indicated that an estimated 20% of DMHC-regulated
plans and 23% of CDI-regulated policies send written
notification to women who are 40 to indicate their
eligibility for breast cancer screening. Of the portion of
the population insured by the California Public Employees'
Retirement System (CalPERS) who have coverage subject to
this bill, CHBRP estimated 50% receive a written
notification. Medi-Cal indicated that it does not require
notification of eligibility for mammography screening to
enrollees at age 40 but, because Medi-Cal, like CalPERS,
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contracts with commercial providers for coverage for a
portion of its enrollees, CHBRP assumed that 20% of the
portion of women age 40 years in Medi-Cal, Access for
Infants and Mothers (AIM), and Major Risk Medical Insurance
Program (MRMIP) with coverage subject to this bill already
receive notification for mammograms.
CHBRP estimated that the cost of a single mammogram is about
$96 and the unit price of a mammogram plus the costs of
services due to false-positive test results is estimated at
$169. While this bill is not expected to affect the unit
cost of mammography or increase the mammography rate due to
increases in coverage, CHBRP indicated that this bill will
increase utilization as a result of the required one-time
generic notification letter, with the expected total annual
number of mammograms increasing by 0.38% or 20,000.
Total expenditures as a result of this bill are expected to
increase by 0.004%. Employer premium expenditures for
group insurance would increase by about $2 million and
premium expenditures for individuals with group insurance,
CalPERS, AIM, or MRMIP would increase by about $537,000.
CalPERS expenditures would increase by $75,000 and Medi-Cal
managed care expenditures would increase by $374,000. With
regard to changes in per member per month amounts, this
bill is expected to lead to premium increases of less than
1%. Additionally, CHBRP noted that the notification
requirement in this bill will lead to increased
administrative costs within both the private and public
segments of the market. CHBRP identified the cost of
written notification in the form of a one-time, generic
letter to covered women at age 40 at $96,000.
c) Public Health Impact . According to CHBRP, it is
estimated that screening an additional 20,000 women with
mammography would, over time, prevent approximately 16
deaths per year from breast cancer. It would take roughly
14 years following implementation of this bill for this
reduction in mortality to be realized, although qualitative
improvements, such as a decrease in the aggressiveness of
cancer and less treatment for metastatic disease would be
expected sooner. CHBRP also added that an estimated
reduction in 16 premature deaths annually as a result of
this bill would translate into savings of 366 life- years
and $5.2 million in productivity that would otherwise be
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lost. Furthermore, CHBRP stated that research on
mammography utilization by race/ethnicity suggests that
some of the differences in health outcomes among non-white
women can be explained by their lower rates of mammography
utilization. According to CHBRP, to the extent that
notification increases mammography screening among these
groups, there is the potential for this bill to reduce
racial/ethnic disparities in screening rates and health
outcomes associated with breast cancer. Finally, CHBRP
stated that while this bill will result in premium
increases of less than 1%, it is unlikely that this bill
will result in an increase in the uninsured or contribute
to the long-term health impacts of being uninsured.
5)SUPPORT . Supporters, including the sponsor, the American
College of Obstetricians and Gynecologists, ACS, and the
California Medical Association, state that this bill will make
changes to the insurance mandate for mammography coverage to
provide health care providers the flexibility to ensure that
women receive the most appropriate breast cancer screening
services regardless of age. They also point out that the
notice required in this bill will serve as an important
reminder to women about the importance of screening for their
health.
6)OPPOSITION . The Association of California Life and Health
Insurance Companies (ACLHIC) and Health Net are opposed to
this bill and contend that the requirement to send a notice
for the testing of one specific medical condition will be
costly, burdensome, and counterproductive to the insurance
industry's efforts to make health insurance more affordable
and available to all Californians.
7)PRIOR LEGISLATION . 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)POLICY COMMENT . This bill does not identify the type of
written notification that is required. For example, the
notification could be provided in the evidence of coverage
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document or via a generic one-time letter. The author may
wish to amend this bill to specify the form, such as an
affirmative letter that will be sent to each covered woman
when she reaches the age of 40, and the frequency of the
notification.
9)SUGGESTED TECHNICAL AMENDMENT . This bill requires health
insurers to send the notice to policyholders, which also
includes employers. The author may wish to clarify with the
following technical amendment: on page 4, line 30, delete
"policyholder" and insert "insured."
REGISTERED SUPPORT / OPPOSITION :
Support
American College of Obstetricians and Gynecologists, District IX
(sponsor)
American Cancer Society
American Federation of State, County and Municipal Employees,
AFL-CIO
California Communities United Institute
California Medical Association
City of West Hollywood
Junior Leagues of California State Public Affairs Committee
Planned Parenthood Affiliates of California
Opposition
Association of California Life and Health Insurance Companies
Health Net
Analysis Prepared by : Cassie Rafanan / HEALTH / (916)
319-2097