BILL ANALYSIS
SENATE HEALTH
COMMITTEE ANALYSIS
Senator Elaine K. Alquist, Chair
BILL NO: AB 56
A
AUTHOR: Portantino
B
AMENDED: July 8, 2009
HEARING DATE: July 15, 2009
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CONSULTANT:
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Park/
SUBJECT
Health care coverage: mammographies
SUMMARY
Expands the terms under which health insurers are required
to provide coverage for mammography, beginning July 1,
2010, and requires health plans and health insurers to
provide an enrollee or insured with information regarding
recommended timelines for an individual to undergo tests
for the screening or diagnosis of breast cancer, as
specified.
CHANGES TO EXISTING LAW
Existing law:
Existing law provides for the regulation of health plans by
the Department of Managed Health Care (DMHC) and health
insurers by the California Department of Insurance (CDI).
Existing law 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.
Existing law requires individual or group health insurance
policies and self-insured employee welfare benefit plans to
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provide coverage for mammograms, upon the referral of the
physician, nurse practitioner, or certified nurse-midwife,
for breast cancer screening and diagnostic purposes,
according to the following: 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.
This bill:
This bill would require every individual or group policy of
health insurance 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, without reference to age or frequency (which
current law prescribes), and additionally include physician
assistants among the list of providers who may provide a
referral for mammography that is covered. The bill would
also exclude self-insured employee welfare benefit plans
from these requirements beginning July 1, 2010.
The bill would add physician assistants among the list of
providers who may provide a referral for mammography that
is covered by a health plan under the jurisdiction of DMHC,
beginning July 1, 2010.
The bill would require a health plan and a health insurer
to provide an enrollee or insured with information
regarding recommended timelines for an individual to
undergo tests for the screening or diagnosis of breast
cancer. The bill would allow this information to be
provided by written letter sent to the enrollee or insured,
by publication in a newsletter sent to the enrollee or
insured, by publication in evidence of coverage, by direct
telephone call to the enrollee or insured, by electronic
transmission, by 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 the
recommended timelines for testing. The bill would provide
that a plan or insurer could comply with this requirement
through communications made by a plan or insurer's
contracted providers that satisfy the requirements of this
STAFF ANALYSIS OF ASSEMBLY BILL 56 (Portantino) Page
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section.
The bill would exempt specialized health plans from the
requirement to provide the information above. This bill
would exempt the following policies from the requirement to
provide mammograms and information above: 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.
FISCAL IMPACT
In analyzing the introduced version of the bill, the
California Health Benefits Review Program (CHBRP) predicted
annual costs of $374,000 (50 percent General Fund) to
Medi-Cal and $75,000 (60 percent General Fund) to CalPERS
to account for mailings to eligible women and related
increased mammography that may result from notifications
required by this bill. In the private insurance market,
annual increased premium costs of $2.4 million were
predicted, as a result of increased mammography screening
resulting from this bill.
According to the Assembly Appropriations Committee,
subsequent amendments to this bill provided health plans
and insurers flexibility with respect to mode and timing of
communication with enrollees about mammography
recommendations. These amendments likely reduce or
eliminate notification costs. The committee notes that, to
the extent this bill increases mammography provided to
Medi-Cal recipients, costs will increase accordingly.
Currently, Medi-Cal reimburses analog mammography at $72,
half of which is paid for by the General Fund. This bill,
as amended, will have unknown impacts on the private
insurance market.
BACKGROUND AND DISCUSSION
According to the author, this bill is needed to remove the
age-based utilization of mammograms in law applicable to
health insurers. The author states that existing law,
which requires health insurers to pay for a baseline
mammogram at 35 years of age, a mammogram every other year
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beginning at age 40, and then annually 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
notes that scientific studies have determined that, for
many high-risk women, their risk of developing breast
cancer is not just age related, and they often develop
cancer at an earlier age than the general population. 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 by
her age.
The author adds that the notification requirement in this
bill will increase the number of women receiving
mammograms, save lives, and reduce treatment costs.
California Health Benefits Review Program
Pursuant to AB 1996 (Thomson), Chapter 795, Statutes of
2002, and SB 1704 (Kuehl), Chapter 684, Statutes of 2006,
which asks the University of California to assess
legislation proposing a mandated benefit or service, or the
repeal of a mandated benefit or service, the California
Health Benefits Review Program (CHBRP) prepared a written
analysis of the public health, medical, and economic
impacts of this measure. The following are highlights from
the analysis:
In reviewing AB 56, as introduced, CHBRP focused its
analysis on screening instead of diagnosis, based on the
broad agreement between the multiple national organizations
that breast cancer screening should begin as early as age
40 for 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 (dated March 16, 2009), CHBRP
reported:
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
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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 7 to 9 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.
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 percent of
health plans and insurers cover mammography as a routine
screening test when referred by a provider. Currently,
about 51 percent 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 percent of DMHC-regulated plans and 23 percent 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 percent 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, contracts with commercial providers for
coverage for a portion of its enrollees, CHBRP assumed
that 20 percent 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.
NOTE: CHBRP did not query health plans and health
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insurers regarding other forms of notification. To the
extent that notification, other than a one-time generic
letter sent in the calendar year of a female enrollee or
insured's 40th birthday, as allowed in the current bill,
proves to be more or less effective than written
notification, the utilization increase, and ensuing
costs, would change accordingly.
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 a one-time generic notification letter
would increase utilization by 0.38 percent or 20,000
additional mammograms.
Total expenditures, as a result of 20,000 additional
mammograms, would be expected to increase by 0.004
percent, which would increase employer premium
expenditures for group insurance by about $2 million and
premium expenditures for individuals with group
insurance, CalPERS, AIM, or MRMIP by about $537,000.
With regard to changes in per member per month amounts,
20,000 additional mammograms would be expected to result
in premium increases of less than one percent.
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 would translate into savings of 366 life- years
and $5.2 million in productivity that would otherwise be
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.
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According to CHBRP, white women have the highest rates of
breast cancer, followed closely by African-American
women, Asian Pacific Islander women, and Hispanic women.
African-American women have the highest mortality rate.
CHBRP notes that, to the extent that notification
increases mammography screening among these groups, there
is the potential to reduce racial/ethnic disparities in
screening rates and health outcomes associated with
breast cancer. In addition, a small number of men are
diagnosed with breast cancer. Finally, CHBRP stated that
while an additional 20,000 mammograms would result in
premium increases of less than one percent, it is
unlikely that such a figure would result in an increase
in the uninsured or contribute to the long-term health
impacts of being uninsured.
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,
causing more than 4,200 deaths annually. According to the
California Breast Cancer Research Program, the breast
cancer death rate in California has dropped 20 percent
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 an early
stage, receive effective treatment, and survive the
disease.
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
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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.
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.
Held in the Assembly Appropriations Committee.
Arguments in support
The American College of Obstetricians and Gynecologists,
the sponsor of this measure, writes that this measure will
rectify a discrepancy between health plans and health
insurers, and correct the medical inaccuracy of the
Insurance Code, which has codified guidelines for
mammography that are now outdated. The American Cancer
Society writes 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. The California Medical
Association states that the bill will help decrease the
number of deaths related to breast cancer, as early
detection is seen as the most crucial element to successful
breast cancer treatment.
GlaxoSmithKline states that the most effective way of
lowering health care costs and creating a healthy society
is through prevention and early detection.
Arguments in opposition
The Association of California Life and Health Insurance
Companies (ACLHIC) states, in reference to the prior
version of the bill, that it is opposed to the measure,
unless amended, because there are approximately six
national guidelines that recommend when a female should
begin to undergo screening for breast cancer. ACLHIC
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expresses concern that it may become impossible to comply
with this measure if those guidelines do not agree on the
appropriate age that a female should commence with the
testing, and has requested several amendments.
The California Association of Health Plans (CAHP) writes,
in reference to a prior version of the bill, that it is
opposed to the measure, unless amended, because its health
plans and their provider partners are already working to
notify women of their eligibility for breast cancer
screenings, or to identify women that have not had
necessary testing. CAHP states that plans and providers are
motivated to encourage mammograms and other tests as part
of publicly reported quality measures and pay for
performance projects. CAHP believes that communication is a
central part of these efforts by health plans and provider
groups, and the current version of AB 56 will hinder those
efforts. CAHP also states that much of the language of this
bill is also unclear and does not take into consideration
the communication currently taking place among plans,
provider groups, and patients. CAHP has provided language
to the author that it believes would provide clarity and
take into account some of the innovative approaches its
plans have initiated to promote better health outcomes.
Health Net writes that it sends preventive care screening
guidelines to all members, and if the rate for screening
breast cancer falls below a set percentage, Health Net will
contact members where there has not been a mammogram
encounter. Health Net writes, in reference to the prior
bill, that selective contacts with women who have not
received screening are more effective than the approach
envisioned in the bill.
PRIOR ACTIONS
Assembly Floor: 50-26
Assembly Appropriations:12-5
Assembly Health: 13-6
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COMMENTS
1.Recent amendments.
Recent amendments to the bill, many of them suggested by
parties previously opposed, expand the method by which
health plans and health insurers may provide an enrollee
or insured with information regarding recommended
timelines for an individual to undergo tests for the
screening or diagnosis of breast cancer. Additionally,
the amendments expand the type of policies exempted from
requirements to provide mammography and information on
screening and diagnosis; add physician assistants to the
list of providers eligible to make a referral for a
covered mammography beginning July 1, 2010, to the extent
allowed by their scope of practice; and exclude
self-insured employee welfare benefit plans from the
requirement to provide mammography beginning July 1,
2010.
2.Self-insured employee welfare benefit plans.
According to informal guidance from Legislative Counsel,
the state does not have jurisdiction in mandating
coverage requirements for self-insured employee welfare
benefit plans.
POSITIONS
The following positions are in reference to a prior version
of the bill. It is unclear whether recent amendments change
any of the positions below.
Support: American College of Obstetricians and
Gynecologists, District IX (sponsor)
American Cancer Society
American Federation of State, County, and Municipal
Employees
BayBio
California Commission on the Status of Women
California Medical Association
City of West Hollywood
GlaxoSmithKline
Junior Leagues of California State Public Affairs
Committee
Planned Parenthood Affiliates of California
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Susan G. Komen for the Cure California Collaborative
One individual
Oppose:
Association of California Life and Health Insurance
Companies (unless
amended)
California Association of Health Plans (unless
amended)
Department of Health Care Services (prior version)
Health Net (prior version)
Office of the Insurance Advisor
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