BILL ANALYSIS
AB 113
Page 1
Date of Hearing: January 12, 2010
ASSEMBLY COMMITTEE ON HEALTH
Dave Jones, Chair
AB 113 (Portantino) - As Amended: January 4, 2010
SUBJECT : Health care coverage: mammographies.
SUMMARY : Requires health care service plan (health plan)
contracts and health insurance policies, that are issued,
amended, delivered, or renewed on or after July 1, 2011, to
provide coverage for mammography for screening or diagnostic
purposes upon referral of certain health care professionals,
regardless of age. Specifically, this bill :
1)Requires health plan contracts and health insurance policies,
that are issued, amended, delivered, or renewed on or after
July 1, 2011, to provide coverage for mammography for
screening or diagnostic purposes upon referral of certain
health care professionals, regardless of age.
2)Exempts 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.
3)Requires health plans and health insurers to provide
subscribers and policyholders with information regarding
recommended timelines for breast cancer screening or diagnosis
through written letter, publication in a newsletter,
publication in evidence of coverage, direct telephone call,
electronic transmission, 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 recommended
timelines for testing.
EXISTING LAW :
1)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).
2)Requires health plans to cover mammography for screening or
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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 by statute 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. The
author adds that the requirement in this bill that will have
insurance companies provide information to women on when to
begin screening for breast cancer will increase the number of
women receiving mammograms, save lives, and reduce treatment
costs. Providing this information will be easy to do, is
almost cost free and will increase insurance company HEDIS
scores.
2)PREVALENCE OF BREAST CANCER . According to the American Cancer
Society's "Breast Cancer Facts & Figures 2007-2008," excluding
cancers of the skin, breast cancer is the most common cancer
among women; accounting for more than one in four cancers
diagnosed in U.S. women. It is the second leading cause of
death of 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 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
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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.
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, 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 one
to two years beginning at age 40; or 50 for those women of
average risk for breast cancer. By and large, routine
baseline mammograms in women younger than 40 years are not
recommended.
In November 2009, USPSTF issued new screening guidelines that
recommend against routine screening mammography in women ages
40 to 49. The guidelines instead recommend screening every
other year for women ages 50 to 74. The recommendations state
that the decision to start regular, biennial screening
mammography before the age of 50 years should be an individual
one and take patient context into account, including the
patient's values regarding specific benefits and harms.
4)CHBRP REPORT . Pursuant to AB 1996 (Thomson), Chapter 795,
Statutes of 2002, and SB 1704 (Kuehl), Chapter 684, Statutes
of 2006, which ask the University of California to assess
legislation proposing a mandated benefit or service, or the
repeal of a mandated benefit or service, CHBRP provided an
analysis of the public health, medical, and economic impacts
of this bill. In reviewing last year's AB 56 (Portantino),
which contains substantially similar provisions to this bill,
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.
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CHBRP is in the process of updating its analysis given the
change to screening guidelines issued by USPSTF, however
CHBRP's March 2009 report stated:
a) Medical Effectiveness . 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 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 . Approximately
21.3 million individuals in California are enrolled in
health plans or policies that would be subject to the
mandate in AB 56. 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 AB 56, 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, 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, and Major Risk Medical
Insurance Program with coverage subject to AB 56 already
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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 AB 56 was not expected to affect the unit cost
of mammography or increase the mammography rate due to
increases in coverage, CHBRP indicated that utilization
would increase 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.
c) Public Health Impact . It is estimated that an
additional 20,000 mammography screenings would, over time,
prevent approximately 16 deaths per year from breast
cancer. It would take roughly 14 years following
implementation of AB 56 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 AB 56 would have translated
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. According to
CHBRP, to the extent that notification increases
mammography screening among these groups, there was the
potential for AB 56 to reduce racial/ethnic disparities in
screening rates and health outcomes associated with breast
cancer. Finally, CHBRP stated that while AB 56 would have
resulted in premium increases of less than 1%, it is
unlikely that it would have resulted in an increase in the
uninsured or contribute to the long-term health impacts of
being uninsured.
5)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
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2234 was held in the Assembly Appropriations Committee.
AB 56 (Portantino) contained provisions identical to those
contained in this bill. Governor Schwarzenegger vetoed AB 56,
stating, in part: "California has over 40 mandates on its
health care service plans and health insurance policies. While
these mandates are well-intentioned, the costs associated with
the cumulative effect of these mandates mean that these costs
are passed through to the purchaser and consumer."
REGISTERED SUPPORT / OPPOSITION :
Support
None on file.
Opposition
None on file.
Analysis Prepared by : Melanie Moreno / HEALTH / (916)
319-2097