BILL ANALYSIS
SENATE HEALTH
COMMITTEE ANALYSIS
Senator Elaine K. Alquist, Chair
BILL NO: AB 113
A
AUTHOR: Portantino
B
AMENDED: January 4, 2010
HEARING DATE: June 16, 2010
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CONSULTANT:
1
Tadeo
3
SUBJECT
Health care coverage: mammographies
SUMMARY
Requires health care service 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 by a health care professional, based on medical
need, instead of age.
CHANGES TO EXISTING LAW
Existing law:
Provides for the regulation of health care service plans
(health plans) by the Department of Managed Health Care
(DMHC) and individual or group health insurers (insurers)
by the California Department of Insurance (CDI).
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.
Requires individual or group health insurance policies and
self-insured employee welfare benefit plans to provide
coverage for mammograms, upon the referral of a physician,
Continued---
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nurse practitioner, or certified nurse-midwife, for breast
cancer screening and diagnostic purposes.
Requires individual or group health insurance policies and
self-insured employee welfare benefit plans, upon referral,
to provide at least 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.
Establishes the Physician Assistant Practice Act
administered by the Physician Assistant Committee of the
Medical Board of California (MBC) to regulate physician
assistants.
Provides that a physician assistant may perform those
medical services as set forth by the regulations of MBC
when the services are rendered under the supervision of a
licensed physician and surgeon approved by MBC, except as
otherwise provided.
This bill:
Requires every individual or group policy of health
insurance issued, amended, delivered, or renewed on or
after July 1, 2011, 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.
Incorporates a physician assistant among the list of
providers who may provide a referral for mammography that
is covered.
Incorporates a physician assistant 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, 2011.
Excludes self-insured employee welfare benefit plans from
these requirements.
Requires health plans and health insurers to provide
subscribers and policyholders with information regarding
recommended timelines for breast cancer screening or
diagnosis.
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Allows this information to be provided by a written letter,
publication in evidence of coverage or a newsletter, 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.
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 from the requirements in the
bill.
FISCAL IMPACT
According to the Assembly Appropriations Committee analysis
of AB 113, the bill would impose no direct state fiscal
impact. The analysis also states that, the new information
disclosure requirements in the bill would codify current
notification practices about mammography and other breast
cancer screening and diagnostic methods that health plans
and insurers currently follow.
BACKGROUND AND DISCUSSION
The author states that AB 113 would require insurers to
provide coverage for a mammogram when it is ordered by a
health care professional, instead of based on an arbitrary
age-based schedule, which allows health care providers to
determine when a woman should have a mammogram based on her
specific risks of developing breast cancer. The author
also states that the existing Insurance Code provisions
concerning mammography were enacted 20 years ago, and are
outdated.
The author further states that the current "one size fits
all" approach for screening and diagnosing breast cancer
endangers the lives of women who are at a higher risk of
developing breast cancer. 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.
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The author additionally states that notification about when
to start screening for breast cancer increases the number
of women receiving mammograms, resulting in a increase in
lives saved and a decrease in treatment costs. Finally,
the author argues that AB 113 will make breast cancer
screening requirements the same for health plans and
insurers.
Prevalence of breast cancer
One in nine women in California has a chance of being
diagnosed with breast cancer in her lifetime. 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, 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. The California Health Benefits Review Program
(CHBRP) reports that while white women are most likely to
get the disease, African-American women have the highest
death rate.
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, CHBRP provided an
analysis of the public health, medical, and economic
impacts of AB 56 (Portantino, 2009), which contains
substantially similar provisions to this bill.
In a letter dated January 8, 2010, CHBRP states that the
aspects of its analysis of AB 56 that concern the
mammography coverage requirements continue to be relevant
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to AB 113, but the aspects that concern the notification
requirements are not applicable to AB 113. According to
CHBRP, AB 113 differs from AB 56 in terms of who is
specified to receive notification, what the content of the
communication would be, the method of communication, and
its timing. CHBRP adds that, the communication
requirements specified in AB 113 are so broad that it is
unlikely CHBRP would be able to project any
communication-related utilization, cost, or public health
impacts for AB 113.
CHBRP also points out that AB 113 differs from AB 56 by
explicitly listing physicians assistants as providers who
may make referrals for mammography screenings, but notes
that its AB 56 analysis did not exclude any provider types,
who are licensed to order mammography screenings.
CHBRP states that the conclusions reached in the 2009
analysis of AB 56 regarding mammography coverage - that
virtually all females enrolled in CDI-regulated policies
already have coverage similar to the proposed mandate -
are relevant to AB 113. Key conclusions in CHBRP's AB 56
analysis regarding the mammography coverage requirement
relevant to AB 113 include:
Medical Effectiveness: According to CHBRP, the AB 56
analysis concluded that there is a preponderance of
evidence that, among women ages 40 years and older,
mammography screening reduces breast cancer mortality.
Evidence shows that women ages 40-49 experience a
smaller reduction in breast cancer mortality than
women 50 years of age and older, and false-positive
results are more frequent in the 40-49 year age group.
Given that both bills require coverage for
mammography screenings upon provider referral, neither
bill's language conflicts with the U.S. Preventive
Services Task Force (USPSTF) November 2009 changes to
its mammography screening recommendations. The USPSTF
currently recommends "biennial screening mammography
for women ages 50 to 74 years." It also recommends
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." The USPSTF is the only
organization cited in the AB 56 analysis known to have
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changed its recommendation since that analysis was
issued.
Utilization, Cost, and Coverage Impacts : According to
CHBRP, the analysis projected no change in coverage
due to the mammography coverage requirements in AB 56,
and, therefore, no impacts on utilization or cost, due
to the mammography requirements in AB 56.
Public Health Impacts: According to CHBRP, the
analysis projected no change in coverage due to
mammography coverage requirements in AB 56, and
therefore, no impacts on utilization or public health,
due to the mammography coverage requirements in AB 56.
CHBRP concludes that, because the impacts presented in its
analysis of AB 56 are almost exclusively related to the
notification requirement, the differing communication
requirements in AB 113 would probably result in lower
impact or no impact estimates for utilization, cost, and
public health were CHBRP to analyze AB 113.
National breast cancer screening guidelines and safety
Several organizations have adopted evidence-based national
recommendations for breast cancer. The U.S. Preventive
Services Task Force (USPSTF) issued new screening
guidelines in November 2009 that recommend against any
routine mammography screening for women 40 to 49 years of
age, and instead recommend routine screening every other
year for women 50 to 74 years of age. The USPSTF states
that, while there is evidence that screening with film
mammography reduces breast cancer mortality, there is a
greater absolute reduction for women ages 50 to 74 years
than for younger women. The USPSTF reports that harm due
to screening includes false-positive results, additional
medical visits and imaging, biopsies in women without
cancer, and unnecessary treatment and radiation exposure.
These recommendations apply to women who are not at
increased risk for breast cancer by virtue of a known
underlying genetic mutation or history of chest radiation.
The American Academy of Family Physicians and the American
College of Physicians guidelines are similar to the USPSTF
guidelines.
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The American Cancer Society continues to recommend annual
screening using mammography and clinical breast examination
for all women beginning at age 40, and that women with a
higher risk of breast cancer consult a doctor about the
best approach for them, which could mean starting
mammograms when they are younger, having extra screening
tests, or having more frequent exams. The American Medical
Association and the College of Obstetrics and Gynecology
follow similar guidelines.
Both the USPSTF and the American Cancer Society find that
mammography has limitations - some women who are screened
will have false alarms, some cancers will be missed, some
women will undergo unnecessary treatment, but both agree
that the overall effectiveness of mammography increases
with increasing age.
The Breast Cancer Fund, a non-profit organization dedicated
to examining breast cancer and exposure to chemical and
radiation links, states that there is evidence that medical
X-rays (including mammography, fluoroscopy and CT scans)
are an important and controllable cause of breast cancer.
Although X-rays have been a valuable diagnostic tool for
more than a century, the radiation dose has not always been
carefully controlled and sometimes has been higher than
needed to obtain high quality images. Fortunately, the dose
given per X-ray has been drastically reduced over the past
several decades and the regulatory oversight of equipment
and personnel has increased. In mammography, efforts to
reduce the radiation dose to lower levels has been achieved
without compromising image quality. Digital mammography can
yield doses that are one-third those of conventional
mammography. According to the Centers for Disease Control,
mammography is the best available method to detect breast
cancer in its earliest, most treatable form.
Physician assistants
Physician assistants, under the supervision of a physician,
are authorized to perform medical services in all modes of
practice and medical specialty by regulations adopted by
the MBC. The medical services that physician assistants
are authorized to perform include conducting patient
histories and examinations, ordering X-rays, diagnostic
studies, physical therapy and nursing services, instituting
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treatment procedures, initiating hospital admissions,
ordering medications and performing various surgical
procedures.
A physician assistant and his or her supervising physician
and surgeon establish written guidelines for the adequate
supervision of the physician assistant, which may be
satisfied by the adoption of protocols for some or all of
the tasks performed by the physician assistant. The
protocol must meet requirements specified by law.
Related bills
SB 836 (Oropeza) requires DPH to provide breast cancer
screening and diagnostic services to any individual 40
years of age or older, and to provide services to any
individual who is symptomatic, upon a doctor's
recommendation, if other state eligibility criteria are
met. Expresses legislative intent to "fully meet the
demand" for the Every Woman Counts program based on
eligibility guidelines in place as of December 31, 2009
which includes women 40 years of age and older. Requires
DPH to notify the Joint Legislative Budget Committee at
least 90 days prior to changing eligibility requirements
for services or reducing access to screening services..
This bill was held in Senate Appropriations Committee.
AB 1640 (Evans, Nava) reverses new administrative policy
changes regarding eligibility and enrollment requirements
for breast cancer screenings covered under "Every Woman
Counts," a state program designed for low-income women who
are uninsured or
underinsured. This bill is currently in the Senate Rules
Committee.
Prior legislation
AB 56 (Portantino) of 2009 contained provisions identical
to those contained in this bill and was vetoed by Governor
Schwarzenegger. In his veto address he stated, in part,
"The addition of a new mandate, no matter how small, will
only serve to increase the overall cost of health care."
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
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and health insurers to notify female enrollees or
policyholders in writing of their eligibility for testing.
This bill was held in the Assembly Appropriations
Committee.
Arguments in support
The American Congress of Obstetricians and Gynecologists,
District IX, California (ACOG), sponsor of AB 113, states
that the idea of the bill is two-fold; to rectify a
discrepancy and medical inaccuracy in the Insurance Code
relative to mammography coverage, and to make women aware
of their coverage. ACOG points out that the Knox-Keene Act
regulating HMOs provides for mammography upon referral by a
physician or other appropriate health care provider. ACOG
notes that the Insurance Code cites a baseline mammography
at age 35, which is no longer the standard, provides for
mammography at age 40, which is appropriate, but makes no
provision for higher risk women that may need a mammography
prior to age 40. ACOG contends that clarifying the
Insurance Code could reduce administrative costs incurred
by patients having to fight with insurers over inconsistent
sections of law; and that the notice required by the bill
should be able to be done with existing resources.
The American Cancer Society states that AB 113 would make
changes to the existing mammography coverage for
CDI-regulated plans by allowing health care providers the
flexibility to provide the most appropriate mammography
services.
Arguments in opposition
The Department of Health Care Services states that AB 113
is unnecessary, as it related to Medi-Cal managed health
plans, because these plans already send out materials
educating their members on the importance of preventive
care, including breast cancer screening.
COMMENTS
1. Technical amendment. AB 113 is intended to create
consistent standards for breast cancer screening between
health plans and health insurers. However the bill leaves
current insurer coverage provisions in place, creating
conflicting standards. A suggested amendment would be to
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sunset the current health insurer provisions consistent
with the date the provisions provided for in this bill
would begin.
Suggested amendment:
On page 4, lines 19 - 26:
10123.81. (a) On or after January 2000 Until June 30, 2011 ,
every individual or group policy of disability insurance or
self-insured employee welfare benefit plan that is issued,
amended, or renewed, shall be deemed to provide coverage
for at least the following, upon the referral of a nurse
practitioner, certified nurse-midwife, or physician,
providing care to the patient and operating within the
scope of practice provided under existing law for breast
cancer screening or diagnostic purposes:
PRIOR ACTIONS
Assembly Health: 18-0
Assembly Appropriations: 17-0
Assembly Floor: 68-0
POSITIONS
Support: American Congress of Obstetricians and
Gynecologists, District IX, CA
(sponsor)
American Cancer Society
BayBio
California Academy of Physician Assistants
California Medical Association
California Nurse-Midwives Association
City of West Hollywood
GlaxoSmithKline
Planned Parenthood Advocacy Project Los Angeles
County
Planned Parenthood Affiliates of California
Planned Parenthood of Santa Barbara, Ventura and San
Luis Obispo Counties,
Inc.
Susan G. Komen for the Cure (seven California
affiliates)
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Oppose: Department of Health Care Services
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