BILL ANALYSIS
AB 359
Page 1
Date of Hearing: April 28, 2009
ASSEMBLY COMMITTEE ON HEALTH
Dave Jones, Chair
AB 359 (Nava) - As Amended: April 15, 2009
SUBJECT : Breast and cervical cancer: early detection
screening: digital mammography:
reimbursement rates.
SUMMARY : Requires coverage of digital mammography screening
through the Department of Public Health (DPH) Every Woman Counts
(EWC) Program and the Medi-Cal Program, as specified.
Specifically, this bill :
1)Requires DPH to cover digital mammography screening when
analog mammography services are not available from an EWC
provider.
2)Permits DPH to authorize coverage of digital mammography
screening when digital and analog mammographies are both
available from an EWC provider.
3)Authorizes DPH to reimburse a provider for digital mammography
only if the provider agrees to receive reimbursement in full
at the analog rate.
4)Authorizes the Department of Health Care Services (DHCS) to
reimburse a provider for digital mammography in the Medi-Cal
Program only at the analog mammography rate and only if the
provider agrees to receive reimbursement in full at the analog
rate.
EXISTING LAW :
1)Establishes the California Breast Cancer Act of 1993 which
mandates 50% of the revenues collected from a two-cent tax on
tobacco products for breast cancer control.
2)Establishes in federal law the Breast and Cervical Cancer
Mortality Prevention Act of 1990 which creates the National
Breast and Cervical Cancer Early Detection Program and
authorizes the Centers for Disease Control and Prevention
(CDC) to administer grants to states for screening services
for underserved eligible women, 40 years of age and older.
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3)Requires DPH to provide for breast and cervical cancer
screening services under the grants in 2) above, at the level
of funding budgeted from state and other resources during the
fiscal year (FY) in which the Legislature has appropriated
funds for this purpose. These screenings are provided under
the EWC Program and are not deemed an entitlement. Provides
that analog mammography is covered by the EWC Program.
4)Establishes the Medi-Cal Program, administered by DHCS, and
under which qualified low-income persons receive health care
benefits. Requires DHCS to cover mammography to the extent
required or permitted by federal law. Medi-Cal reimbursement
for analog mammography is currently $70 and for digital
mammography, $133.
FISCAL EFFECT : This bill has not yet been analyzed by a fiscal
committee.
COMMENTS :
1)PURPOSE OF THIS BILL . The author states the EWC Program
reimburses for breast cancer screening only if performed on
analog equipment. However, the author reports mammography
providers are increasingly converting to digital equipment,
leaving large areas of the state without an analog provider
and requiring women in some areas to travel over two hours for
a free mammogram. The author argues that this barrier has
reduced the number of women who obtain mammograms, thereby
reducing early detection and treatment and putting their lives
at risk. The author states this bill will be an important
step towards ensuring California's underinsured and uninsured
women are receiving the coverage they need to diagnose and
treat breast cancer at its earliest stage.
2)BACKGROUND . According to a California Cancer Registry (CCR)
report, "Cancer in California, 2008," among women, breast
cancer is the most commonly diagnosed cancer and the second
most common cause of cancer death. CCR estimated that in
2008, more than 21,000 California women would be diagnosed
with primary breast cancer, and more than 4,200 California
women would die from the disease. According to the California
Breast Cancer Research Program (CBCRP), because of early
detection through widespread mammogram screening, a California
woman diagnosed with breast cancer today has a better chance
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of surviving than in the past. Since 1973, according to the
CBCRP, the breast cancer death rate in California has dropped
20%. However, 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 early stage, receive effective treatment, and
survive the disease. According to CBCRP, white women are most
likely to get the disease, followed closely by
African-American women, then Asian Pacific Islander women,
with the lowest rate among Hispanic women. African-American
women have the highest death rate, even though they are less
likely than white women to get the disease. Death rates for
Asian Pacific Islander and Hispanic women, although they were
lower to begin with, have not improved in recent years.
Income level also matters. According to CBCRP, low-income
women are less likely to survive breast cancer, in part
because their tumors are more likely to be caught later, when
treatment is less successful.
3)EVERY WOMAN COUNTS PROGRAM . According to DPH's Internet Web
site, the Cancer Detection Section of DPH administers the EWC
program and has provided access to breast and cervical cancer
screening and diagnostic services to medically underserved
women since 1991. Breast cancer screening services are
provided free to women who meet the following qualifications:
a) Are 40 years of age or older; b) Live in California; c)
Have no health insurance or a co-payment or a deductible they
cannot afford; and, d) Have a family income below 200% of the
federal poverty level. According to DPH, based on the 2000
Census, approximately 1.2 million women were eligible for
breast cancer screening services under the EWC program.
Approximately 270,000 women, or 20-24% of the eligible women
actually obtained EWC services in FY 2007-08. To date, the
Cancer Detection Section of DPH has been able to serve all
eligible women seeking services.
Approximately 1,000 primary care providers (PCPs) are enrolled
in EWC; these PCPs refer patients to Medi-Cal providers for
breast cancer screening services, which include clinical
breast exams, screening mammograms, and diagnostic work-ups.
EWC services may also include additional screening or
diagnostic procedures if an exam or mammogram is found to be
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abnormal. EWC does not provide cancer treatment. If a woman
is diagnosed with breast or cervical cancer, treatment
services are available for qualified women through the
Medi-Cal Breast and Cervical Cancer Treatment Program (BCCTP)
or a state-funded BCCTP.
The EWC program is funded by the federal Breast and Cervical
Cancer Mortality Prevention Act of 1990 (Public Law 101-354),
the California Breast Cancer Act of 1993 and Proposition 99
tobacco tax funds. Every $3 of federal funds must be matched
by $1 of nonfederal resources. For FY 2008-09, the EWC
clinical claims program budget for breast cancer screening
includes $3.45 million federal funding; approximately $5.96
million from the Breast Cancer Control Account, a special
state fund from revenues collected from a two-cent tax on
tobacco products for breast cancer control; and approximately
$26.6 million from Proposition 99 tobacco tax funds.
4)DIGITAL MAMMOGRAPHY . One of the most recent advances in X-ray
mammography is digital (computerized) mammography. Digital
mammography is similar to standard (analog) mammography in
that X-rays are used to produce detailed images of the breast.
Digital mammography uses essentially the same mammography
system as analog mammography, but the system is equipped with
a digital receptor and a computer instead of a film cassette.
To date, studies of digital mammography and standard analog
mammography have shown that digital mammography is generally
comparable to analog in terms of detecting breast cancer. In
2001, the National Cancer Institute (NCI) initiated a large
trial to compare the two types of mammography. NCI released
preliminary findings which showed no difference in detecting
breast cancer for the general population of women. However,
NCI reported that women who had dense breasts, were younger
than age 50, or had reached or were near menopause, may
benefit from digital, rather than analog mammography. A study
published in the March 2001 issue of Radiologic Clinics of
North America also found that the use of digital mammography
can lead to fewer callbacks (repeat mammograms) than analog
mammography. Other reported benefits of digital mammography
include: a) Improved contrast between dense and non-dense
breast tissue; b) Faster image acquisition; c) Shorter exam
time; d) Easier image storage; e) Physician manipulation of
breast images for more accurate detection; and, f) Transmittal
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of images over phone lines or a network for remote
consultation with other physicians.
Digital mammography systems cost approximately one and one-half
to four times as much as standard analog mammography systems.
While procedural time saved by using digital mammography over
standard analog mammography justifies part of the cost for
facilities that perform several thousand mammograms each year,
studies are currently underway to determine whether the high
cost of digital mammography is justifiable in terms of its
benefits in detecting breast cancer.
5)SUPPORT . The County of Santa Barbara, sponsor of this bill,
writes in support of this bill that its public health
department administers EWC for Santa Barbara, Ventura, and San
Luis Obispo Counties. The County of Santa Barbara states
2,248 regional clients are impacted by the lack of access to
analog mammography, and this bill would allow providers to
provide digital mammography in areas where there is no access
to analog mammography. The County of Santa Barbara further
argues this bill will not cost the state additional money.
The American College of Obstetricians and Gynecologists,
District IX (California) writes in support of a prior version
of this bill that as more radiologists replace their old
equipment with newer digital equipment, there may be
communities where only digital mammography is available. The
City and County of San Francisco writes in support of a prior
version that the San Francisco Department of Public Health
participates in EWC and that most providers have upgraded to
digital mammography in recent years and this bill will prevent
the need for travel when analog mammography is not an option.
The American Cancer Society (ACS) writes in support of a prior
version that the federal government has revised its thinking
on coverage for digital mammography reimbursement. ACS writes
digital mammography is currently twice as expensive as analog
mammography and it is important to ensure coverage for analog
mammography is still an available option when offered, and
encourages the consideration of intent language that
encourages use of analog mammography when available. The
Medical Oncology Association of Southern California, Inc.
writes in support of a prior version that this bill will
assist greatly in the fight against breast cancer by ensuring
California's uninsured and underinsured women are getting the
coverage needed to diagnose and treat breast cancer in its
earliest stage. The California Primary Care Association
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writes in strong support of the prior version of this bill
that in rural areas, often only digital mammography is
available, and the provider or clinic is either not reimbursed
or must refer the patient to a provider that can provide
analog mammography. The American Federation of State, County,
and Municipal Employees, AFL-CIO writes it supports this bill
because it ensures people of color, who make up the majority
of Californians in poverty, are provided with care.
6)RELATED AND PREVIOUS LEGISLATION .
a) AB 56 (Portantino), pending in the Assembly, requires
health insurers to provide coverage for mammography upon
provider referral, and requires health plans and health
insurers to notify female enrollees or insureds in writing
of their eligibility for testing.
b) AB 2035 (Ma) introduced in 2008 would have declared the
intent of the Legislature to enact an increase in funding
for mammograms for women participating to the Breast and
Cervical Cancer Early Detection Program. AB 2035 was
subsequently amended to address domestic violence.
c) AB 2887 (Berg) of 2008 was nearly identical to this
bill, except it did not include Medi-Cal provisions or a
requirement that the provider agree to receiving payment at
the analog rate. AB 2887 was held under submission on the
Assembly Appropriations Committee suspense file.
d) SB 1348 (Cedillo) also of 2008 would have required DPH
to provide breast cancer screening services to women who
are 38 years of age and older and who meet other
eligibility standards for breast cancer screening services
under existing state and federal law. SB 1348 was held
under submission on the Senate Appropriations Committee
suspense file.
e) AB 478 (Friedman), Chapter 660, Statutes of 1993,
establishes a two-cent tax on each pack of cigarettes sold,
with the revenue deposited in the Breast Cancer Fund and
divided equally between the Breast Cancer Research Account
and the Breast Cancer Control Account.
f) AB 2055 (Freidman), Chapter 661, Statutes of 1993,
establishes the Breast Cancer Control Account for purposes
of breast cancer research, detection services and
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education; and modifies the allocation of tobacco tax funds
so that 50% of the funds are devoted to research and 50%
for early detection services for uninsured and underinsured
women.
7)DRAFTING CONCERN . The sponsor states that their intention for
the recent amendment, which includes the Medi-Cal provision,
is to allow a Medi-Cal provider to be reimbursed for digital
mammography at the analog rate if he or she chooses. However,
as this bill is drafted, it could be interpreted to limit
reimbursement for digital mammography to the analog rate. The
author may wish to clarify the language in order to better
reflect their intent.
REGISTERED SUPPORT / OPPOSITION :
Support
County of Santa Barbara (sponsor)
American Cancer Society (prior version)
American College of Obstetricians and Gynecologists, District IX
/ CA (prior version)
American Federation of State, County, and Municipal Employees,
AFL-CIO
California Communities United Institute (prior version)
California Primary Care Association (prior version)
City and County of San Francisco (prior version)
Medical Oncology Association of Southern California, Inc. (prior
version)
Opposition
None on file.
Analysis Prepared by : Tanya Robinson-Taylor and Allegra Kim /
HEALTH / (916) 319-2097