BILL ANALYSIS
SENATE HEALTH
COMMITTEE ANALYSIS
Senator Elaine K. Alquist, Chair
BILL NO: AB 359
A
AUTHOR: Nava
B
AMENDED: June 2, 2009
HEARING DATE: July 8, 2009
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CONSULTANT:
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Tadeo/
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SUBJECT
Breast and cervical cancer: early detection screening:
digital mammography: reimbursement rates
SUMMARY
Allows, for all mammography screenings conducted prior to
January 1, 2014, providers in the Every Woman Counts
program to employ digital mammography technology when
analog technology is not available, and limits the digital
mammography screening reimbursement rate to the Medi-Cal
reimbursement rate for analog mammography.
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.
CHANGES TO EXISTING LAW
Existing federal law:
Creates, under the Breast and Cervical Cancer Mortality
Prevention Act of 1990, 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
Continued---
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eligible women, 40 years of age and older.
Existing state law:
Establishes the Breast Cancer Control Program, administered
by DPH, to provide breast and cervical cancer screening
services under the CDC grant at the level of funding
budgeted from state and other resources during the fiscal
year in which the Legislature has appropriated funds for
this purpose. These screenings are provided under the
Every Woman Counts program and are not deemed an
entitlement.
Establishes the Medi-Cal Program, administered by DHCS,
under which qualified low-income persons receive health
care benefits.
Requires provider rates of payment for screening services
in the Every Woman Counts program, to be identical to the
rates of payment for the same services performed by the
same provider type pursuant to the Medi-Cal Program.
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.
This bill:
Allows providers in the Every Woman Counts program to
employ digital mammography technology when analog
technology is not available for all mammography screenings
conducted prior to January 1, 2014.
Requires the Every Woman Counts program to cover digital
mammography screening when analog mammography services are
not available from an EWC provider. Limits the digital
mammography screening reimbursement rate to the Medi-Cal
reimbursement rate for analog mammography.
Authorizes 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.
FISCAL IMPACT
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According to the Assembly Appropriations Committee analysis
of AB 359, a one-time cost of less than $10,000 General
Fund for DHCS to update payment systems.
BACKGROUND AND DISCUSSION
The author states that, the Every Woman Counts Program
reimburses for breast cancer screening only if performed on
analog equipment, but that 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
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 contends that, AB 359 is
important to assure California's underinsured and uninsured
women are receiving the coverage they need to diagnose and
treat breast cancer at its earliest stage.
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 of surviving than
in the past. Since 1973, according to the CBCRP, the
breast cancer death rate in California has dropped 20
percent, even though 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. 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.
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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. 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.
Every Woman Counts program
The Cancer Detection Section of DPH administers the Every
Woman Counts program, which 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:
Are 40 years of age or older;
Live in California;
Have no health insurance or a co-payment or
deductible they cannot afford; and,
Have a family income below 200 percent 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 Every Woman Counts program.
Approximately 270,000 women, or 20-24 percent of the
eligible women actually obtained Every Woman Counts
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 Every Woman Counts; these PCPs refer patients
to Medi-Cal providers for breast cancer screening services,
which include clinical breast exams, screening mammograms,
and diagnostic work-ups. Every Woman Counts services may
also include additional screening or diagnostic procedures
if an exam or mammogram is found to be 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.
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The Every Woman Counts program is funded by the federal
Breast and Cervical Cancer Mortality Prevention Act of
1990, the California Breast Cancer Act of 1993 and
Proposition 99 tobacco tax funds. Every $3 of federal
funds must be matched by $1 of non-federal resources. For
FY 2008-09, the Every Woman Counts 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.
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:
Improved contrast between dense and non-dense
breast tissue;
Faster image acquisition;
Shorter exam time;
Easier image storage;
Physician manipulation of breast images for more
accurate detection; and,
Transmittal of images over phone lines or a network
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for remote consultation with other physicians.
Digital mammography systems cost between 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.
Arguments in support
Proponents state that, as more and more providers
transition to digital mammography equipment, analog
mammography becomes less available and women who depend on
this screening through the Every Woman Counts Program face
an access issue. Proponents further state that, AB 359
would ensure that a screening option is still available in
the absence of analog mammography. Proponents contend that
early breast cancer screening leads to early diagnosis
which means a much higher survival rate, and AB 359 would
ensure that women have access to this basic screening tool.
Related bills
AB 56 (Portantino) would require health insurers to provide
coverage for mammography upon provider referral, and health
plans and health insurers to notify female enrollees or
insureds in writing of their eligibility for testing.
Pending in the Senate Health Committee.
Prior legislation
AB 2035 (Ma, 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. This bill was amended to address
a different issue.
AB 2887 (Berg, 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. This bill was held under submission on
the Assembly Appropriations Committee suspense file.
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SB 1348 (Cedillo, 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. This bill was held under submission on
the Senate Appropriations Committee suspense file.
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.
AB 2055 (Freidman), Chapter 661, Statutes of 1993,
establishes the Breast Cancer Control Account for purposes
of breast cancer research, detection services and
education. Modifies the allocation of tobacco tax funds so
that 50 percent of the funds are devoted to research and 50
percent for early detection services for uninsured and
underinsured women.
COMMENTS
1) Correction of drafting error in the language.
It is the author's intention to limit AB 359 to services
in the Every Woman Counts program. A drafting error in
the bill authorizes 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. The
language should apply to the Every Woman Counts program
only.
Suggested amendments:
Page 3, after line 3, add:
(C) For the purposes of this section, digital mammography
screening may be reimbursed, pursuant to Section
14132.16, but only at the analog rate , and only if the
provider agrees to receive reimbursement in full at the
analog rate.
Page 3, line 36 - page 4, line 2:
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(3) Except as specified in Section 14132.165 104150. (b)
of the Health and Safety Code , the Breast and Cervical
Cancer Early Detection Program established pursuant to
Article 1.5 (commencing with Section 104150) of Chapter 2
of Part 1 of Division 103 of the Health and Safety Code
and the breast cancer programs specified in Section
30461.6 of the Revenue and Taxation Code.
Page 4, lines 19 - 25:
SEC. 3. Section 14132.165 is added to the Welfare and
Institutions Code, immediately following Section
14132.16, to read:
14132.165. Digital mammography screening may be
reimbursed pursuant to Section 14132.16, but only at the
analog rate and only if the provider agrees to receive
reimbursement in full at the analog rate.
PRIOR ACTIONS
Assembly Floor: 77-1
Assembly Appropriations:12-5
Assembly Health: 17-0
POSITIONS
Support: American Cancer Society
American College of Obstetricians and
Gynecologists, District IX/CA
American Federation of State, County and
Municipal Employees, AFL-CIO
California Communities United Institute
California Primary Care Association
California Radiological Society
City and County of San Francisco
County of Santa Barbara
Medical Oncology Association of Southern
California, Inc.
Oppose: None received
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