BILL ANALYSIS �
Senate Appropriations Committee Fiscal Summary
Senator Christine Kehoe, Chair
SB 173 (Simitian)
Hearing Date: 5/23/2011 Amended: 5/4/2011
Consultant: Katie Johnson Policy Vote: Health 7-1
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BILL SUMMARY: SB 173 would require a health care practitioner
who performs a mammography examination, pursuant to requirements
on health care service plans and health insurers to cover
mammography for purposes of breast cancer screening and
diagnosis, to include a specified notice in the summary of the
written report sent to a patient identified as having dense
breast tissue.
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Fiscal Impact (in thousands)
Major Provisions 2011-12 2012-13 2013-14 Fund
Potential increased follow-up low hundreds of thousands to
General/*
screening Medi-Cal millions of dollars Federal
Potential increased follow-up low hundreds of thousands to
General/**
screening CalPERS millions of dollars Special/
Federal/
Other
*Medi-Cal costs shared 50 percent General Fund, 50 percent
federal funds.
**CalPERS costs shared 55 percent General Fund, 45 percent
special and other funds.
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STAFF COMMENTS: This bill meets the criteria for referral to the
Suspense File.
This bill would require a health care practitioner who performs
a mammography examination to include a notice in the summary of
the written report sent to a patient identified as having dense
breasts that would say, "Because your mammogram demonstrates
that you have dense breast tissue, which could hide small
abnormalities, you might benefit from supplementary screening
SB 173 (Simitian)
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tests, depending on your individual risk factors. A report of
your mammography results, which contains information about your
breast density, has been sent to your physician's office and you
should contact your physician if you have any questions or
concerns about this report."
Only health care practitioners performing mammography pursuant
to the requirements on health care service plans and health
insurers to cover mammography for purposes of breast cancer
screening and diagnosis would be subject to these provisions.
This would include practitioners performing mammography for
Medi-Cal managed care plan beneficiaries and individuals with
health care coverage through the California Public Employees
Retirement System (CalPERS).
To the extent that 1) a patient is identified as having
heterogeneously dense or extremely dense breasts and receives
this notice in the summary of the mammography report, 2) that
the patient in #1 reads the notice, and 3) acts on the notice
and schedules a follow-up appointment with her primary care
physician that she otherwise would not have scheduled had she
not received the notice, there would be an increased amount of
physician follow-up visits.
Additionally, if the physician orders supplementary testing,
such as an ultrasound or a breast magnetic resonance imaging
test (BMRI), there would be additional utilization of services.
Finally, if a physician were to order a BMRI, there could be
greater risk of false positives, according to a research review
conducted by the California Health Benefits Review Program
(CHBRP), and therefore of invasive diagnostic testing.
According to the SB 173 CHBRP analysis, there are 5.2 million
mammograms, at a unit cost of $190, performed for health plan
and health insurer enrollees annually and approximately 47
percent of women have dense breast tissue. If those women read
and acted on the required notice, there could be an increase in
utilization of breast cancer screening benefits than there would
have been without this bill. Potential costs to Medi-Cal and
CalPERS, in total for both programs and all funding sources,
would be in the hundreds of thousands of dollars to low millions
on the low estimate and in the millions of dollars on the higher
estimate. Medi-Cal costs would be shared 50 percent General Fund
SB 173 (Simitian)
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and 50 percent federal funds, and CalPERS costs would be shared
55 percent General Fund and 45 percent special and other funds.
(Lower estimate: if 10 percent of women with dense breast tissue
acted on the notice and saw their doctor and if 10 percent - 50
percent of them received follow-up screening; higher estimate:
if 50 percent of women with dense breast tissue acted on the
notice and saw their doctor and if 10 - 50% of them received
follow-up screening).
Literature reviews by CHBRP concluded the following about
BMRI-1) the high sensitivity of BRMI may be useful to identify
breast cancers in a target population of high risk women; 2)
false-positive rates of BMRI are twice as high as those for
mammography; and 3) there is insufficient evidence that BMRI
screening decreases breast cancer mortality and improves health
outcomes. There are approximately 51,000 BMRIs performed on
enrollees annually in health plans and policyholders of health
insurance policies at a unit cost of $1,750.
Literature reviews by CHBRP concluded the following about Breast
Ultrasound-1) there is insufficient evidence that ultrasound
improves the sensitivity of breast cancer screening when used to
screen asymptomatic women with dense breast tissue or those
considered high risk; 2) false-positive rates for breast
ultrasound was twice as high as that of mammography; 3) there is
insufficient evidence that breast ultrasound screening decreases
breast cancer mortality and improves health outcomes. There are
approximately 487,000 ultrasounds performed annually on
enrollees in health plans and policyholders of health insurance
policies at a unit cost of $186.
The average per unit cost includes additional follow-up services
to verify screening results; however, in contrast to
mammography, baseline utilization and per-unit costs for breast
ultrasound and BMRIs cannot distinguish between screening and
diagnostic utilization.