Download Assembly Appropriations

AB 2764
Page 1
Date of Hearing: May 11, 2016
ASSEMBLY COMMITTEE ON APPROPRIATIONS
Lorena Gonzalez, Chair
AB 2764 (Bonilla) – As Amended March 18, 2016
Policy Committee:
Health
Vote:
11 - 3
Urgency: No
State Mandated Local Program: Yes
Reimbursable: No
SUMMARY:
This bill requires coverage of mammography by health plans and insurers to include digital
mammography and digital breast tomosynthesis (DBT).
FISCAL EFFECT:
1) According to the California Health Benefits Review Program (CHBRP):
a) Costs to Medi-Cal of $12.8 million (GF/federal), and costs to CalPERS of $1.4 million
(GF/federal/special/local).
b) Increased employer-funded premium costs in the private insurance market of
approximately $17.8 million.
c) Increased premium expenditures by employees and individuals purchasing insurance of
$18.3 million, and reduced total out-of-pocket expenses of $10.8 million (based on $11.7
million in newly covered benefits, offset by cost-sharing of $0.9 million).
2) CHBRP also notes utilization of DBT and related costs may grow further in future years.
CHBRP only estimates costs for a 12-month period post-mandate. With an estimated twothirds of machines DBT-ready in 2017, CHBRP projections assume an increase of the
portion of digital mammograms accompanied by DBTs - from near 30% to near 50%. In
future years, as more DBT-ready machines become available, DBTs could accompany as
many as 90% of digital mammograms.
This increased utilization appears to suggest costs could be higher than noted here within one
to two years after the projection horizon, but CHBRP costs beyond the first year are difficult
to estimate due to changing breast cancer screening and treatment technology. CHBRP also
assumes DBT is provided without cost-sharing, as it is a preventive screening test.
3) Ongoing costs of $480,000 to the Department of Managed Care (DMHC) for an expected
increase in complaints and independent medical reviews based on denial of coverage due to
questions of medical necessity. (Managed Care Fund).
4) Minor costs to the California Department of Insurance (Insurance Fund) and DMHC,
(Managed Care Fund) to verify health plans and insurers comply with this requirement.
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COMMENTS:
1) Purpose. According to the author, patients are being billed for DBT since health plans are
not providing coverage on the basis that DBT is investigational. The sponsor of this bill, the
California Radiological Society, states the use of DBT in addition to two-dimensional (2D)
mammography will detect more cancers early on, reduce false positives, and help reduce
health care costs associated with high recall rates as well as false positives.
2) Background. Mammography provides an x-ray picture of the breast, and can be conducted
as a screening or diagnostic test. As a screening test, its purpose is to identify potentially
cancerous abnormalities in asymptomatic women. As a diagnostic test, it further investigates
identified abnormalities or checks for abnormalities among women previously treated for
breast cancer. DBT takes multiple cross-sectional images of the breast and then uses a
computer algorithm to reconstruct a three-dimensional image. Digital mammography is
frequently used as a breast cancer screening test. Less frequently, DBT is added to digital
mammography when screening for breast cancer.
3) Current coverage guidelines and Essential Health Benefits (EHBs). The federal
Affordable Care Act (ACA) requires health plans in the individual and small-group markets
to cover ten types of health benefits, called EHBs. EHBs include preventive services without
cost-sharing, for all preventive services given a high grade of evidence by the United States
Preventive Services Task Force (USPSTF), an independent, volunteer panel of national
experts in prevention and evidence-based medicine. Mammography is recommended by
USPSTF for certain women and is covered with no cost-sharing.
For any new state mandate that exceeds EHBs as defined in the ACA, the state must make
payments to defray the cost of those additionally mandated benefits, either by paying the
covered individual or employer directly, or by paying the plan. Although this mandate
requires coverage of DBT, which is currently not covered by some plans, DBT is a form of
mammography. Since mammography is already required to be covered, CHBRP indicates
this bill does not appear to exceed EHBs and therefore poses no additional fiscal risk to the
state associated with exceeding EHBs.
4) Screening results in benefits and harms. It is important to understand that while screening
is beneficial for women whose cancer is detected early, it can also cause harm. USPSTF
recommendations, for example, are based on an assessment of net benefit—identified
benefits minus identified harms. Routine screening is intended to catch the development of
disease early enough for treatment to be beneficial. However, screening can lead to harms
such as incorrect diagnosis; unnecessary diagnostic tests and treatment; anxiety,
psychological harm, and lost productivity; and unnecessary radiation exposure from the Xrays used in mammography. On balance, routine screening is usually recommended for a
population if the benefits (like early detection of dangerous and treatable cancers) outweigh
the harms.
5) Breast cancer screening recommendations. There is consensus on the benefit of screening
mammography from many nationally recognized groups. CHBRP states clinical guidelines
from the American Academy of Family Physicians (AAFP), American Congress of
Obstetrics and Gynecology (ACOG), American College of Radiology (ACR), American
Cancer Society (ACS), National Comprehensive Cancer Network (NCCN), and USPSTF all
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recommend mammography for breast cancer screening. Mammography is also used in
diagnosis, to follow up on a clinical finding or a screening mammogram.
Currently, there are no clinical guidelines recommending the use of DBT for breast cancer
screening or diagnosis. The ACR has found that DBT is no longer an investigational
modality and “improves key screening parameters compared to digital mammography,” but
October 2015 ACS guidelines, as well as recommendations from AAFP, ACOG, NCCN, and
USPSTF have cited insufficient evidence to recommend the use of DBT as a screening tool
for breast cancer. The recent USPSTF and ACS recommendations on breast cancer
screening were based on systematic evidence reviews by experts.
In sum, CHBRP finds this bill appears to increase costs and utilization of screening tests with
little evidence of meaningful clinical benefits, such as improvements in morbidity, diseasefree survival, or mortality.
6) Support. The California Radiological Society, the sponsor of this bill, contends this mandate
ensures coverage of the state of the art in breast cancer screening and diagnosis, DBT offers
higher accuracy and lower call-backs, and higher accuracy will lower costs overall. They
state DBT allow radiologists to identify small cancers at an earlier stage while they are more
treatable. They note a number of independent medical reviews have overturned plan
decisions to deny coverage for DBT.
7) Opposition. Health plans and insurers, as well as the California Chamber of Commerce,
oppose this bill. Plans state the USPSTF has specifically stated it does not support the blanket
use of DBT because studies have not demonstrated an improvement in patient outcomes, a
decrease in the occurrence of disease, or a decrease in the amount of treatment. They also state
more generally that mandates raise premiums at a time when health care affordability is a
significant issue for families.
Analysis Prepared by:
Lisa Murawski / APPR. / (916) 319-2081