Legislature(2005 - 2006)CAPITOL 17
02/06/2006 03:15 PM LABOR & COMMERCE
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HB 393-INSURANCE FOR COLORECTAL CANCER SCREENING CHAIR ANDERSON announced that the first order of business would be HOUSE BILL NO. 393, "An Act requiring that certain health care insurance plans provide coverage for the costs of colorectal cancer screening examinations and laboratory tests; and providing for an effective date." HEATH HILYARD, Staff to Representative Anderson, Alaska State Legislature, Sponsor, explained that this bill will establish a minimum standard requirement that colorectal cancer screening be provided in healthcare policies in Alaska, particularly to those individuals who are over 50 years of age. He added that this is important because colorectal cancer, if caught in the early stages, has a 90 percent survival rate; however, if caught late, the survival rate is around 10 percent. 3:31:28 PM EMILY NENON, Alaska Government Relations Director, American Cancer Society (ACS), stated that she has been researching this legislation for 4 years. She explained that colorectal cancer is the second leading cause of cancer deaths in the United States, adding that Alaska has an above average rate for colon cancer in the general population. She went on to say that the Alaska Native population has the highest rate of colon cancer of any population group in the country. Ms. Nenon also explained that [via a colonoscopy, the doctor] can remove polyps before they become cancerous, adding that this is the only screening tool available that can prevent cancer. She stated that a colonoscopy is over 90 percent effective at detecting colon cancer. MS. NENON informed the committee that currently 18 states and the District of Columbia have passed laws that require state regulated plans to cover colon cancer screening according to the ACS guidelines. In regards to plans that are not state regulated, she explained that in the past couple of years, ACS has increased the number of Federal plans that cover colon cancer screening. She also informed the committee that current state law requires coverage for breast, cervical, and prostate cancer, pointing out that colon cancer is the only cancer with recommended screening that is not listed. She commented that [ACS] would like to give people the opportunity to have all cancer screening covered by insurance, and adding colon cancer screening would complete the list. 3:36:02 PM CHAIR ANDERSON inquired about the different types of colon cancer screening. 3:36:24 PM MS. NENON replied that it is important for doctors and patients to make a decision about which screening is most appropriate for the patient. She stated that colonoscopy is the "gold standard" because of its ability to find and remove pre-cancerous tissue, adding that it is not appropriate for everyone. She explained that in addition to the colonoscopy, the guidelines in [HB 393] include fecal occult blood test (FOBT), double-contrast barium enema, and flexible sigmoidoscopy. She went on to say that the colonoscopy only needs to be repeated once every 10 years for a person at average risk - for example one colonoscopy at age 50, another at age 60. Ms. Nenon added that after age 65, Medicare covers this procedure. MS. NENON, in response to a question, confirmed that the cost for each procedure is different. She explained that the ACS did a study on this issue, looking at the cost of covering a combination of FOBT and flexible sigmoidoscopy, which are commonly covered by insurance, versus a colonoscopy. The study showed that if a person receives a positive result from an FOBT, they are referred on to receive a flexible sigmoidoscopy or a colonoscopy. At this point, these are considered "diagnostic" tests. Ms. Nenon went on to say that the FOBT has a very high false-positive rate, and a person who receives a false positive and goes on to receive a colonoscopy then has to pay for both tests. Therefore, it would be more cost effective to start out with the colonoscopy. CHAIR ANDERSON asked for clarification regarding who would be covered by HB 393. 3:41:21 PM MS. NENON responded that the retired state employee [insurance] plan does not cover colon cancer screening, adding that each state-regulated insurance plan varies as to what is covered. Self-insured plans are not regulated by the state, and ACS is working with these employers so that they will be able to make the changes on their own. CHAIR ANDERSON offered his belief that if this legislation passes the population that will be affected will be small. REPRESENTATIVE LYNN asked how often a "high-risk" person would be required to get a colonoscopy. MR. HILYARD referred to page 2, lines 24-26, which read in part: For individuals considered at high risk for colorectal cancer, screening shall be provided at a frequency determined necessary by a health care provider. REPRESENTATIVE LYNN surmised then, that whatever frequency the healthcare provider decided would then be covered. 3:44:53 PM REPRESENTATIVE LEDOUX, referring to page 1, lines 10-11, asked why fraternal benefit societies are exempt. MS. NENON replied that this legislation was drafted to match other cancer screening statutes, and so she does not know why this population is exempt or how many plans fall under this category. She noted that someone from the Division of Insurance may be able to offer this information. REPRESENTATIVE LEDOUX, referring to page 2, subsection f, asked if it is common for the insurance provider to notify the enrollee of coverage. MS. NENON replied that this type of language is being added around the country, and is intended to inform people of what their plan covers and what they are eligible for. 3:47:09 PM REPRESENTATIVE ROKEBERG stated that he recently received information from the Division of Insurance that there are 118 thousand individuals covered under small or large group plans who would be affected by this legislation. He noted that 83 percent of the people in Alaska would not be covered by this bill. 3:50:51 PM REPRESENTATIVE CRAWFORD noted that most union trust plans are already covering [colon cancer screening]. CHAIR ANDERSON offered his belief that the 83 percent figure may be misleading, adding that although this bill does not mandate it, many independent insurance groups are already covering these costs. REPRESENTATIVE ROKEBERG responded that this law impacts a limited number of people, and has no impact on groups that may cover [colon cancer screening]. 3:51:52 PM REPRESENTATIVE LEDOUX asked if this legislation could be expanded to include [independent insurance groups]. REPRESENTATIVE ROKEBERG replied that [independent insurance groups] are excluded by federal law. 3:52:47 PM BRIAN SWEENEY JR., M.D., informed the committee that he is a gastroenterologist, and is board certified in internal medicine and gastroenterology. He stated that 93 percent of patients that are diagnosed with stage one cancer survive five years, while only 8 percent of those patients who are diagnosed with stage four cancer survive five years. He, too, explained that colonoscopy is the only type of cancer screening that is able to detect cancer before it starts, adding that FOBT has a 20-40 percent rate of saving lives and flexible sigmoidoscopy has a 60 percent rate. In regard to colonoscopy, he stated that there is not an exact number, but computer models have shown an 80 percent reduction in mortality. DR. SWEENEY informed the committee that 40 percent of [individuals at risk] receive colon cancer screening, which he noted is up from 20 percent in the last five to ten years. He opined that the real danger is that some individuals may be at higher risk and so the insurance company may not want to cover a "screening procedure," which may result in a decision not to have the procedure done. He explained that colonoscopy done once every ten years is more cost effective than any other screening test that has been studied, including mammography and pap smears. CHAIR ANDERSON asked if Dr. Sweeney would agree that because colon cancer screening has the ability to catch cancer before it begins, the legislation is valuable. DR. SWEENEY replied that he would agree, adding that on average, colon cancer is diagnosed at age 67, at which point Medicare pays for the medical treatment. He expressed concern that taxpayers pay for this service. He opined that the cancer most likely began as a polyp when the individual was in his/her 50s and could have been taken care of [with screening]. With regard to the issue of saving money, he opined that for an individual who has a cancerous polyp and does not have it removed, cost is not the issue. 3:58:11 PM DR. SWEENEY, in response to questions from Representative Rokeberg, explained the procedure for a double-contrast barium enema. He stated that the ACS guidelines are used in this bill. He went on to say that the ACS lists this as a potential screening test, while the American College of Gastroenterology has eliminated it from their colorectal cancer screening guidelines. He expressed his agreement with removing the double-contrast barium enema from the screening guidelines, adding that there have not been any studies showing the test's ability to screen and save lives. In addition, if something is found with this test, a colonoscopy is still needed. REPRESENTATIVE ROKEBERG asked if allowing family practitioners to perform the "less intrusive" colon screening procedures is appropriate. DR. SWEENEY responded that FOBT has a 3-10 percent positive rate, must be done every year, and has a high false positive rate. He explained that studies have shown that the most accurate results come from the colonoscopy, not from FOBT or flexible sigmoidoscopy. He stated that if the guidelines are followed exactly, the patients who receive a positive result FOBT and flexible sigmoidoscopy will still need to have a colonoscopy. He opined that getting a person to do any kind of testing is better than nothing. 4:03:00 PM REPRESENTATIVE ROKEBERG asked if he would recommend including the basic tests that can be done by a general practitioner. DR. SWEENEY responded that he would include it. He explained that although he feels colonoscopy is "the best" screening test, no randomized studies have been done to show how effective colonoscopy is. CHAIR ANDERSON commented that it is important to know that all of the tests are critical. 4:04:21 PM DR. SWEENEY replied that there have been computer models that suggest that if a person were to do both the FOBT and flexible sigmoidoscopy, more lives may be saved than by doing the colonoscopy. 4:05:25 PM REPRESENTATIVE ROKEBERG noted that the legislation provides coverage for those over 50 years of age, or less than 50 years of age with a high risk of colon cancer. He asked what would be required for someone to be considered "high risk." DR. SWEENEY replied that having two first-degree relatives (mother/father) who die of colorectal cancer makes a person "high risk". He expressed his feeling that there is no excuse for not screening "high risk" patients, adding that in this case, a colonoscopy would be the most appropriate, since a person with a family history would be likely to get colon cancer higher up in the colon. He stated that a person who has one or two first-degree relatives with colon cancer should begin screening at age 40. He went on to say that the American College of Gastroenterology did a study that showed that African Americans should begin screening for colon cancer at the age of 45. 4:08:40 PM REPRESENTATIVE ROKEBERG noted that the "patients' bill of rights" is intended to help patients, adding that they can appeal a dispute about coverage. DR. SWEENEY stated that although it sometimes takes extra effort from the patient, he has yet to see any situations where the insurance company refuses to pay for the procedure. REPRESENTATIVE LEDOUX, referring to page 3, line 9, inquired as to the meaning of, "other predisposing factors." DR. SWEENEY explained that this would include persons with a genetic defect which makes them more likely to develop polyps and colon cancer. He added that he feels that these patients are "surveillance" patients, rather than "screening" patients. He went on to say that high-risk patients, such as those with Crohn's Disease, are more likely to receive colonoscopies regularly. CHAIR ANDERSON highlighted that "ethnicity" would fall under [other predisposing factors]. 4:11:22 PM CLAUDIA CHRISTENSEN, Alaska Native Tribal Health Consortium (ANTHC), informed the committee that she has been involved in colorectal cancer screening for the past six years. She stated that in addition to having a high rate of colorectal cancer, Alaska Natives also have low screening rates in comparison to other ethnic groups, due to the majority of them being located in Alaska's remote and rural areas. Ms. Christensen informed the committee that the ANTHC and the Southcentral Foundation began a screening program in Anchorage, and explained that they offer colonoscopy and flexible sigmoidoscopy. She noted that they now have a 50 percent screening rate, which is "well over the national average." She went on to say that rural areas still have low screening rates, adding that the ANTHC is working on recognizing patients with a family history in order that they begin screening. Ms. Christensen stated that the ANTHC does not have gastroenterologists, but does have general surgeons who make field visits to rural areas in an effort to increase screening rates. 4:13:47 PM REPRESENTATIVE ROKEBERG asked what type of health insurance is available for Alaska Natives. MS. CHRISTENSEN replied that the Indian Health Service (IHS) covers colorectal screening for Alaska Natives living in areas where the screening is offered, adding that not all Alaska Natives use the IHS. REPRESENTATIVE ROKEBERG opined that some Alaska Natives have a health insurance company as their primary carrier but use the IHS as a backup. With regard to the issue of "stop loss" insurance, he said that some individuals may be covered under a high deductible. DR. SWEENEY, in response to questions from Representative Rokeberg, stated that billable charges for a colonoscopy are around $2,500, including operating room costs. He added that Medicare reimbursement is around $700. He explained that facility fees range from $1,500-$2,000, while the doctor's fee is about [$750-$1,000], noting that if a polyp is found, the cost rises. 4:16:43 PM STEPHEN WARREN informed the committee that his brother was recently diagnosed with symptomatic colorectal cancer and has a 10 percent chance of survival. He stated that his brother's insurance did not cover the screening and, urged the committee to pass HB 393. MR. WARREN, in response to questions from Representative Rokeberg, said that he is not aware of what insurance company was used, adding that his brother works for the state. 4:18:30 PM RICK URION informed the committee that although he usually speaks on behalf of the Division of Occupational Licensing, he would be speaking today as a "cancer patient." He said "It makes a whole lot of sense to me, given my personal experience, that you would spend a few bucks up front, to save ... the big costs ... later on if you have full-blown cancer." He informed the committee that he had received a colonoscopy during which polyps were removed. Less than one year later, a second colonoscopy was performed, this time finding full-blown cancer. He said "I'm before you today as, I hope to say, a 'cancer survivor' because of early detection, and I think it's a wonderful thing that you would include this in insurance policies, and I think it's a good deal." 4:20:13 PM REED STOOPS, Lobbyist for the American Health Insurance Association (AHIA), explained that there have been 12 or more mandated coverages adopted by the legislature. Individually, the cost implications are "marginal", but when combined, the cost is more significant. He stated that this policy trade off provides better coverage, but raises the cost for [small groups and individuals]. Mr. Stoops noted that the AHIA recommends mandated offerings as an alternative to [mandated] coverage, thus giving the individual the option to buy coverage but not requiring it. Referring to a handout in committee packets, he recommended that the committee adopt language from Tennessee law, which references current American Cancer Society guidelines and United States Preventive Services Task Force guidelines, explaining that this would keep the law up to date with the most recent research. CHAIR ANDERSON moved that the committee adopt Amendment 1, as follows: Page 2, lines 5-14; Delete all material Insert: "coverage for colorectal cancer examinations and laboratory tests specified in current American Cancer Society guidelines or United States Preventive Services Task Force guidelines for colorectal cancer screening of asymptomatic individuals." [Following was a brief discussion regarding other language in the handout.] REPRESENTATIVE LYNN objected for discussion purposes and asked if this language would cover the guidelines that are currently written out in the bill. CHAIR ANDERSON offered his understanding that it would and would also allow for any future changes. REPRESENTATIVE ROKEBERG asked Chair Anderson if he would be amenable to amending Amendment 1 by adding the words "as an optional benefit." CHAIR ANDERSON said he would not be amenable to such an amendment to Amendment 1. CHAIR ANDERSON asked if there was any further objection to Amendment 1. There being none, Amendment 1 was adopted. 4:28:31 PM MR. STOOPS, in response to questions from Representative Rokeberg, stated that Aetna, Inc., is a member of the AHIA and traditionally covers colorectal screening, including the State of Alaska plan. He stated that Aetna, Inc., and Blue Cross Blue Shield have a combined market share of 80-85 percent. He noted that the agencies who represent the small-group and individual market in Alaska will be affected the most by the legislation. REPRESENTATIVE LEDOUX asked if there was any information regarding the change in individual policy cost if HB 393 were to pass. MR. STOOPS replied that he would attempt to get cost information before the next committee hearing. 4:31:15 PM JEFFREY TROUTT, Deputy Director, Division of Insurance, Department of Commerce, Community, & Economic Development (DCCED), in response to questions from Representative Rokeberg, informed the committee that the department does not support or actively oppose mandates. He explained that HB 393 would cost money, but was unable to give an exact amount. REPRESENTATIVE ROKEBERG asked if there is an average deductible for "stop loss" [insurance] carriers, and requested information on how Blue Cross Blue Shield will be affected. MR. TROUTT replied that he is not aware of whether there is an average or deductible. CHAIR ANDERSON requested that this information be supplied before the bill is heard in the next committee of referral. 4:33:32 PM REPRESENTATIVE LYNN moved to report HB 393, as amended, out of committee with individual recommendations and the accompanying fiscal notes. REPRESENTATIVE ROKEBERG objected, and urged committee members to consider the ramifications, pointing out that a majority of the people in Alaska are covered by independent insurance plans or "stop loss" plans and therefore would not be affected by this legislation. He commented that 20 percent of Alaskans and 50 percent of the children in Alaska are on Medicaid, and asked members to consider the direction of healthcare in Alaska, and urged them to "be very careful." REPRESENTATIVE ROKEBERG then withdrew his objection. CHAIR ANDERSON commented that he would be interested in seeing the statistics regarding the aforementioned states that have similar laws, and whether insurance carriers will say they won't provide services in Alaska because of mandatory colorectal screening. CHAIR ANDERSON asked whether there was any further objection. There being none, CSHB 393(L&C) was reported from the committee.