Proposed Mandated Health Insurance Benefits
JLARC staff evaluate proposed health insurance mandates in support of the Special Advisory Commission on Mandated Health Insurance Benefits.
JLARC Report In Brief
Evaluation of HB 1405: Mandated Coverage of Intensity Modulated Radiation Therapy (IMRT) for Specified Cancer Sites
Intensity Modulated Radiation Therapy (IMRT) is a significant advance in radiation technology which allows physicians to better target cancerous tumors while simultaneously sparing surrounding tissue. Recently, several third-party payers have limited their coverage of IMRT to specific cancer sites in the human body, which led to the proposal of HB 1405. Among the sites for which IMRT is no longer covered by some insurers are breast and lung cancer.
Medical Efficacy and Effectiveness
There is a general consensus that sufficient medical evidence exists to support the use of IMRT for some cancer sites, in particular the prostate and head and neck. However, current medical evidence for the use of IMRT for other cancer sites, in particular breast and lung, is not as conclusive. Most existing research is based on dosimetric studies rather than clinical trials. These studies conclude that, while IMRT could lead to improved treatment and reduced morbidity in breast and lung cancer patients, further research demonstrating clinical outcomes is needed. However, medical experts at two Virginia medical schools assert that the current level of evidence is sufficient to demonstrate the superiority of IMRT over conventional techniques for breast cancer and lung cancer in some cases, particularly considering historical standards for the adoption of radiation technology.
Social Impact
The availability of IMRT has increased significantly in recent years and may be offered at nearly all radiation treatment facilities across Virginia in the near future. However, the use of IMRT varies substantially among radiation therapy providers. IMRT is used most frequently to treat prostate cancer and head and neck cancer, but it is also used for other cancer sites including breast and lung cancers. Approximately one-third of health insurance companies appear to provide the level of coverage for IMRT mandated in HB 1405, although other insurers likely provide coverage for those sites where IMRT is used most frequently. For most patients without insurance coverage, treatment costs would be a significant expense.
Financial Impact
The proposed mandate would not have a significant impact on treatment costs, utilization, or most radiation providers in the near term because the cancer sites where IMRT is used most frequently are already generally covered by insurance. There may be an impact on radiation centers that use IMRT to frequently treat other types of cancer, such as breast and lung cancers. Based on survey responses from 21 insurance companies, the median monthly premium costs for the proposed mandate are estimated to range from $1.00 to $2.00, which appears to be within the range of the estimated impact of existing mandates. HB 1405 would increase the total cost of health care, but it would also increase the availability of IMRT, which may be particularly important for patients where it appears to be the only treatment option.
Balancing Medical, Social, and Financial Considerations
Whether the need for the proposed mandate outweighs the costs may be different in the short term than the long term. In the short term, the need does not appear to outweigh the costs because most insurance companies already provide coverage for the cancer sites where IMRT is used most frequently and its use is most widely accepted. However, medical experts indicate that future research may provide more conclusive evidence that IMRT is superior for cancer sites where it is now considered investigational by some insurance companies, including breast and lung cancers. In the absence of the mandate and if insurance companies do not modify their policies to reflect emerging research, the adoption of IMRT for other cancer sites may be impeded. An additional consideration is whether it is appropriate for the State to mandate a treatment as specific as IMRT. Medical technology and research will advance, which may make such a specific mandate obsolete in the future.
| Report No. 341: Oct 2006, 44 pages | Report (pdf) | Briefing (pdf) |