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 House Bill 2156: Mandated Coverage of Second Opinions for Primary Malignant Brain Tumor Patients at NCI Comprehensive Cancer Centers
House Bill 2156 would mandate health insurance coverage of second opinion evaluations for primary malignant brain tumor patients at any of the 39 Comprehensive Cancer Centers designated by the National Cancer Institute (NCI) across the United States. There are no NCI Comprehensive Cancer Centers in Virginia, but there are two NCI-designated Cancer Centers in the State.
Medical Efficacy and Effectiveness
Medical experts at two Virginia medical schools, NCI, and several Comprehensive Cancer Centers in the mid-Atlantic region indicated that while it is preferable for patients to receive a second opinion evaluation at a multidisciplinary cancer center, it is not necessary that it be a Comprehensive Cancer Center. Staff at NCI and several Comprehensive Cancer Centers further indicated that the university health systems in Virginia (also the NCI Cancer Centers in the State) would be equally competent at providing a second opinion as a Comprehensive Cancer Center. Helping primary malignant brain tumor patients gain access to clinical trials is another rationale for the proposed mandate. However, data from NCI shows that the majority of clinical trials are not held at Comprehensive Cancer Centers.
Social Impact
Patients most impacted by the proposed mandate would be those enrolled in fully insured health maintenance organizations (HMOs)-an estimated 60 new primary malignant brain tumor patients annually. None of the HMOs responding to a Bureau of Insurance (BOI) survey provide the proposed coverage at all Comprehensive Cancer Centers. However, about one-third indicated that some of these centers are included in their networks. The remaining two-thirds indicated that even though these centers are not in their networks, they may provide coverage for a second opinion at these centers in certain situations. Further, many HMOs offer optional features that provide patients with out-of-network coverage. In addition to HMOs, patients covered through individual plans (less than five percent of Virginians) could also be affected by the proposed mandate. It appears that even among patients that have the proposed coverage, relatively few (one to six percent) obtain second opinion evaluations at Comprehensive Cancer Centers. For those patients without coverage, some may be able to pay for the benefit out-of-pocket; others may be able to access similar evaluations through Virginia's clinical trials mandate.
Financial Impact
The proposed mandate is not expected to have a measurable impact on the cost of second opinions or providers of second opinions due to the small number of patients involved. Any increase in premiums is also expected to be minor (median estimates are about $0.20 monthly), probably less than that of any existing mandates. The impact on the total cost of health care is expected to be negligible due to the small number of patients affected and the narrow scope of the proposed mandate.
Balancing Medical, Social, and Financial Considerations
The proposed mandate is consistent with the role of health insurance and is not expected to have a significant impact on cost. However, it does not appear to be the best way to address the concerns of advocates and patients. Medical experts at Comprehensive Cancer Centers in the mid-Atlantic region, NCI, and two Virginia medical schools indicate that it is not necessary to gain access to a Comprehensive Cancer Center to obtain a high-quality, multidisciplinary second opinion. If a concern among advocates is ensuring that patients have access to clinical trials and are aware of other investigational treatments, then it appears that strengthening the clinical trials mandate to ensure that insurance companies cover the initial clinical trial evaluation would more directly address patient needs than the provisions of the proposed mandate.
| Report No. 354: Jul 2007, 43 pages | Report (pdf) | Briefing (pdf) |