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 SB 991 and HB 2426: Repeals of Mandated Offer for Autologous Bone Marrow Transplant or Stem Cell Transplant for Breast Cancer
High dose chemotherapy (HDC) with an autologous bone marrow transplant (ABMT) or a stem cell transplant (SCT) is a procedure involving the administration of a toxic dose of chemotherapy to kill cancer cells, followed by ABMT or SCT to reduce the effects of the treatment on the patient's body. In the mid-1990s, oncologists believed this treatment would provide greater therapeutic benefit than conventional therapy to patients with the most serious forms of breast cancer. However, recent clinical research has determined that HDC-ABMT/SCT provides no additional benefit over conventional chemotherapy. SB 991 and HB 2426 would repeal provisions of Virginia's mandated offer of this procedure to reflect this research and eliminate a possibly obsolete statute.
Medical Efficacy and Effectiveness
Clinical trials have found that high dose chemotherapy with autologous bone marrow transplant or stem cell transplant (HDC-ABMT/SCT) offers no additional benefit to breast cancer patients over conventional chemotherapy. Additionally, patients receiving HDC-ABMT/SCT are more likely to experience treatment-related complications than patients receiving conventional chemotherapy.
Today, most health care experts recommend that breast cancer patients only receive HDC-ABMT/SCT in the context of a well-designed clinical study. Although HDC-ABMT/SCT does not offer additional benefit to breast cancer patients, the treatment does offer additional benefit to people suffering from other diseases, such as Hodgkin's disease, multiple myeloma, neuroblastoma, or leukemia.
Social Impact
Since the release in 2000 of findings from clinical trials indicating that HDC-ABMT/SCT does not provide breast cancer patients additional benefits, the use and availability of the treatment have greatly decreased. Only three medical facilities in Virginia have dedicated bone marrow and stem cell transplant programs. JLARC staff did not find any evidence to indicate that physicians are currently using HDC-ABMT/SCT for breast cancer patients in Virginia. Further, JLARC staff did not find any evidence that insurance companies have paid claims for Virginia breast cancer patients to receive HDC-ABMT/SCT since 2003. If the mandate were repealed, it is likely that many insurance companies would drop coverage for this treatment. Patients who access the treatment through a clinical trial, as recommended by most medical experts, would still have coverage under the clinical trials mandate; however, patients accessing the treatment outside a clinical trial would be likely to face financial hardship since the treatment costs from 140 to 285 percent of Virginia's median household income.
Financial Impact
The proposed repeals would not have a significant financial impact. Physicians and patients have already stopped using the treatment, so demand is unlikely to decrease any further as a result of the proposed repeals. Due to the already diminished demand for the treatment, the mandate's premium impact is low. Therefore, repealing the mandate is likely to have a very small, if any, premium impact.
Balancing Medical, Social, and Financial COnsiderations
Given the potentially catastrophic financial impact to an individual or family for obtaining HDC-ABMT/SCT, the current mandate is consistent with the role of insurance. Although this mandate is consistent with the role of insurance, the need for the mandate appears to be minimal. While the cost of the mandate appears to be relatively low and similar to other mandates, it is necessary to consider whether it is appropriate for the State to mandate a very specific procedure that has a very low demand and utilization rate. Additionally, according to medical experts, most breast cancer patients receiving HDC-ABMT/SCT do not experience any superior results to breast cancer patients receiving conventional chemotherapy or newer types of treatment.
| Report No. 357: Sep 2007, 48 pages | Report (pdf) | Briefing (pdf) |