SENATE BILL REPORT

                   SB 5297

              As Reported By Senate Committee On:

            Health & Long-Term Care, March 4, 1997

Title:  An act relating to health insurance benefits for mastectomies.

Brief Description:  Establishing health care benefits for mastectomies.

Sponsors:  Senators Franklin, Winsley, Kohl, Patterson, Thibaudeau, Goings, Fraser, Heavey, Snyder, Loveland, Prentice, McAuliffe, Spanel, Rasmussen, Wojahn, Fairley, Sheldon, Wood, Brown and Haugen.

Brief History:

Committee Activity:  Health & Long‑Term Care:  2/27/97, 3/4/97 [DP].

SENATE COMMITTEE ON HEALTH & LONG-TERM CARE

Majority Report:  Do pass.

  Signed by Senators Deccio, Chair; Wood, Vice Chair; Benton, Fairley, Franklin, Strannigan and Wojahn.

Staff:  Don Sloma (786-7319)

Background:  Reports began surfacing in the media and among some health consumers and providers last year that some managed health care plans had established payment policies precluding overnight hospital stays following mastectomies.  The National Conference of State Legislatures reports that while most mastectomy patients are hospitalized for 24 hours or more, Milliman and Robertson (a consulting firm that does clinical protocols for managed care organizations) and perhaps other, similar organizations, had guidelines that called for outpatient mastectomies as a Abest case@ scenario.

A recent nationwide survey of 1,000 health plans conducted by the American Association of Health Plans (AAHP) found none denying an overnight hospital stay following a mastectomy as a matter of official policy.  They did, however, find instances when physicians felt pressured not to approve such a stay.

An AAHP official statement on the subject is, A It is the policy of the AAHP that the decision about whether outpatient or inpatient care best meets the needs of a woman undergoing removal of a breast should be made by the woman=s physician after consultation with the patient.  Health plans do not and should not require outpatient care for removal of a breast.  As a matter of practice, physicians should make all medical treatment decisions based on the best available scientific information and the unique characteristics of each patient.@

Summary of Bill:  Every health carrier, including the high risk pool, and every health plan operated by the state Health Care Authority that provides coverage for mastectomies must permit the attending health care provider to make decisions about the length of inpatient stay and follow-up care.  Such decision may not be made through contracts or agreements with health plans or between hospitals and providers.  These decisions must be based on accepted medical practice.

No carrier may take adverse action regarding plan participation or payments against a provider for adhering to the terms of the act.  However, nothing in the act may be construed to prevent an insurer from using capitation or other financial incentive payment mechanisms.  Every carrier must notify its policyholders of the requirements in this act within one year of the effective date of the act.

Appropriation:  None.

Fiscal Note:  Available.

Effective Date:  Ninety days after adjournment of session in which bill is passed.

Testimony For:  The bill is needed to stop health carriers from forcing health providers to discharge patients from hospitals within hours of a radical mastectomy.  It replaces the principle of individual health provider control over patient care.  While it might be better to apply this principle to all health care decisions, it certainly should be applied in the case of mastectomies.

Testimony Against:  This is a mandated benefit.  While attending health care providers should make these decisions, such a law is an inappropriate use of government power.  Health carriers can and will see that patients are not forced out of hospitals arbitrarily.  But this bill does not allow health carriers to use the best research on patient outcomes to shape clinical care and contain costs.  It takes a piecemeal approach to the problem and will increase costs, paperwork and undermine creativity.

Testified:  Cathleen Carr, Ph.D, WA State Women=s Health Care Coalition (pro); Theresa Miller/David Allen, American Cancer Society (pro); Scott DeNies, Ken Bertrand, Group Health.