1. The extent to which the mandated health benefit may increase or decrease the cost of the treatment, service or equipment, supplies or drugs, as applicable, over the next five years.
The prostate screening mandate has been in effect since 2000. One meta-analysis reported that the price of PSA testing in cost analyses fell about $26 between 1993 and 2002.60 During this period, PSA testing became widespread; increasing the efficiency and lowering the price of providing the test. It is unclear how much more the unit cost of PSA tests can continue to fall 10 years later. As Connecticut’s population ages, the number of men aged 50-75 may increase resulting in higher overall costs even if the per unit test costs remain unchanged. For further information, please see the Ingenix Consulting Actuarial and Economic Report.
2. The extent to which the mandated health benefit may increase the appropriate or inappropriate use of the treatment, service or equipment, supplies or drugs, as applicable, over the next five years.
The results of the ERSPC trial estimated that over-treatment occurred in 27-56 percent of the cases found.
Another study reported over-treatment rates up to 84 percent.61
3. The extent to which the mandated health benefit may serve as an alternative for more expensive or less expensive treatment, service or equipment, supplies or drugs, as applicable.
58 Conversation with Scott Anderson, State Comptroller’s office, September 14, 2010
59 Heijnsdijk EAM, der Kinderen A, Wever, EM et al. 2009. Overdetection, Overtreatment and Costs in Prostate-Specific Antigen Screening for Prostate Cancer. British Journal of Cancer 101: 1833-1838.
60 Ekwueme DU, Stroud LA, Chen Y. 2007. Cost Analysis of Screening for, Diagnosing and Staging Prostate Cancer Based on a Systematic Review of Published Studies. Preventing Chronic Disease 4(4): 1-17.
61 Sennfält K, Sandblom G, Carlsson P et al. 2004. Costs and Effects of Prostate Cancer Screening in Sweden. Scandinavian Journal of Urology and Nephrology 38; 291-298.
The American Cancer Society recommends offering prostate cancer screening to the populations identified in the legislation. Screening can lead to early detection of prostate cancer, which may or may not lead to less expensive treatment. However, prostate cancer treatment has risks as well, and many prostate cancers are slow-growing and unlikely to become clinically significant before the patient dies of other causes. PSA screening cannot currently discriminate among the various forms of prostate cancer. Positive screenings which result in treatment of an “indolent” cancer can increase costs.
4. The methods that will be implemented to manage the utilization and costs of the mandated health benefit.
The legislation does not prohibit insurers and MCOs from employing utilization management, prior authorization, or other utilization tools at their discretion. Cancer screening guidelines from organizations like the U.S. Preventive Task Force62 and the American Cancer Society63 encourage personal choice over routine screens. To contain costs, insurers may try to encourage ‘watchful waiting’ treatment instead of radical prostatectomy for low-grade cancers rather than limit screening itself.
5. The extent to which insurance coverage for the treatment, service or equipment, supplies or drugs, as applicable, may be reasonably expected to increase or decrease the insurance premiums and administrative expenses for policyholders.
Insurance premiums include medical cost and retention costs. Medical cost accounts for medical services.
Retention costs include administrative cost and profit (for for-profit insurers/MCOs) or contribution to surplus (for not-for-profit insurers/MCOs). (For further discussion, please see Appendix II, Ingenix Consulting Actuarial and Economic Report, page 14.)
Group plans: When the medical cost of the mandate is spread to all insureds in group plans, medical costs are estimated to be $0.19 PMPM and retention costs are estimated to be $0.04 PMPM in 2010. Thus the total effect on insurance premiums is estimated at $0.23 PMPM in 2010, which is 0.1 percent of premium.
Individual policies: When the medical cost of the mandate is spread to all insureds in individual policies, medical costs are estimated to be $0.11 PMPM and retention costs are estimated to be $0.03 PMPM in 2010. Thus the total effect on insurance premiums is estimated at $0.14 PMPM in 2010, which is 0.1 percent of premium.
It is unclear how much of this cost would be covered by employers and insurance carriers even without the mandate since it is included in nearly all self-funded plans in Connecticut.
For further information, please see Appendix II: Ingenix Consulting Actuarial and Economic Report.
62 U.S. Preventive Services Task Force. 2008. Screening for Prostate Cancer: U.S. Preventive Services Task Force Recommendation Statement.
Annals of Internal Medicine 149 (3): 185-191.
63 American Cancer Society. 2010. American Cancer Society Guidelines for the Early Detection of Cancer. Available at:
http://www.cancer.org/Healthy/FindCancerEarly/CancerScreeningGuidelines/american-cancer-society-guidelines-for-the-early-detection-of-cancer. Accessed on Sept. 26, 2010.
6. The extent to which the treatment, service or equipment, supplies or drugs, as applicable, is more or less expensive than an existing treatment, service or equipment, supplies or drugs, as applicable, that is determined to be equally safe and effective by credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community.
As discussed in Section IV, Question 10, there are currently no alternatives to prostate cancer screening in order to detect prostate cancer. The two main screening methods, PSA blood tests and physical exams (DRE), are low cost but both have short-comings. PSA tests are very sensitive to changes in the prostate but do not specifically detect cancer. DRE exams are not particularly sensitive to small changes in the prostate, but are more likely to find advanced cancer.
Several attempts have been made to modify the PSA test to make it more specific to finding cancer as opposed to other conditions like benign prostate hyperplasia (BPH). Lower levels of free (as opposed complex) PSA are associated with prostate cancer compared to BPH.64 The ERSPC trial used multiple cut-off values from 2.5, 3.0, and 4.0 ng/ml to refer men for additional testing or biopsy. Many physicians use ‘PSA velocity’, or the rate of increase in PSA levels over time, to assess prostate cancer risks. One study found that up to 21 percent of PSA values over 4.0 ng/ml, a standard cut-off level, return to normal over time.65 However, differences in laboratory techniques can lead to a difference in PSA levels of up to 25 percent on a given test.66 These alternatives provide supplementary data and uses rather than replacements for the standard tests listed above.
7. The impact of insurance coverage for the treatment, service or equipment, supplies or drugs, as applicable, on the total cost of health care, including potential benefits or savings to insurers and employers resulting from prevention or early detection of disease or illness related to such coverage.
The total cost of health care is understood to be the funds flowing into the medical system, which are the medical costs portion of insurance premiums and the cost sharing of the insureds. Actuarial analysis of claims data received from insurers/MCOs in Connecticut shows an expected impact in 2010 of $3,549,247 for prostate screening for Connecticut residents covered by fully-insured group and individual health insurance plans.
Economic benefits of the mandate may accrue to employers in terms of worker productivity. The economic benefits to business of employees with prostate cancer returning to work or on-the-job productivity may offset or be higher than the costs of cancer screening covered by the mandate.
8. The impact of the mandated health care benefit on the cost of health care for small employers, as defined in section 38a-564 of the general statutes, and for employers other than small employers.
This mandate costs about $0.19 per member per month. In general, the cost of mandates may be part of a premium increase or a redesign of benefits. If the premium increases, the employer may decide to absorb that cost or increase the employee’s payments toward the premium. If benefits are redesigned, coverage for other benefits, not mandated, may be dropped. Alternatively, firms may increase employee cost-sharing at
64 Catalona WJ, Partin AW Slawin KM et. al. 1998. Use of the Percentage of Free Prostate-Specific Antigen to Enhance Differentiation of Prostate Cancer from Benign Prostatic Diseases. Journal of the American Medical Association 279: 1542-1547.
65 Eastham JA, Riedel E, Scardino PT et. al. 2003. Variation of Serum Prostate-Specific Antigen Levels. Journal of the American Medical Association 289: 2695-2700.
66 Slev PR, La’ulu SL Roberts WL. 2008. Intermethod Differences in Results for Total PSA, Free PSA and Percentage of Free PSA. American Journal of Clinical Pathology 129: 952-958.
the point of service level with increased co-payments or deductibles. To some degree, both the employer and the employee are sensitive to increasing prices. As health insurance costs rise, the employer and/or the employee may opt out of offering / purchasing health insurance.
Small businesses tend to be more sensitive to price changes than large businesses. Also, small businesses are more likely to offer less comprehensive insurance coverage at lower cost. As a result, mandates constitute a larger portion of the health insurance premium. Any increase in mandates constitutes a higher percentage rise for small business compared to large businesses. While this particular benefit represents a minimal increase in premiums (<1 percent PMPM), the combined expense of all mandates may cause small businesses to discontinue providing health insurance to their employees.
9. The impact of the mandated health benefit on cost-shifting between private and public payers of health care coverage and on the overall cost of the health care delivery system in the state.
At a cost of $0.19 PMPM, this mandate is unlikely to affect a firm’s or individual’s decision to insure. The cumulative cost of all the mandates, however, may cause some firms or individuals to drop insurance. These individuals may be eligible for state health insurance programs if their income meets program guidelines.
For instance, families with children are eligible for HUSKY A insurance if family income is no more than 185 percent of the federal poverty line. People who meet these criteria may move from private to public insurance and, consequently, increase public health insurance expenses.
The Ingenix Consulting report estimates the impact of this mandate on the overall cost of the health care delivery system in the state to be $4,173,989. This includes the medical cost included in premiums and cost sharing by insured individuals.
The estimated impact on the overall cost of the health care delivery system in the state assumes that the State of Connecticut plans continue to comply with this mandate even though these plans are now self- insured.