Unformatted text preview: Informing Medicaid Policy With Cancerrelated Health Services Research
Siran M. Koroukian, Ph.D. Department of Epidemiology and Biostatistics Case Western Reserve University Background Disparities in cancerrelated outcomes by Medicaid status have been documented: Medicaid beneficiaries are more likely than their nonMedicaid counterparts to: be diagnosed with advanced stages of cancer to receive disparate cancer treatment and followup care => to experience poor prognosis Conceptual Framework
Patient Sociodemographics: Age, Race/Ethnicity, Sex, Insurance Status Medicaid Status Cancerrelated outcomes:
Cancer Stage at Diagnosis Access to and use of cancer screening services Disparate cancer treatment and followup care Access to and use of services for cancer treatment and followup care Insurance status, Medicaid status, and cancerrelated outcomes
Insured Insurance Status: Uninsured/ Underinsured HIGH OUTOFPOCKET EXPENDITURES / POVERTY/ RESOURCE DEPLETION Inadequate access to and use of health services ? ? ? Adequate access to and use of health services Early Stage Diagnosis Receipt of adequate care Favorable outcomes/ good prognosis Advanced stage disease Unfavorabl e Outcome/ Poor Prognosis PARTICIPATION IN MEDICAID Receipt of disparate care/ Resource depletion ? Policy Questions: Is Medicaid status associated with poor cancer (disease) related outcomes? => Evaluate the effectiveness of the Medicaid program in cancer (disease) prevention and control CHALLENGING HYPOTHESIS: PARTICIPATION IN MEDICAID IS ASSOCIATED WITH IMPROVED CANCERRELATED OUTCOMES Cancer as a CASE STUDY to examine policyrelevant questions Difficulty to extract relevant disease information for other clinical entities to conduct policy analysis Availability of data from cancer registry information on when cancer was diagnosed, and the stage at which it was diagnosed (disease prevention) Availability of wellestablished treatment protocols for some of the most common cancers comparisons between treatment received and guidelines, using claims data (disease control) Cancer treatment and followup care Quality of care Disease burden Cancer screening services Developing the linked Medicaid and Ohio Cancer Incidence Surveillance System (OCISS) Linked database to mirror the SEER Medicare files at the Federal level, enabling the development of longitudinal records at the patient level to study patterns of enrollment in Medicaid and use of health services. Patient unique identifier in Medicaid to link enrollment and claims data across different time spans and service types. Linkage algorithm using patient identifiers: Patient first and last name Date of birth Social security number Project approved by the Institutional Review Board at the Ohio Department of Health and by the Ohio Department of Job and Family Services Description of the OCISS OCISS: Mandatory reporting of all incident cases of cancer (except insitu cervical, squamous cell and basal cell carcinoma), since January, 1992 Relevant data elements include: Patient demographics Patient residence at the time of diagnosis Type of cancer Date of cancer at diagnosis Cancer stage Surgical treatment Medicaid files Enrollment data Date of enrollment in Medicaid Length of participation in Medicaid prior to cancer diagnosis Claims data Health care utilization Screening Treatment (surgical; radiation therapy; chemotherapy) Followup care Study 1: Assessing the effectiveness of Medicaid in breast and cervical cancer prevention* Analysis of cancer stage at diagnosis by timing of enrollment in Medicaid. Given that Medicaid is a "safety net" program, does it matter that we look at the timing of enrollment in Medicaid in relation to cancer diagnosis?
* Koroukian SM. Assessing the effectiveness of Medicaid in breast and cervical cancer prevention. Journal of Public Health Management and Practice, 2003; 9(4): 306314. Figure 1: Proportion of women with advancedstage breast and cervical cancer at the time of diagnosis, by Medicaid status
% Diagnosed with Distant Metastases and 95% Confidence Interval 8 4 0 Non-Medicaid Medicaid Medicaid Status Figure 2: Proportion of women with advancedstage breast and cervical cancer at the time of diagnosis, by Medicaid status, and by timing of enrollment in the Medicaid program in relation to cancer diagnosis
% Diagnosed with Distant Metastases and 95% Confidence Interval 20 16 12 8 4 0
M Pe ed ri ica -D id ia gn os is* M Po ed st ica -D id ia gn os is* * No nM ed ica id M Pr ed e- ica D id ia , gn os is Medicaid Status and Timing of Enrollment in Medicaid
* Peri-Diagnosis: Women enrolled in Medicaid in the 2 months prior to, upon, or in the 2 months following cancer diagnosis ** Post-Diagnosis: Women enrolled in Medicaid 3 months after cancer diagnosis Study conclusions and implications Women enrolled in Medicaid shortly before, at, or after cancer diagnosis are significantly more likely to present with advancedstages of the disease. Implications: Methodological: importance to account for timing of enrollment in Medicaid when identifying patients by Medicaid status Policy: Medicaid as a safety net program. Could/should Medicaid reach out to the uninsured and the underinsured? Breast and Cervical Cancer Early Detection Program: Who are the individuals presenting to Medicaid with advanced stages of cancer? Gaining better understanding of high risk populations and develop more effective targeting strategies for cancer screening. Study 2*: Does length of enrollment in Medicaid matter that people receive cancer screening services? Participation in the Medicaid program for the short term, and/or on a on/off basis does not benefit the patient Participation in Medicaid for the longer term may be associated with: Continuity of care Increased likelihood to use services that are in the realm of preventive/screening/routine/followup care *Koroukian SM. Length of Enrollment in Medicaid Predicts the Use of Screening Mammography Among Ohio Medicaid Beneficiaries. Accepted for Publication, J Clin Epidemiol. Mammography Screening in the Ohio Medicaid Population by Length of Enrollment in Medicaid 30 % With Screening 25 20 15 10 5 0 1992 1993 1994 1995 1996 1997 1998 1999 Study Years <= 3 mos 4-6 mos 7-9 mos >= 10 mos Women 40-64 years of age, with no participation in Managed Care programs, Medicare or spenddown, and no stay in nursing homes after enrollment in Medicaid Women with At Least One Screening Mammography in the 8year Period, 19921999, by length of enrollment in Medicaid
% Women with at least one screening mammography 80 70 60 50 40 30 20 10 0 <= 12 13-24 25-36 37-48 49-60 61-72 73-84 85-96 Months of enrollment in Medicaid
Women 40-64 years of age, with no participation in Managed Care programs, Medicare or spenddown, and no stay in nursing homes Frequency of Screening Mammography in the 8-year Period, 19921999, by length of enrollment in Medicaid
100% 80% % of Total 60% 40% 20% 0% <=12 13-24 25-36 37-48 49-60 61-72 73-84 85-96 Months of enrollment in Medicaid
Women 40-64 years of age, with no participation in Managed Care programs, Medicare or spenddown, and no stay in nursing homes after enrollment in Medicaid 4+ 3 2 1 0 Average Number of Mammography Exams per Year by Length of Enrollment in Medicaid
Average # of mammography exams per year 0.3 0.2 0.1 0 1 2 3 4 5 6 7 8 Years of Enrollment in Medicaid Women 40-64 years of age, with no participation in Managed Care programs, Medicare or spenddown, and no stay in nursing homes Conclusions and study implications Increased length of enrollment in Medicaid is associated with greater likelihood to undergo screening Additional analysis needed to determine whether increased use of screening services reflects continuity of care Implications: Methodological: Importance to account for length of participation in Medicaid in studying use of screening/preventive services; Policy: Promote/facilitate sustained enrollment in Medicaid in order to enhance continuity of care Cancerrelated studies to inform Medicaid on other methodological issues Ability of claims to identify incident cases of breast cancer (Koroukian SM et al. HSR Journal 2003; 38(3): 947960). Discussion Cancer as a case study. The findings are likely to also apply to other clinical entities. If participation of the underinsured and uninsured in the Medicaid program is associated with improved outcomes, perhaps consider proactive "recruitment" of individuals with potentially poor patterns of access to care into the Medicaid program. Gain a better understanding of the uninsured and underinsured populations in this case, individuals joining the Medicaid program upon being diagnosed with catastrophic illness. Study funded by an American Cancer Society grant underway to examine the characteristics of this population in association with community attributes, such as poverty and education. Gain a better understanding on the effectiveness of Medicaid in cancer prevention and control. A new study funded by the NCI (K07 CA096705) to examine differences in cancerrelated outcomes in lowincome Medicare beneficiaries is participation associated with improved outcomes? Cost burden to the Medicaid program Quality of care Access: urban vs. rural Availability of health care resources (e.g., radiation oncologists in association with breast conserving surgery; hospital type and practice patterns in cancer treatment and followup care) Future Studies Acknowledgments The National Cancer Institute (F32 CA84621) American Cancer Society (IRG 9102209) American Cancer Society (IRG Collaborators: Gregory S. Cooper, M.D. Alfred A. Rimm, Ph.D. ...
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