Download Informing Medicaid Policy With Cancer

Informing Medicaid Policy
With Cancer-related Health
Services Research
Siran M. Koroukian, Ph.D.
Department of Epidemiology and
Biostatistics
Case Western Reserve University
Background
• Disparities in cancer-related outcomes by
Medicaid status have been documented:
Medicaid beneficiaries are more likely than their
non-Medicaid counterparts to:
– be diagnosed with advanced stages of cancer
– to receive disparate cancer treatment and follow-up
care
=> to experience poor prognosis
Conceptual Framework
Patient Sociodemographics:
•Age, Race/Ethnicity, Sex,
•Insurance Status
•Medicaid Status
Cancer-related outcomes:
Cancer Stage at Diagnosis
Access to and use of cancer
screening services
Access to and use of services for
cancer treatment and follow-up care
Disparate cancer treatment
and follow-up care
Insurance status, Medicaid status,
and cancer-related outcomes
Adequate
access to
and use
of health
services
Insured
Insurance Status:
Uninsured/
Underinsured
HIGH OUT-OF-POCKET
EXPENDITURES /
POVERTY/
RESOURCE DEPLETION
Inadequate access
to and use of
health services
?
?
?
PARTICIPATION IN MEDICAID
Early Stage
Diagnosis
Receipt of
adequate care
Advancedstage disease
Receipt of
disparate care/
Resource
depletion
Favorable
outcomes/
good
prognosis
Unfavorable
Outcome/
Poor
Prognosis
?
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
CANCER-RELATED OUTCOMES
Cancer as a CASE STUDY to
examine policy-relevant 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)
– Cancer screening services
• Availability of well-established treatment protocols for some of
the most common cancers  comparisons between treatment
received and guidelines, using claims data (disease control)
– Cancer treatment and follow-up care
– Quality of care
– Disease burden
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)
• Follow-up 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): 306-314.
Figure 1: Proportion of women with advanced-stage breast and
cervical cancer at the time of diagnosis, by Medicaid status
% Diagnosed with
Distant Metastases
and 95% Confidence Interval
12
8
4
0
Non-Medicaid
Medicaid Status
Medicaid
Figure 2: Proportion of women with advanced-stage 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
24
20
16
12
8
4
0
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 advanced-stages 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/follow-up
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
% With Screening
30
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 8-year
% Women with at least one
screening mammography
Period, 1992-1999, by length of enrollment in Medicaid
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,
1992-1999, by length of enrollment in Medicaid
100%
% of Total
80%
4+
3
2
1
0
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
Average # of mammography
exams per year
Average Number of Mammography Exams per Year by
Length of Enrollment in Medicaid
0.3
0.2
0.1
0
1
2
3
4
5
6
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
7
8
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
Cancer-related 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): 947-960).
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.
Future Studies
• 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 cancer-related 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 follow-up care)
Acknowledgments
• The National Cancer Institute (F32 CA84621)
• American Cancer Society (IRG - 91-022-09)
• Collaborators:
– Gregory S. Cooper, M.D.
– Alfred A. Rimm, Ph.D.