Download Health Systems Analysis Data Sources: The health system analysis

Health Systems and Public Policy Analysis
Health Systems Analysis Data Sources:
The health system analysis was completed first by listing known organizations (grantees,
hospitals, health departments, etc.) that offer breast cancer services in the three target counties.
Online databases identified additional organizations. A Google search and websites of selected
organizations provided needed contact information.
Once organizations were identified, all data were collected to identify breast health services
available by either phone calls or in-person meetings.
Findings were analyzed for the three target counties of Bibb, Peach, and Monroe after the
completion of the Health System Analysis (HSA) template. Services offered, location, and
number of organizations in each county were compared to evaluate gaps within the continuum
of care.
Health Systems Overview
The Breast Cancer Continuum of Care (CoC)
Figure 1. The Breast Cancer Continuum of Care
The Breast Cancer Continuum of Care (CoC) is a model that shows how a woman typically
moves through the health care system for breast care. A woman would ideally move through the
CoC quickly and seamlessly, receiving timely, quality care in order to have the best outcomes.
Education can play an important role throughout the entire CoC.
While a woman may enter the continuum at any point, ideally, a woman would enter the CoC by
getting screened for breast cancer – with a clinical breast exam or a screening mammogram. If
the screening test results are normal, she would loop back into follow-up care, where she would
get another screening exam at the recommended interval. Education plays a significant role
both in providing education to encourage women to get screened and reinforcing the need to
continue to get screened routinely thereafter.
If a screening exam resulted in abnormal results, diagnostic tests would be needed, possibly
several diagnostic tests, to determine if the abnormal finding is in fact breast cancer. These
tests might include a diagnostic mammogram and breast ultrasound or biopsy. If the tests were
negative (or benign) and breast cancer was not found, she would go into the follow-up loop, and
return for screening at the recommended interval. The recommended intervals may range from
3 to 6 months for some women to 12 months for most women. Education plays a vital role in
communicating the importance of proactively getting test results, keeping follow-up
appointments, and understanding what it all means. Education can empower a woman and help
manage anxiety and fear.
If breast cancer is diagnosed, she would proceed to treatment. Education can cover topics,
including treatment options, how a pathology report determines the best options for treatment,
understanding side effects and how to manage them, and helping to formulate questions a
woman may have for her providers.
For some breast cancer patients, treatment may last a few months and for others, it may last
years. While the CoC model shows that follow up and survivorship come after treatment ends,
they actually may occur at the same time. Follow up and survivorship may include the following
factors: navigating insurance issues, locating financial assistance, symptom management, such
as pain, fatigue, sexual issues, bone health, etc. Education may address topics such as making
healthy lifestyle choices, long term effects of treatment, managing side effects, the importance
of follow-up appointments, and communication with their providers. Most women will return to
screening at a recommended interval after treatment ends, or for some, during treatment (such
as those taking long term hormone therapy).
There are often delays in moving from one point of the continuum to another – at the point of
follow-up of abnormal screening exam results, starting treatment, and completing treatment –
that can all contribute to poorer outcomes. There are also many reasons a woman cannot enter
or continue in the breast cancer CoC. These barriers may include lack of transportation, system
issues, including long waits for appointments and inconvenient clinic hours, language barriers,
fear, and lack of information or the wrong information (myths and misconceptions). Most
importantly, education can address some of these barriers and help a woman progress more
quickly through the CoC.
Central Georgia Affiliate of Susan G. Komen®
Target Counties Analysis
Bibb County
In Bibb County there are eight screening providers, five diagnostics providers, four treatment
providers, and three support/survivorship providers. Table 8 provides a summary of the CoC
strengths and weaknesses in Bibb County. Table 9 provides a summary of the current and
potential partnerships in Bibb County.
Table 8. The strengths and weaknesses of the breast health system in Bibb County.
Strengths
Weaknesses
New cancer center offering all services in one
No mobile mammography units
facility
Two major hospitals
Limited federal funding
Geographic location central to all counties in
the service area
Available services across the entire continuum
of care
Table 9. Existing and potential key Mission related partnerships in Bibb County.
Existing Partnerships
Potential New Partnerships
Several organizations are former or current
Black congregations
grantees
Several organizations have sponsored Komen Health District
Central Georgia events
Board Members represent staff from both
Health Department
major hospitals
Survivorship organizations
Monroe County
In Monroe County there are two screening providers, one diagnostics provider, and zero
treatment or support/survivorship providers. Table 10 provides a summary of the CoC strengths
and weaknesses in Monroe County. Table 11 provides a summary of the current and potential
partnerships in Monroe County.
Table 10. The strengths and weaknesses of the breast health system in Monroe County.
Strengths
Weaknesses
Health Department and hospital in central
No nurse navigator
location
Hospital
Limited screening services
Limited diagnostic services
No treatment services
No survivorship services
Not within convenient driving distance to
facilities in surrounding counties
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Table 11. Existing and potential key Mission related partnerships in Monroe County.
Existing Partnerships
Potential New Partnerships
Black congregations
Health Department
Hospital
Peach County
In Peach County there are two screening providers, one diagnostics provider, and zero
treatment or support/survivorship providers. Table 12 provides a summary of the CoC strengths
and weaknesses in Peach County. Table 13 provides a summary of the current and potential
partnerships in Peach County.
Table 12. The strengths and weaknesses of the breast health system in Peach County.
Strengths
Weaknesses
Within reasonable driving distance to facilities
No nurse navigator
in surrounding counties
Hospital
No treatment services
No survivorship services
Limited screening services
Limited diagnostic services
Table 13. Existing and potential key Mission related partnerships in Peach County.
Existing Partnerships
Potential New Partnerships
Black congregations
Health Department
Hospital
Public Policy Overview
National Breast and Cervical Cancer Early Detection Program (NBCCEDP)
The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) was
established in 1990 to provide free or reduced cost mammograms and Pap tests to low-income,
uninsured, and underinsured women. The program is directed by the Center for Disease Control
(CDC) and Prevention. The NBCCEDP currently funds all 50 states, the District of Columbia,
five U S territories, and eleven American Indian/Alaska Native tribes to provide breast and
cervical cancer screening services. Breast cancer services provided by the NBCCEDP include
clinical breast exams, mammograms, diagnostic testing if results are abnormal, and referrals to
treatment.
The Georgia Breast and Cervical Cancer Program (BCCP) and Medicaid
With a combination of federal and state funds, the Georgia Breast and Cervical Cancer Program
(BCCP) provides access to timely breast and cervical cancer screening and diagnostic services
to Georgia women residents. Breast cancer services are available for underinsured and
uninsured women between the ages of 40 – 64 who live at or below the 200.0 percent federal
poverty line. In Georgia, a woman is eligible for BCCP if her provider receives NBCCEDP funds
Central Georgia Affiliate of Susan G. Komen®
and the service was within the scope of a grant, sub-grant or contract under that state program
— even if the woman’s screening may not have been paid directly from NBCCEDP funds. The
Georgia BCCP serves approximately 15,000 women for breast screening each year. There are
more than 100,000 women in Georgia who meet BCCP eligibility criteria.
Breast cancer services provided by BCCP include screening and diagnostic services, diagnostic
evaluations if results are abnormal, and referral to treatment through the Women’s Health
Medicaid Program. Medicaid will cover costs associated with treatment and can reimburse her
for the costs of diagnostic services if she paid for services out of pocket.
In order to qualify for Medicaid for breast cancer, a woman must be:
 Diagnosed and in need of treatment for breast cancer
 At or below 200.0 percent of the FPL income
 Uninsured
 Under the age of 65
 A Georgia resident and
 A United States citizen or qualified alien
The Georgia Department of Public Health’s Office of Cancer Prevention, Screening, and
Treatment offers information about program eligibility requirements and how to enroll. Women
who meet program eligibility and wish to use BCCP services must be screened by the health
department in their county of residence. Women who are diagnosed with breast cancer and who
wish to receive Women’s Health Medicaid must apply at the health department at their county of
residence.
The Susan G. Komen Central Georgia Affiliate has a history of providing community grants to
organizations that either accept BCCP funds and/or assist women with the process of enrolling
in Women’s Health Medicaid. In the next four years, the Affiliate would like to establish strong
partnerships with the health district and targeted health departments.
Georgia Comprehensive Cancer Control Coalition
The Georgia Comprehensive Cancer Control Plan (GCCCP) is a segment of a national effort
initiated by the Centers for Disease Control and Prevention aimed at reducing cancer-related
morbidity and mortality.
Georgia’s Comprehensive Cancer Control Plan breast cancer objective is to ensure all women,
regardless of income, race or employment status, have access to high quality breast cancer
screening as well as genetic screening, counseling, and preventive clinical services related to
hereditary breast cancer.
The targets related to breast cancer control are:
 By 2019, increase from 77.0 percent to 81.1 percent, the proportion of women who
receive breast cancer screenings based on the most recent US Preventive Task Force
guidelines of females aged 50 to 74 years.
 By 2019, reduce income and insurance coverage disparities in breast and cervical
cancer screening rates by 10.0 percent.
 By 2019, increase by 25.0 percent the proportion of individuals at high risk for breast
cancer who receive evidence-based genetic risk assessment and appropriate screening.
Central Georgia Affiliate of Susan G. Komen®
There are currently no existing relationships between the Affiliate and the State’s
Comprehensive Cancer Control Coalition, but the objective and targets of the Coalition align
with the Affiliate’s mission to ensure and increase quality breast cancer services for all. The
Affiliate will consider possible partnerships in the next four years.
The Affordable Care Act
The 2010 Affordable Care Act (ACA) has the potential to extend coverage to many of the 47
million uninsured nonelderly people in the nation, including the 1,849,000 uninsured Georgians,
according to the Kaiser Family Foundation. The ACA establishes coverage provisions across
the income spectrum by providing states the option to expand Medicaid and by offering tax
credits for those who purchase through the Health Insurance Marketplace (Kaiser Family
Foundation, 2014).
Passage of the Affordable Care Act gave states the option of expanding Medicaid eligibility
guidelines to improve insurance coverage rates among residents. Effective January 1, 2014,
Georgia decided not to expand Medicaid coverage to low income adults. As a result, 22.0
percent of Georgia’s population falls into the “coverage gap,” meaning their incomes are too
high to be eligible for Medicaid and too low to receive tax credits through the Marketplace.
Uninsured residents of Georgia will either have to consider seeking insurance coverage through
the federal Marketplace or through private companies since Georgia did not expand Medicaid
eligibility. According to the Kaiser Family Foundation, 21.7 percent of Georgia residents are
estimated to be uninsured prior to the insurance mandate. This number is expected to decrease
to 18.2 percent (about 1,870,000 people) after the insurance mandate. Forty-eight percent of
Georgia residents who have health insurance are insured by their employer, twenty-seven
percent are insured by public programs like Medicaid and Medicare, and five percent purchase
individual private policies (Kaiser Family Foundation, 2014).
In 2011-2012, it was estimated that 26.0 percent of Georgia’s female population aged 18 to 64
was uninsured (Table 5), which is a higher rate than the overall population rate. In the same
time period, it was estimated that 45.0 percent of Georgia’s low-income female population aged
18 to 64 was uninsured. The insurance mandate in Georgia may help to increase insurance
coverage. The above rates demonstrate, however, that specific effort is needed for uninsured,
low-income females.
Within Affiliate target communities, two out of the three target communities experience higher
rates of uninsurance than the Affiliate service area as a whole and the state of Georgia (Table
5), meaning a higher percentage of women residing in Bibb County and Peach County rely on
access to breast health services provided through the BCCP program and free clinics. Because
Georgia chose not to expand Medicaid eligibility, low-income women in the service area will
continue to rely on government programs to receive essential health care services like
screening mammograms.
Implementation of health care reform through the ACA will increase access to breast and
cervical cancer screening services for many low-income, underserved women through
expanded insurance coverage and eliminating cost-sharing. Under the provisions of the ACA all
health plans in the Health Insurance Marketplace must offer “essential benefits” which include
breast cancer mammography screenings every one to two years for women over 40, breast
cancer genetic test counseling (BRCA) for women at higher risk for breast cancer, and breast
Central Georgia Affiliate of Susan G. Komen®
cancer chemoprevention counseling. These services must be provided without charging a copay or co-insurance.
Although many more women in Georgia may have insurance coverage through the ACA Health
Insurance Marketplace and have these benefits available to them, many barriers still exist that
could prevent full utilization of these benefits. These contributing barriers include geographic
isolation, limited health literacy or self-efficacy, lack of provider recommendation, inconvenient
times to access services, and language barriers. Since Georgia chose not to expand Medicaid,
more than 266,000 women will not gain access to any affordable health care coverage in
Georgia in 2014. Women diagnosed through the Breast and Cervical Cancer Program (BCCP)
gain eligibility for comprehensive treatment services through the Women’s Health Medicaid
program. Funding for the BCCP program will be critical for women who will not be insured
through Medicaid, the Marketplace, or private insurers. Thus, those uninsured women can
continue to receive breast cancer screening, diagnostic, and treatment services (American
Society Cancer Action Network, 2014).
The ACA will require insurance companies to cover 100.0 percent of the cost of screening
mammograms for women over the age of 40; however, the insurance rate has not substantially
increased in Georgia since implementation of the insurance mandate and many women are still
expected to be uninsured.
Affiliate’s Public Policy Activities
The Affiliate does not currently participate in local public policy activities but plans to explore
opportunities to influence public policy related to breast health in the future. The Affiliate will
support the following national Susan G. Komen advocacy priorities:
 Federal funding for breast cancer research
 Funding for the National Breast and Cervical Cancer Early Detection Program
 Supporting legislation that requires health insurers to cover oral anti-cancer drugs on
terms no less favorable than the coverage provided for IV-administered anti-cancer
drugs
 Advocating in support of Medicaid Expansion
Health Systems and Public Policy Analysis Findings
Central to health systems provision are financing, insurance, and delivery of health care
services by different health providers. Thus, the reduction of breast cancer mortality and
morbidity requires breast cancer screenings, appropriate treatment, and timely follow-up.
Overall, the Central Georgia Affiliate service area has facilities and organizations that provide
services across the entire continuum of care and each target county receives limited federal
funding through the BCCP program to offer qualified women free services. However, the Health
System’s Analysis reveals that there are major gaps in access to care within the target counties.
Monroe County has one health department which offers clinical breast exams and one hospital
that offers screening and diagnostic mammograms and ultra-sounds. There are no additional
diagnostic services and absolutely no treatment or survivorship services in Monroe County.
There is not a nurse navigator at the hospital; patients usually rely on the doctors to direct them
to treatment. If someone is diagnosed with breast cancer, he or she is usually referred to the
hospital in Bibb County which is not within a convenient driving distance.
Central Georgia Affiliate of Susan G. Komen®
Peach County has one health department, which offers clinical breast exams and one hospital
that offers screening and diagnostic mammograms, and ultra-sounds. There are no additional
diagnostic services and absolutely no treatment or survivorship services in Peach County.
There is not a nurse navigator at the hospital; patients usually rely on the doctors to direct them
to treatment. If someone is diagnosed with breast cancer, he or she is usually referred to the
hospital in Houston County, which is within reasonable driving distance or the hospital in Bibb
County, which is not within a convenient driving distance.
The lack of local breast health services in Peach and Monroe Counties creates a major burden
to breast cancer patients or survivors who have been diagnosed with breast cancer and need
further medical attention or support services. Poor breast health outcomes, such as high death
dates and high incidences of late-stage diagnosis could be related to lack of access to care
within each county.
The strengths of breast health services in Bibb County include health care intervention
accessibility and quality care. Bibb County has a community health center, a volunteer clinic,
and a health department that provide screening services and referrals for screening
mammograms. There are two major hospitals that offer breast health services across the entire
continuum of care. Bibb County is within reasonable driving distance to the Affiliate’s seven
additional service counties. A recent strength of Bibb County is the opening of a new cancer
center in November 2014 at the major hospital where most of the population in the Affiliate’s
service area seek breast health services beyond clinical breast exams and screening and
diagnostic mammograms. The new Peyton Anderson Cancer Center will create less confusion
for patients by offering a one-stop shop facility for all cancer treatment, from screenings to
survivorship services. With the centralization of breast health services, patients will receive
lower costs and be able to receive quicker care.
The hospitals in Bibb County lack mobile mammography units to provide services to medically
underserved women in the surrounding service area. Provision of a mobile mammography unit
or transportation system would allow the hospitals to extend services to women residing in
surrounding rural areas who have trouble accessing treatment and survivorship services due to
long distances. In recent years, indigent care funding has decreased from $4,000,000 to
$475,000. This causes the county to rely heavily on BCCP funds. Since there is a high
population of uninsured women in Bibb County, the health department experiences strained
funding for BCCP services and limited availability to screening and diagnostic mammograms to
all eligible women.
Within the Affiliate’s target communities, a majority of the existing partnerships are located in
Bibb County. Many of the organizations listed on the Health System’s Analysis are either former
or current grantees. A majority of the organizations and businesses that sponsor Komen Central
Georgia events are located in Bibb County. The Affiliate will work to strengthen education
outreach and resources to existing and future partners. The Affiliate aims to seek more nonfunding partnerships in Bibb County with faith-based organizations and predominately Black
congregations to educate Black and rural communities about the risk of breast cancer and
inform them where they can receive breast health services. Strong partnerships in Bibb County
are essential for the Affiliate to maintain because the county provides services to patients in the
Affiliate’s entire service area.
There are currently no existing funding partnerships in Monroe County or Peach County. We
have not awarded a community grant in either of these counties. The nurses and staff at the
health departments and hospitals will serve as valuable resources in the future to better
Central Georgia Affiliate of Susan G. Komen®
understand the status of breast health services in these counties. The Affiliate will form
partnerships in the future with faith-based organizations and predominately Black congregations
to educate Black and rural communities about the risk of breast cancer and inform them where
they can receive breast health services.
Because Georgia is not expanding Medicaid eligibility, many residents will remain uninsured
because they do not fall within Medicaid eligibility guidelines and their income tax is too high to
receive a health insurance premium tax credit through the Marketplace. Many women will
continue to rely on BCCP services and clinics to receive screenings. These facilities, however,
lack the funds and resources needed to provide services for the entire population. When funds
are no longer available, women must wait until the next fiscal year, which can delay a life-saving
mammogram. Also, NBCCEDP does not extend coverage to men, which causes major
challenges for uninsured men diagnosed with breast cancer. Treatment for patients who are
diagnosed with breast cancer but who do not have health insurance can be paid through
Women’s Health Medicaid for qualified applicants.
The Affiliate does not currently participate in public policy activities. The Affiliate will work on
sharing the 2015 Community Profile with local officials, city mayors, and county mayors to
inform them of the work and needs in the service area. They will also be encouraged to support
and attend Race for the Cure, grantee site visits, and other Central Georgia Affiliate events. The
Affiliate will further explore opportunities to influence breast health public policy in the next four
years.
Central Georgia Affiliate of Susan G. Komen®