New cancer program combines population screening with public health intervention
New cancer program combines population screening with public health intervention
The Breast and Cervical Cancer Prevention and Treatment Act of 2000 established a new state coverage option under Medicaid that permits states to extend Medicaid to any uninsured woman under age 65 who was screened and diagnosed with breast or cervical cancer through the National Breast and Cervical Cancer Early Detection Program funded by the Centers for Disease Control and Prevention (CDC).
Creation of this coverage option has been seen as a groundbreaking effort to use population-wide public health screening programs as pathways for publicly funded health insurance.
The Centers for Medicare & Medicaid Services (CMS) contracted with George Washington University’s Center for Health Services Research and Policy to conduct an 18-month study to analyze initial steps by states to implement the act. The intent was to determine: (1) how states are taking advantage of the new Medicaid option; (2) how state Medicaid agencies and Title XV grantees (which are responsible for administering the detection program) are collaborating on implementation; (3) whether and how implementation of the treatment act is affecting operation of the screening; (4) what procedures are involved for enrolling women in Medicaid; and (5) states’ experience in implementing the treatment act.
Disease-based coverage category
Principal investigator Kathleen Maloy tells State Health Watch that after the screening program got under way, it became evident that many women were uninsured or underinsured for treatment following their free screening. The Breast and Cervical Cancer Prevention and Treatment Act creates a Medicaid coverage category that is unusual because it is disease-based rather than income-based. Some 48 states have adopted the treatment program as an optional Medicaid service and so far have given it a lot of support, Ms. Maloy says. Women in the program have access to all Medicaid services and the coverage lasts for as long as they have a cancer diagnosis.
Making a difference for women
She says the ultimate goal of the evaluation is to demonstrate that the program makes a difference for women and that there will be better outcomes if women have health care coverage through Medicaid. The first step in that process is to document that the program has been put in place in states and to look at how states implemented the new coverage category.
The first 10 states to implement and be analyzed were Alabama, Alaska, Georgia, Illinois, Iowa, New Hampshire, South Dakota, Utah, Washington, and West Virginia.
Initial findings have been that the Title XV and Title XIX agencies in the 10 states were working well together to adopt the prevention and treatment act and on relatively equal footing, although the Title XV agencies generally took the lead on implementation and worked through questions with the CDC and CMS.
States reported having a lot of confusion about the meaning of the three screening options in particular as well as other aspects of implementation. The three options are: (1) CDC Title XV funds paid for all or part of the costs of screening services; (2) the woman was screened under a state Breast and Cervical Cancer Early Detection Program in which her particular clinical service was not paid for by Title XV funds but was done by a provider funded at least in part by Title XV; and (3) the woman was screened by any other provider and/or entity and the state agency that received a Title XV grant has elected to include screening activities by that provider as screening activities pursuant to Title XV. The researchers say that confusion about the screening options "did not appear to constrain these states’ decision making about implementation."
States, they say, considered and selected screening options largely based on the design and scope of their existing Title XV National Breast and Cervical Cancer Early Detection Program screening network. Moreover, they decided what their screening network would be and then determined which option seemed to fit their choice.
The initial report says that state experiences with enrollment and expenditures for the coverage varied, and it is difficult to generalize about the experiences. Four states reported greater than anticipated enrollment.
According to the report, the researchers found substantial variability regarding states’ capacities for data collection and monitoring. The uncertainty about data capacity and quality is likely to present future challenges for designing a data-based impact evaluation.
Ms. Maloy says the question about data collection will come into play more next year as the research starts to look at documented outcomes of the care provided under the new law. Resolving data collection issues could be difficult, she says, because it might mean a very large information technology expenditure for only a small number of beneficiaries.
She says the ability of various state agencies to work together synergistically for this program has implications for other efforts in the future if there is interest in further extending insurance coverage by disease. It seemed to work well to involve the Title XV agency at the front end, to gather eligibility information and transmit it to the Medicaid agency. Other lessons learned, she says, are that it’s important to look carefully at the screening network, what the outreach activities are like, and those who are likely to be brought into coverage. And it’s important to make eligibility and enrollment as easy as possible so more women are encouraged to apply and obtain coverage.
"It’s good to see how excited state officials are about this program, how important it is to them in dealing with women who have a hard time finding providers," Ms. Maloy tells State Health Watch. "There’s a strong sense of support and excitement for implementing the screening and enrolling women for treatment."
[Contact Ms. Maloy at (202) 296-6922. E-mail: [email protected].]
The Breast and Cervical Cancer Prevention and Treatment Act of 2000 established a new state coverage option under Medicaid that permits states to extend Medicaid to any uninsured woman under age 65 who was screened and diagnosed with breast or cervical cancer through the National Breast and Cervical Cancer Early Detection Program funded by the Centers for Disease Control and Prevention (CDC).Subscribe Now for Access
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