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: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 Cancer Stage at Diagnosis Disparate cancer treatment and follow-up care Cancer-related outcomes: Patient Sociodemographics: Age, Race/Ethnicity, Sex, Insurance Status Medicaid Status Access to and use of cancer screening services Access to and use of services for cancer treatment and follow-up care

Insurance status, Medicaid status, and cancer-related outcomes Insurance Status: Insured Uninsured/ Underinsured Adequate access to and use of health services Favorable outcomes/ good prognosis Inadequate access to and use of health services Advanced- stage disease Receipt of disparate care/ Resource depletion Early Stage Diagnosis Receipt of adequate care HIGH OUT-OF-POCKET EXPENDITURES / POVERTY/ RESOURCE DEPLETION PARTICIPATION IN MEDICAID Unfavorable Outcome/ Poor Prognosis ? ? ? ?

Policy Questions: Is Medicaid status associated with poor cancer (disease) related outcomes?Is Medicaid status associated with poor cancer (disease) related outcomes? => Evaluate the effectiveness of the Medicaid program in cancer (disease) prevention and control=> Evaluate the effectiveness of the Medicaid program in cancer (disease) prevention and control CHALLENGING HYPOTHESIS: PARTICIPATION IN MEDICAID IS ASSOCIATED WITH IMPROVED CANCER-RELATED OUTCOMESCHALLENGING 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 analysisDifficulty 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 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)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.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.Patient unique identifier in Medicaid to link enrollment and claims data across different time spans and service types. Linkage algorithm using patient identifiers: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 ServicesProject 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, 1992OCISS: Mandatory reporting of all incident cases of cancer (except insitu cervical, squamous cell and basal cell carcinoma), since January, 1992 Relevant data elements include: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 Enrollment data  –Date of enrollment in Medicaid –Length of participation in Medicaid prior to cancer diagnosis Claims data Claims data  –Health care utilization ScreeningScreening Treatment (surgical; radiation therapy; chemotherapy)Treatment (surgical; radiation therapy; chemotherapy) Follow-up careFollow-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.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?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):

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 Medicaid Status

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 Medicaid Status and Timing of Enrollment in Medicaid Non-Medicaid Medicaid, Pre-Diagnosis Medicaid Peri-Diagnosis* Medicaid Post-Diagnosis** * 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.Women enrolled in Medicaid shortly before, at, or after cancer diagnosis are significantly more likely to present with advanced-stages of the disease. Implications: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 patientParticipation 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: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 Women 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 Period, , by length of enrollment in Medicaid Women 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, , by length of enrollment in Medicaid Women years of age, with no participation in Managed Care programs, Medicare or spenddown, and no stay in nursing homes after enrollment in Medicaid

Average Number of Mammography Exams per Year by Length of Enrollment in Medicaid Women 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 screeningIncreased 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 careAdditional analysis needed to determine whether increased use of screening services reflects continuity of care Implications: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): ).Ability of claims to identify incident cases of breast cancer (Koroukian SM et al. HSR Journal 2003; 38(3): ).

Discussion Cancer as a case study. The findings are likely to also apply to other clinical entities.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.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.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 low- income Medicare beneficiaries – is participation associated with improved outcomes?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 low- income Medicare beneficiaries – is participation associated with improved outcomes? Cost burden to the Medicaid programCost burden to the Medicaid program Quality of careQuality 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)The National Cancer Institute (F32 CA84621) American Cancer Society (IRG -American Cancer Society (IRG ) Collaborators: – –Gregory S. Cooper, M.D. – –Alfred A. Rimm, Ph.D.