Two physicians who are healthcare researchers have done an analysis of colorectal screening levels for Medicaid beneficiaries, and, finding those levels to be unjustifiably low, are recommending that a quality measure be developed in Medicaid for colorectal screening.
Beverly Green, M.D., M.P.H., and Laura Logan, M.D., M.P.H., discuss the issue in an article posted to the Health Affairs Blog on August 31, entitled “From Research To: Action: Advocating For A Medicaid Colorectal Cancer Screening Quality Measure.” Dr. Green is a senior Investigator Kaiser Permanente Washington Health Research Institute and a Family Physician Kaiser Permanente Washington; Dr. is a Professor in the UW Department of Family Medicine, an investigator in the Washington Wyoming Alaska Montana Idaho (WWAMI) Rural Health Research Center, and a practicing family physician.
As the physician researchers write, “Colorectal cancer (CRC) is the second-leading cause of cancer death in the US, but it does not have to be. Prevention and early intervention can save lives. Screening prevents CRC by finding and removing pre-cancerous lesions before they become cancerous. Screening also detects CRC early; when CRC is localized, 5-year survival is over 90 percent. Five-year survival for late-stage CRC, however, is less than 20 percent. Screening is also potentially cost-saving, because CRC treatment is expensive. Screening tests include colonoscopy and fecal screening tests; our and others’ research has demonstrated that mailing such tests can significantly increase CRC screening uptake by 22 percent on average, regardless of race, ethnicity, preferred language, income, or insurance type—resulting in CRC screening rates over 80 percent and markedly decreased CRC mortality.”
Indeed, they write, “There are striking screening disparities, especially for Medicaid-insured adults. In 2018, only 54 percent of Medicaid-insured, age-eligible adults were current for CRC screening, compared to 65 percent of commercially insured adults, 73 percent of Medicare-only or dual Medicare and Medicaid-insured adults, and 80 percent of Medicare- and privately insured adults. Over 75 percent of CRC deaths occur in adults who are not up to date for CRC screening. Medicaid enrollees are also 50 percent more likely to present with late-stage colon cancer and die from it than those with commercial or Medicare insurance. Why are CRC screening rates so much lower and outcomes worse among Medicaid-insured populations?” they ask.
The answer? “In contrast, CMS has required managed Medicare Advantage plans to report a core set of quality measures, including CRC screening rates and other Healthcare Effectiveness Data and Information Set (HEDIS) measures (e.g., flu vaccine uptake, hypertension control, access to care) as part of the “Star” quality rating program since 2007. Plans receive reimbursement bonuses and other benefits (e.g., longer open enrollment periods) based on their overall star performance, providing strong motivation for health plans to focus on improvements in care being measured. Among top performing health plans, Medicare CRC screening rates have been consistently over 80 percent, and over 90 percent in some health plans. Including CRC screening in the Medicaid core set of quality performance measures would be a critical step towards decreasing CRC disparities among Medicaid enrollees and reaching CRC screening rates on par with Medicare.”
The researchers go on to discuss BeneFIT, a fecal immunochemical testing (FIT) program funded by the Centers for Disease Control and Prevention (CDC), and which was implemented and evaluated in two Medicaid managed care plans, one in Washington, and one in Oregon. As they note, “The plans used claims data to identify enrollees overdue for CRC screening and vendors to mail FIT kits directly to over 10,000 enrollees, with about 18 percent completing FIT within 6 months. During this time, Oregon required insurance plans to report Medicaid screening rates, while Washington did not. Plans in both states were required to report Medicare CRC screening rates to the CMS. In year 2 of the program, the Washington health plan no longer offered mailed FIT kits to all Medicaid-insured enrollees, limiting the program to only special needs enrollees (those with Medicare as well as Medicaid insurance), while the Oregon plan expanded its program to include more Medicaid enrollees. Several health plans in Washington state have shared that the lack of a Medicaid reporting requirement contributed to their decision to offer the program only to Medicare/Medicaid enrollees, and not the larger population of age-eligible Medicaid-only enrollees not current for CRC screening.”
The doctors go on to argue that “[E]ffective low-cost strategies exist for increasing CRC screening uptake,” and that “Reporting allows plans to track their progress and identify plans with best practices.” Also, purely as a matter of equity, CRC screening reporting is already acquired for Medicare plans, for accreditation by the NCQA (National Committee on Quality Assurance), and for federal qualified health centers to receive grants. And, so far, four states measure Medicaid CRC screening rates.
“Measuring CRC screening will allow state Medicaid health authorities and Medicaid insurance plans to identify disparities, but it will not fix them,” they note. “Additional steps will be required, including: adoption of evidence-based strategies (e.g., Medicaid health plans implementing mailed FIT programs), and CMS (and states) requiring reporting and incentivizing Medicaid CRC screening performance. These steps will lead to increased CRC screening, resulting in CRC prevention or detection of earlier-stage CRC, and decreased CRC mortality disparities among Medicaid enrollees.”
