Comparing Breast Cancer Outcomes Between Medicaid and the Ohio Breast and Cervical Cancer Early Detection Program

Abstract

Purpose: To compare outcomes between women enrolling in Medicaid after being diagnosed with breast cancer and those referred to Medicaid through the Ohio Breast and Cervical Cancer Early Detection Program (BCCEDP). Methods: Using linked data from the 2002 to 2008 Ohio CancerIncidence Surveillance System, Medicaid, the BCCEDP database, and Ohio death certificates (through 2010), we identified women 40 to 64 years of age diagnosed with incident invasive breast cancer during the study years and enrolled in Medicaid 3 months before or after cancer diagnosis. We compared the following outcomes across BCCEDP one-time and repeat participants and nonparticipants: (1) cancer stage at diagnosis, (2) treatment delays, (3) receipt of standard treatment, and (4) survival. We conducted multivariable logistic regression and survival analysis to examine the association between BCCEDP participation and the outcomes of interest, controlling for potential confounders. Results:We identified 427 and 654 BCCEDP participants and nonparticipants, respectively; 28.5% of BCCEDP women were repeat participants. Compared with nonparticipants, BCCEDP one-time and repeat participants were significantly less likely to be diagnosed with advanced-stage cancer (one-time: adjusted odds ratio [AOR], 0.64; 95% CI, 0.49 to 0.85; repeat: AOR, 0.34; 95% CI, 0.23 to 0.52), or experience delays in treatment initiation (one-time: adjusted hazard ratio [AHR], 1.29; 95% CI, 1.09 to 1.51; repeat: AHR, 1.38; 95% CI, 1.11 to 1.72). In addition, although we observed no difference in receipt of standard cancer treatment, BCCEDP participants experienced cancer-specific and overall survival benefits. Conclusion:Compared with nonparticipants, BCCEDP participants experienced earlier breast cancer stage at diagnosis, shorter time to treatment initiation, and survival benefits.

The Breast and Cervical Cancer Early Detection Program, Medicaid, and breast cancer outcomes among Ohio's underserved women

“…In agreement with our and others' previous studies, women in the Medicaid/peridiagnosis group represented the most vulnerable subgroup of our study population: more than 1 in 5 women (21.9%) in the Medicaid/peridiagnosis group presented with metastatic disease. This percentage is nearly 3 times that observed among Medicaid/prediagnosis beneficiaries and BCCEDP 1‐time users (7.0% and 7.7%, respectively) and 5 times that for non‐Medicaid/non‐BCCEDP women (4.3%).…”

“…Data from the OCISS, BCCEDP, Ohio Medicaid enrollment files, and death certificates were linked with patient identifiers (first and last names, date of birth, and Social Security number) with a multistep deterministic algorithm, as previously described. 28…”

“…27 For breast cancer, these indicators include the following: abnormal screening results with complete follow-up (performance standard at 90%), time from abnormal screening results to a final diagnosis > 60 days (25%), treatment started for breast cancer (90% within 9 months postscreening), and time from the diagnosis of breast cancer to the start of treatment > 60 days (20%). 27 To gain a better understanding of the BCCEDP's role in the state's efforts to reduce breast cancer disparities, we compared breast cancer stage and mortality across 1) BCCEDP 1-time and repeat users, 2) Medicaid beneficiaries (distinguishing between those who had been in Medicaid before their cancer diagnosis [prediagnosis beneficiaries] and those enrolling in Medicaid around the time of their cancer diagnosis [peridiagnosis beneficiaries]), 28,29 and 3) all others (identified neither as BCCEDP participants nor as Medicaid beneficiaries). We hypothesized the following: 1) BCCEDP women would experience more favorable breast cancer stage and mortality outcomes than Medicaid beneficiaries; 2) although the most favorable outcomes would be observed among non-BCCEDP women and non-Medicaid women, the most vulnerable women would be identified in the Medicaid/peridiagnosis group; and 3) BCCEDP repeat users would experience more favorable outcomes than BCCEDP 1-time users.…”

Post–Affordable Care Act Improvements in Cancer Stage Among Ohio Medicaid Beneficiaries Resulted From an Increase in Stable Coverage

“…We used data from the Ohio Cancer Incidence Surveillance System (OCISS) and Ohio Medicaid enrollment data, which we linked using a deterministic linkage algorithm based on the patient's social security number, first and last name, date of birth, and sex. [17][18][19][20]29 Further contextual data were derived from the 2013-2017 American Community Survey data from the US Census (income, education, and percent uninsured at the census tract level; urbanicity/rurality of patients' county of residence) and the Health Resources Service Administration to identify Health Professional Shortage Areas (HPSAs).…”

“…The importance of accounting for individuals' enrollment history in Medicaid when evaluating cancer outcomes in Medicaid beneficiaries as a marker for access to and continuity of primary care, 15 as well as uptake of preventive services has been well established. Indeed, compared with individuals enrolled in Medicaid several months before cancer diagnosis, those individuals enrolled in Medicaid shortly before or after cancer diagnosis have higher odds of presenting with advanced-stage disease [15][16][17][18][19] and experiencing adverse survival outcomes. 20,21 This distinction is critical, as it differentiates between those who enroll in Medicaid only upon being diagnosed with a catastrophic illness like cancer (hereafter referred to as the emergently-enrolled), and those who enroll in Medicaid regardless of being diagnosed with a catastrophic illness (the stably-enrolled).…”