Project Title: “Eliminating Barriers to Care and Providing Equitable Specialty Cancer Care Access for Medicaid Patients”
Objectives:
- To improve access to genetic testing and screening for breast cancer in high-risk Medicaid patients
- To create a framework for increasing access to specialty cancer care and clinical trials for lower income patients
Background: Newly diagnosed and relapsed cancer is a nuanced and daunting diagnosis. The time and stage of diagnosis, type of treatment, and delay to treatment all have profound implications on survival and quality of life.1,2 However, not everyone has access to a comprehensive cancer center (CCC) and many barriers exist to care. These barriers, such as lack of insurance, underinsurance, additional financial costs, institutional mistrust and historically poor outreach, lack of transportation, and limited health literacy disproportionately affect minority communities.
The purpose of this project is twofold: to increase access to CCC and other sites that have treatment options such as clinical trials that are not available in the community, and to increase genetic screening for breast cancer, which disproportionally affects minority women.3 Increasing genetic cancer screening and next generation sequencing can lead to earlier diagnosis, earlier treatment, and ultimately better outcomes.
Methods:
- Performed a Health Technology Assessment (HTA) for PALB2 genetic testing for MassHealth. HTA involves a literature review, landscape insurance review, cost effectiveness, presentation on the clinical merits of testing, and updating medical necessity guidelines
- Performed a literature review and worked with different departments in MassHealth and Dana-Farber Cancer Institute to identify gaps in cancer care coverage and access to insurance
Results: Completed PALB2 HTA and submitted recommendation of coverage to the clinical coverage committee. During the landscape review discovered that PALB2 can be covered with a prior authorization. Considering this and additional genetic testing that is now becoming available, advised MassHealth on updating medical necessity guidelines. Presented recommendations to the clinical coverage team which voted to continue testing for PALB2. MassHealth also has decided to cover next generation sequencing for advanced cancer patients and will be updating medical necessity guidelines with anticipatory guidance for future testing and new treatments. For increase to cancer care access, identified gaps in coverage for individuals who do not have breast or cervical cancer. One way of increasing care would be to expand presumptive eligibility. There are multiple avenues of improvement that will rely on payors, providers, hospitals, patient groups, organizations, local, state, and federal governments.
Future Directions:
- MassHealth will continue updating framework on genetic, molecular, and next generation sequencing and reevaluate coverage process for additional cancer care treatment. I will continue to help in an advisory capacity on medical necessity guidance.
- Will continue meeting with different stakeholders on how to improve access for lower income patients to access cancer care. May need additional legislation that expands presumptive eligibility in states without Medicaid expansion and increased eligibility requirements for states with existing frameworks.
Preceptors: Michael Chin MD, Lakshman Swamy MD, and Thomas Emswiler
References
- Wolfson JA, Sun CL, Wyatt LP, Hurria A, Bhatia S. Impact of care at comprehensive cancer centers on outcome: Results from a population-based study. Cancer. 2015;121(21):3885-3893. doi:10.1002/cncr.29576
- NCI-designated cancer sites. National Cancer Institute. https://www.cancer.gov/research/infrastructure/cancer-centers/find
- Emerson MA, Golightly YM, Aiello AE, et al. Breast cancer treatment delays by socioeconomic and health care access latent classes in Black and White women. Cancer. 2020;126(22):4957-4966. doi:10.1002/cncr.33121
