Advancing Health Equity for Medicaid Beneficiaries by Adding Colorectal Cancer Screening to the Centers for Medicare and Medicaid Services Adult Core Set

Abstract

In May 2021, the Centers for Medicare and Medicaid Services (CMS) Quality Measures Voting Members unanimously recommended the addition of colorectal cancer (CRC) screening to the CMS Medicaid Adult Core Set of Quality Measures for adoption in 2022. However, CMS has the latitude to reject recommendations from the Voting Members. The proposed CMS Medicaid CRC screening quality measure should be supported because it is actionable, has alignment with other metrics, is appropriate, is feasible, and will promote equity for all people insured through CMS (Table 1).Table 1CRC Screening Performance Measure Meets Criteria for Addition to the CMS Adult Core Set of Quality MeasuresCharacteristics Considered for Adding a New Quality Measure to the 2022 Medicaid Adult Core SetActionability: Will the measure provide results that can be used to improve healthcare?YesEffective low-cost strategies increase CRC screeningReporting allows states to track their progress and identify plans with best practicesAlignment: Is the measure used in other reporting programs?YesMedicare incentivized HEDIS metric, which includes people dually insured by Medicare and MedicaidNCQA accreditationHRSA grantees (Federally Qualified Health Centers)Appropriateness for state-level reporting: Has the measure been validated and tested for state-level reporting in 1 or more states?YesA National Quality Forum (#0034) quality performance measure for commercial, Medicare, and MedicaidImplemented in Oregon, Minnesota, and New YorkNCQA priority (decreasing disparities, validate HEDIS CRC screening performance measure for Medicaid) – this would push it up the listFeasibility: Will states be able to access the data to calculate the measure?YesAdministrative claims data can be used (BeneFIT demonstrated this)Challenges: colonoscopy look back period is an issue for all health insurance plans. Solutions: requiring reporting improves documentation, which also helps patientsStrategic priority: Will the measure provide results that can be used to improve healthcare?YesBreast and cervical cancer screening are already included in the Medicaid Adult Core SetCRC screening is not included, despite large Medicaid disparitiesUnited States Preventive Services Task Force–Grade A recommendationCurrently no cancer screening performance measures for menMandated reporting for Medicare and commercially insured beneficiaries has led to substantial improvements in CRC screening and improved CRC outcomesAddressing disparities and inequities: Will the measure reduce health inequities currently observed between Medicare and Medicaid beneficiaries?YesMedicaid beneficiaries 50–64 years of age (84.8% people from racial and ethnic minority groups) have increasing incidence and mortality from CRC compared with the decreasing rates for Medicare beneficiaries 65 years and older (25.2% people from racial and ethnic minority groups)American Medical Association’s recent roadmap for achieving national equity and racial justice includes the addition of standards, benchmarks, incentives, and metrics. Addition of the CRC screening Medicaid Quality Measure would directly align with this national goal.HRSA, Health Resources & Services Administration; NCQA, National Committee for Quality Assurance. Open table in a new tab HRSA, Health Resources & Services Administration; NCQA, National Committee for Quality Assurance. The American Medical Association’s recently released social justice and health equity plan includes the addition of standards, benchmarks, incentives, and metrics to “Embed equity in practice, process, action, innovation, and organizational performance and outcomes”.1American Medical AssociationOrganizational strategic plan to embed racial justice and advance health equity, 2021-2023. 2021.https://www.ama-assn.org/system/files/2021-05/ama-equity-strategic-plan.pdfGoogle Scholar Addition of CRC screening to the CMS Medicaid Adult Core Set may foster health equity for nonelderly Medicaid beneficiaries who are more racially and ethnically diverse than Medicare beneficiaries. People from racial and ethnic minority groups comprise 84.8% of Medicaid beneficiaries but only 25.2% of Medicare beneficiaries (US average, 2019).2Kaiser Family FoundationDistribution of the nonelderly with Medicaid by race/ethnicity. KFF 2020.https://www.kff.org/medicaid/state-indicator/medicaid-distribution-nonelderly-by-raceethnicity/Date accessed: January 30, 2021Google Scholar Quality measures are used by health-care organizations and insurance plans, states, and national agencies to assess and compare quality of care. The requirement to measure and improve a quality measure has a profound impact on an organization’s decision to adopt evidence-based programs to improve that quality measure. The level of performance of this quality measure then influences payment, incentives, and accreditation. CMS require managed Medicare Advantage programs to report a core set of quality measures including CRC screening and other measures, as part of the Star Rating Program.3Centers for Medicare & Medicaid ServicesMedicare 2020 Part C & D star ratings technical notes. Centers for Medicare & Medicaid Services - Center for Medicare; 2019:184.https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/Downloads/Star-Ratings-Technical-Notes-Oct-10-2019.pdfGoogle Scholar Plans receive reimbursement bonuses and other benefits based on their overall star performance, which provide strong motivation for health plans to focus on what is being measured. Indeed, it has been said, “what is measured gets done.” Further demonstrating the importance of quality measures is the fact that among 5-star health plans, Medicare CRC screening rates are consistently >80%, and 90% in some health plans.4NCCRT80% hall of fame. Natl Colorectal Cancer Roundtable.https://nccrt.org/what-we-do/80-percent-by-2018/hall-of-fame/Date accessed: April 26, 2021Google Scholar One caveat with assuming that the addition of a new Medicaid quality measure will result in CRC screening rates similar to Medicare beneficiaries is that the Medicaid beneficiaries may have different social and/or structural barriers to care than people receiving Medicare. As part of the Affordable Care Act, CMS is required to identify a core set of quality measures for Medicaid and states are required to have standardized reporting on all or a subset of these quality measures.5MedicaidAdult core set reporting resources | Medicaid.https://www.medicaid.gov/medicaid/quality-of-care/performance-measurement/adult-and-child-health-care-quality-measures/adult-core-set-reporting-resources/index.htmlDate accessed: April 22, 2021Google Scholar Reporting will become mandatory for behavioral health quality measures in the CMS Medicaid Adult Core Set in 2024, but is not required for other adult measures such as for breast and cervical cancer screening. Long-term plans include linking all core set quality measures to Medicaid reimbursement.6Centers for Medicare & Medicaid ServicesCore measures | CMS.https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/Core-MeasuresDate accessed: April 22, 2021Google Scholar The current CMS Medicaid Adult Core Set of Quality Measures includes breast and cervical cancer screening but not CRC screening.7Center for Medicaid and CHIP Services, Division of Quality and Health OutcomesMedicaid and CHIP beneficiary profile. Centers for Medicare & Medicaid Services. Baltimore, MD. February.2020Google Scholar There are currently no Medicaid-required cancer screening quality measures that apply to men. The American Cancer Society estimates that there will be 149,500 new cases of CRC diagnosed in 2021 with 52,980 people dying due to their disease.8Siegel R.L. Miller K.D. Fuchs H.E. et al.Cancer statistics, 2021.CA Cancer J Clin. 2021; 71: 7-33Crossref PubMed Scopus (8685) Google Scholar The 2021 data indicate that CRC is third in incidence for both women and men, with 4.3% of men (1 in 23) and 4.0% of women (1 in 25) being diagnosed with CRC sometime in their lifetimes.8Siegel R.L. Miller K.D. Fuchs H.E. et al.Cancer statistics, 2021.CA Cancer J Clin. 2021; 71: 7-33Crossref PubMed Scopus (8685) Google Scholar In addition, CRC deaths rank second overall for all cancer deaths when combining rates for men and women.8Siegel R.L. Miller K.D. Fuchs H.E. et al.Cancer statistics, 2021.CA Cancer J Clin. 2021; 71: 7-33Crossref PubMed Scopus (8685) Google Scholar Recent Surveillance, Epidemiology, and End Results (SEER) trends indicate that CRC incidence rates increased by 0.3% annually in those aged 50–64 years (2011–2018 data), in sharp contrast to decreases of 3.1% per year in adults aged 65 and older (2012–2018 data), which includes low-income individuals aged 50–64 years eligible for Medicaid insurance in most states.9AnonSEER*Explorer Application.https://seer.cancer.gov/explorer/application.html?site=20&data_type=4&graph_type=6&compareBy=sex&chk_sex_1=1&chk_sex_3=3&chk_sex_2=2&race=1&age_range=1&stage=104&advopt_precision=1&advopt_display=2Date accessed: January 13, 2021Google Scholar In May 2021, the United States Preventive Services Task Force expanded its CRC screening age recommendations to also include screening people 45–49 years of age at average risk.10US Preventive Services Task ForceScreening for colorectal cancer: US Preventive Services Task Force recommendation statement.JAMA. 2021; 325: 1965-1977Crossref PubMed Scopus (298) Google Scholar Pairing this information with CMS data that 14% of the Medicaid population is between the ages of 46 and 64, almost 9.5 million people covered by Medicaid need CRC screening.6Centers for Medicare & Medicaid ServicesCore measures | CMS.https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/Core-MeasuresDate accessed: April 22, 2021Google Scholar CRC screening is effective, decreasing incidence by 25.5% and mortality by 52.4%,11Levin T.R. Corley D.A. Jensen C.D. et al.Effects of organized colorectal cancer screening on cancer incidence and mortality in a large, community-based population.Gastroenterology. 2018; 155: 1383-1391.e5Abstract Full Text Full Text PDF PubMed Scopus (221) Google Scholar and potentially cost-saving because CRC treatment is expensive.12Lansdorp-Vogelaar I. Ballegooijen M van Zauber A.G. et al.Effect of rising chemotherapy costs on the cost savings of colorectal cancer screening.JNCI J Natl Cancer Inst. 2009; 101: 1412-1422Crossref PubMed Scopus (150) Google Scholar In 2018, the percentage of Medicaid beneficiaries who were up-to-date with screening was 54% vs 73% in Medicare-insured adults or 80% when combining screening rates for Medicare and commercial insurance.13American Cancer Society. Colorectal cancer Facts & Figures 2020-2022. Atlanta: American Cancer Society; 2020. Accessed January 11, 2021.Google Scholar We believe this disparity is due in large part to the fact that Medicaid plans, unlike Medicare plans, are not required to report CRC screening rates. Medicaid enrollees are also 50% more likely to present with late-stage colon cancer and die due to it than those with commercial or Medicare insurance.7Center for Medicaid and CHIP Services, Division of Quality and Health OutcomesMedicaid and CHIP beneficiary profile. Centers for Medicare & Medicaid Services. Baltimore, MD. February.2020Google Scholar California Cancer Registry data revealed that for all patients with CRC with known insurance status, 61.2% were diagnosed with late-stage disease but subset analysis highlights the unequal rates for Medi-Cal (CA Medicaid; 70.7%) vs Medicare (63.7%) (California Cancer Plan, 2021–2025). In many states, people from racial and ethnic minority groups represent the majority of people enrolled in Medicaid and the low screening rates contribute to the racial and ethnic disparities in late-stage diagnosis and mortality from CRC.2Kaiser Family FoundationDistribution of the nonelderly with Medicaid by race/ethnicity. KFF 2020.https://www.kff.org/medicaid/state-indicator/medicaid-distribution-nonelderly-by-raceethnicity/Date accessed: January 30, 2021Google Scholar These differences reinforce the importance of adding CRC screening to the CMS Medicaid Adult Core Set of Quality Measures to decrease CRC adverse outcomes from late-stage disease. A survey of state Medicaid agencies reported lack of quality measure as the biggest barrier to increasing CRC screening.14NCCRTImproving colorectal cancer screening rates: a promising practices guide for state-Medicaid agencies. 2018:1–59.https://nccrt.org/resource/a-promising-practices-guide-for-state-medicaid-agencies/Date accessed: January 11, 2021Google Scholar A few states have adopted methods for tracking Medicaid screening rates, including New York, Oregon, Minnesota, and Maryland, which require Medicaid insurance plans to report CRC screening rates.14NCCRTImproving colorectal cancer screening rates: a promising practices guide for state-Medicaid agencies. 2018:1–59.https://nccrt.org/resource/a-promising-practices-guide-for-state-medicaid-agencies/Date accessed: January 11, 2021Google Scholar New York State, Oregon Health Authority, and Minnesota Community Measurement Authority require Medicaid plans to report CRC screening rates using the Health Effectiveness Data and Information Set (HEDIS) measure with New York including benchmarks as part of the process.15New York State Department of HealtheQARR - an online report on quality performance results for health plans in New York state. 2020.https://www.health.ny.gov/health_care/managed_care/reports/eqarr/Date accessed: January 12, 2021Google Scholar The Maryland Department of Health has created a “homegrown” measure based on HEDIS for the 50–64 years of age group.14NCCRTImproving colorectal cancer screening rates: a promising practices guide for state-Medicaid agencies. 2018:1–59.https://nccrt.org/resource/a-promising-practices-guide-for-state-medicaid-agencies/Date accessed: January 11, 2021Google Scholar Several other states track state Medicaid CRC screening rates using Behavioral Risk Factor Survey System or all-payer claims data and do not require Medicaid-specific reporting. Washington only requires reporting of Medicare CRC screening—a key factor in their decision to offer the program only to dual eligible enrollees (Medicare-Medicaid) because some Medicaid data is captured in their Medicare data. States with Medicaid reporting requirements (Table 2) have noted improvements in screening rates over a relatively short time span. Oregon’s Medicaid CRC screening rates have increased by 11% (from 46%–57%) since required reporting began in 2014,14NCCRTImproving colorectal cancer screening rates: a promising practices guide for state-Medicaid agencies. 2018:1–59.https://nccrt.org/resource/a-promising-practices-guide-for-state-medicaid-agencies/Date accessed: January 11, 2021Google Scholar whereas Washington rates only increased by 3% (from 43%–46%)16Washington Health Alliance2019 Community checkup report: improving health care in Washington state. 2020.https://wahealthalliance.org/wp-content/uploads/2020/04/2019-Community-Checkup-Report.pdfGoogle Scholar likely due to restriction to dually eligible people. Minnesota increased its Medicaid screening rate from 47.4%–56.2% from 2011–2017.14NCCRTImproving colorectal cancer screening rates: a promising practices guide for state-Medicaid agencies. 2018:1–59.https://nccrt.org/resource/a-promising-practices-guide-for-state-medicaid-agencies/Date accessed: January 11, 2021Google Scholar New York State reported a 5% increase in screening rates for Medicaid beneficiaries, comparable with the increase observed for their Preferred Provider Organizations between 2012 and 2016 and helped level the screening rate to 61%–62% between both insurance plans.15New York State Department of HealtheQARR - an online report on quality performance results for health plans in New York state. 2020.https://www.health.ny.gov/health_care/managed_care/reports/eqarr/Date accessed: January 12, 2021Google Scholar For comparison, the national CRC screening rates increased by 2% from 67% to 69% between 2014 and 2018 (or 3% when expanding the years to 2012–2018), whereas the overall screening rates for New York, Minnesota, and Washington changed by -2%–+2% during the timeframes indicated, whereas Oregon saw a 4% overall increase.17Centers for Disease Control and PreventionColorectal cancer screening test use | CDC. 2021.https://www.cdc.gov/cancer/ncccp/screening-test-use/index.htmDate accessed: November 5, 2021Google ScholarTable 2Comparison of Screening Rate Changes in States With Medicaid Reporting RequirementsStateScreening measureTime frameMedicaid screening rate (%)Absolute screening rate change (%)Overall screening rate change for states (%)17Centers for Disease Control and PreventionColorectal cancer screening test use | CDC. 2021.https://www.cdc.gov/cancer/ncccp/screening-test-use/index.htmDate accessed: November 5, 2021Google ScholaraState screening rates for specified years are referenced. For states with Medicaid data in odd years, the overall screening rates that overlapped these years were included.Years analyzedTotal no. of years sampledInitial rateFinal fateNew York15New York State Department of HealtheQARR - an online report on quality performance results for health plans in New York state. 2020.https://www.health.ny.gov/health_care/managed_care/reports/eqarr/Date accessed: January 12, 2021Google ScholarMedicaid (HEDIS)2012–201655661+5-2 (2012–2016)Oregon14NCCRTImproving colorectal cancer screening rates: a promising practices guide for state-Medicaid agencies. 2018:1–59.https://nccrt.org/resource/a-promising-practices-guide-for-state-medicaid-agencies/Date accessed: January 11, 2021Google ScholarMedicaid (HEDIS)2014–201744657+11+4 (2014–2018)Minnesota14NCCRTImproving colorectal cancer screening rates: a promising practices guide for state-Medicaid agencies. 2018:1–59.https://nccrt.org/resource/a-promising-practices-guide-for-state-medicaid-agencies/Date accessed: January 11, 2021Google ScholarMedicaid (HEDIS)2011–2017747.456.2+8+2 (2012–2018)Washington16Washington Health Alliance2019 Community checkup report: improving health care in Washington state. 2020.https://wahealthalliance.org/wp-content/uploads/2020/04/2019-Community-Checkup-Report.pdfGoogle ScholarMedicare-Medicaid Dual Eligible2014–201744346+3+1 (2014–2018)National screening rates17Centers for Disease Control and PreventionColorectal cancer screening test use | CDC. 2021.https://www.cdc.gov/cancer/ncccp/screening-test-use/index.htmDate accessed: November 5, 2021Google ScholarbData is only available beginning in 2012, in 2-year increments.NCCCP/CDC2012–201646669+32012–201866669+32014–201846769+2CDC, Centers for Disease Control and Prevention; NCCCP, National Comprehensive Cancer Control Program.a State screening rates for specified years are referenced. For states with Medicaid data in odd years, the overall screening rates that overlapped these years were included.b Data is only available beginning in 2012, in 2-year increments. Open table in a new tab CDC, Centers for Disease Control and Prevention; NCCCP, National Comprehensive Cancer Control Program. Federally Qualified Health Centers (FQHC) have reported increasing Uniform Data Set screening rates for CRC since the 2012 reporting mandate was implemented as part of Health Resources & Services Administration funding to improve and expand health-care services for underserved people.18AnonNational Health Center data. dataHRSA.gov 2020.https://data.hrsa.gov/tools/data-reporting/program-data/nationalDate accessed: December 1, 2020Google Scholar Notably, >77% of FQHC patients are insured, with the majority covered by Medicaid and this population offers surrogate data for screening rates of all Medicaid beneficiaries. In 2018, 44.1% of patients 50–75 years of age who receive their care at FQHCs were up to date on screening compared with the 69% national screening rate.18AnonNational Health Center data. dataHRSA.gov 2020.https://data.hrsa.gov/tools/data-reporting/program-data/nationalDate accessed: December 1, 2020Google Scholar Harmonizing reporting requirements for all Medicaid plan providers would provide additional opportunities to rectify discrepancies in care delivery with the goal to increase CRC screening rates and reduce outcome disparities, including late-stage disease and mortality independent of insurance coverage. When addressing the potential barriers to adoption of the CRC screening quality measure, the main technical difficulty in measuring CRC screening is the look back period of 10 years for colonoscopy, which is a problem for all health plans regardless of insurance type. Medicaid health plans, including those offered through FQHC, already report this data on all their dual-enrolled Medicaid-Medicare beneficiaries, supporting the feasibility of reporting if the CRC screening quality measure is adopted by CMS for Medicaid beneficiaries. Also, several states have been able to overcome the long look back period limitation in reporting their Medicaid CRC screening rates.18AnonNational Health Center data. dataHRSA.gov 2020.https://data.hrsa.gov/tools/data-reporting/program-data/nationalDate accessed: December 1, 2020Google Scholar Since February 2020, the number of individuals enrolled in Medicaid has grown by 9.3 million to 80.5 million in January 2021, an increase of 13.1% that is largely attributed to income and job loss associated with the COVID-19 pandemic.19Corallo B. Analysis of recent national trends in Medicaid and CHIP enrollment. KFF 2021.https://www.kff.org/coronavirus-covid-19/issue-brief/analysis-of-recent-national-trends-in-medicaid-and-chip-enrollment/Date accessed: June 20, 2021Google Scholar Kaiser Family Foundation estimates that groups more sensitive to changes in economic conditions, including children, parents, and other expansion adults (potential Medicaid beneficiaries) will grow faster than the elderly and people with disabilities (potential Medicare beneficiaries).20Hinton E. Stolyar L. Medicaid spending and enrollment trends amid the COVID-19 pandemic – updated for FY 2021 & looking ahead to FY 2022. KFF 2021.https://www.kff.org/coronavirus-covid-19/issue-brief/medicaid-spending-and-enrollment-trends-amid-the-covid-19-pandemic-updated-for-fy-2021-looking-ahead-to-fy-2022/Date accessed: April 1, 2021Google Scholar This highlights the importance of establishing a CRC screening quality measure for a growing segment of our population to help reduce late-stage diagnoses and mortality from CRC. The Voting Members’ unanimous recommendation to add CRC screening to the CMS Medicaid Adult Core Set of Quality Measures is a critical step in promoting equity for people younger than 65 years of age, including those of many racial and ethnic minorities covered by Medicaid insurance who may be disproportionately impacted by late-stage CRC. The adoption of this quality measure would be an additional imperative or incentive to improve delivery of CRC screening and improve prevention and early detection; it may be life saving for Medicaid beneficiaries aged 45–64 years of age.