Medicaid Managed Care Strategies for Increasing Cancer Screening Rates
Mary Beth Dyer, Bailit Health
Preventive screenings to detect Colorectal Cancer (CRC) and lung cancer can make the difference between life and death. The five-year lung cancer survival rate is six percent for those diagnosed at a late stage and 60 percent for those diagnosed at an early stage. Similarly, approximately 60 percent of deaths from CRC could be avoided if everyone age 50 and older were screened regularly for CRC.
CRC screening and lung cancer screening recommendations focus on individuals over age 50. With states’ expansion of Medicaid under the Patient Protection and Affordable Care Act (ACA), a significant number of adults over age 50 are now enrolled in Medicaid managed care organizations (MCOs). Even in states without Medicaid expansion, more older adults may be covered as states have increased the number and types of Medicaid enrollees in managed care plans.
State action is key to increasing cancer screening for adults covered by Medicaid and improve health outcomes. Time is of the essence. States should actively work with Medicaid plans to help enrollees obtain missed cancer screenings. Even before COVID-19, the percentage of eligible individuals screened for lung cancer was estimated to be in single-digit percentages. Similarly, even prior to the COVID-19 pandemic, researchers estimate that up to 31 percent of the U.S. population was not receiving recommended CRC screening. Multiple studies report that even fewer adults covered by Medicaid are up to date with CRC screening recommendations.
Medicaid can reduce cancer’s impact. In 2014 alone, states that expanded Medicaid experienced a 6.4 percent increase in early-stage diagnoses of cancer and no detectable change for late-stage diagnoses compared to states that did not expand Medicaid at that time.
Helping Medicaid Enrollees “Catch Up” on Missed Screenings Due to COVID
The impact of missed cancer screenings due to COVID-19 creates an even greater urgency for state Medicaid programs to advance strategies to encourage cancer screenings and early treatment. While the research on best practices is not conclusive, this expert perspective offers state agencies some promising practices to work with their contracted Medicaid health plans, providers, and enrollees to increase rates of colorectal and lung cancer screening.
Colorectal Cancer Screening:
State Medicaid agencies can review the National Colorectal Cancer Roundtable’s (NCCRT) publication: Improving Colorectal Cancer Screening: Promising Practices for State Medicaid Agencies”  for more details on best practices regarding CRC screening. NCCRT’s research points to the following promising practices for Medicaid agencies to improve CRC screening and treatment:
- Cover and promote CRC test options including mailed fecal immunochemical test programs: New York Medicaid covers stool tests and computer tomography colonography for CRC screening. Oregon has a statewide effort, the Screen to Prevent (STOP) Colon Cancer program, which includes mailing at-home stool tests.
- Define a CRC metric for Medicaid plans: Use available screening data and metrics to measure MCO performance on CRC screening. For example, Maryland developed a homegrown CRC screening measure based on NCQA HEDIS technical specifications for the 50 to 64 age group to track screening rates among Medicaid expansion enrollees.
- Support or mandate public reporting of CRC screening rate: The New York Department of Health publishes an annual report of health plan performance on certain measures, including measures related to breast, cervical and colorectal cancer screening.
- Develop an incentive program/value-based measure for CRC screening: The Louisiana Department of Health (LDH) includes CRC screening as an incentivized measure for Medicaid MCOs. To earn back a portion of their quality withhold, MCOs must improve their CRC screening rates by at least two percentage points. To earn the full amount for the CRC screening measure, an MCO must meet or exceed the best performance reported by any LDH Medicaid MCO for the prior measurement year.
- Provide outreach, education and technical support to MCOs and providers: Maryland’s Medicaid and public health teams worked collaboratively to develop and distribute a CRC screening toolkit for MCOs and promoted it among chief medical officers. Consider opportunities for screening in under-resourced communities post COVID-19, such as identifying community gastroenterologists who commit to performing colonoscopies for Medicaid managed care patients.
- Engage in campaigns to increase awareness and encourage CRC screenings: Arizona’s Medicaid managed care program partnered with their Department of Health Services to improve CRC, breast, and cervical cancer screening and treatment rates through provider education and member outreach conducted by MCOs. With CDC funding, the Oregon Health Authority (OHA) conducted a media campaign called “The Cancer You Can Prevent” to increase CRC screening among Black, American Indian/Alaska Native and Latino(a) communities. OHA conducted interviews and focus groups to understand people’s attitudes towards CRC screening. OHA then developed a campaign where people previously screened share their experiences and encourage others to get screened. The campaign developed materials and messages in English and Spanish used on social media, by health plans, and other communications outlets.
- Consider multi-payer strategies to address preventive CRC screening gaps exacerbated by COVID. The California Medicaid agency is partnering with the state’s health insurance Exchange, and the California Public Employees’ Retirement System to address gaps in CRC screenings due to COVID-19.
Lung Cancer Screening
In early 2021, the United States Preventative Services Task Force (USPSTF) recommended annual screening for lung cancer with low-dose computed tomography (LDCT) in adults aged 50 to 80 years who have a “20 pack-year” smoking history and currently smoke or have quit smoking in the last 15 years. This change dramatically increased the number of individuals meeting lung cancer screening criteria.
Nationally, Medicaid programs vary in eligibility criteria they use for lung cancer screening, whether they require prior-authorization, and whether coverage policies can vary between fee-for-service (FFS) and MCOs or across MCOs. Currently, 40 Medicaid fee-for-service (FFS) programs cover lung cancer screening, 7 programs do not provide coverage, and 3 states did not provide the American Lung Association with information on their coverage policy.
While there is less research readily available on promising lung cancer screening approaches for Medicaid members, state Medicaid managed care programs can consider the following recommendations:
- Lung cancer screening coverage: Medicaid MCO coverage policy for lung cancer screening should be clear and consistent with USPSTF recommendations, covering screening for all applicable adult enrollees over 50. Most heavy smokers, past or present, may meet the new lung cancer screening criteria.
- Reduce pre-authorization barriers: Discourage or prohibit MCOs from requiring pre-authorization for a lung cancer screening scan as a standard practice. Making it easier for providers to order the imaging without waiting for a separate pre-authorization, along with other efforts to expand screening access, has resulted in Kentucky reporting one of the highest lung cancer screening rates in the nation.
- Reduce other barriers for enrollees: Encourage MCOs to improve convenience by enabling enrollees to obtain multiple cancer screening imaging exams at one time where feasible. For example, some radiologists at UCLA Medical Center aim to leverage high adherence to breast cancer screening guidelines to improve adherence to lung cancer screening guidelines. Both screenings are imaging-based and can typically be scheduled together, reducing time that patients must take off from work and travel to obtain screenings.
- Apply promising approaches identified for CRC screening to lung cancer screening initiatives: All but the first promising approach identified for CRC screening should also be considered and applied to increase lung cancer screening for Medicaid MCO enrollees.
For applicable Medicaid enrollees over the age of 50, preventive screening for CRC and lung cancer should be readily available as timely treatment is essential for better outcomes. These options vary in terms of resources needed by states and managed care plans. At a minimum, state Medicaid agencies should set clear expectations for increasing CRC and lung cancer screening in the near term and publish data comparing screening rates by plan, by region, and by enrollee demographics. These types of approaches are a starting place for states, MCOs and providers to implement urgently needed novel approaches to increase CRC and lung cancer screening in the midst of COVID-19 and beyond.
 Madden Yee, Kate. “Can lung cancer screening uptake be improved?”, AuntMinnie.com, available at: https://www.auntminnie.com/index.aspx?sec=sup&sub=cto&pag=dis&ItemID=128705
 CDC, “Vital Signs: Colorectal Cancer Screening Test Use — United States, 2018”, Weekly / March 13, 2020 / 69(10);253–259, available at https://www.cdc.gov/mmwr/volumes/69/wr/mm6910a1.htm
 NCCRT, “Improving Colorectal Cancer Screening Rates: Promising Practices for Medicaid Agencies,” published 2019, available at: https://nccrt.org/resource/a-promising-practices-guide-for-state-medicaid-agencies/.
 New York State Department of Health Medicaid Update. “New York State Medicaid Expansion of Coverage for Colorectal Cancer Screening,” June 2017. Volume 33. No. 6, p.10, available at: https://www.aapc.com/codes/webroot/upload/general_pages_docs/document/jun17_mu.pdf
 Gloria D. Coronado and Beverly B. Green, “Screen to Prevent (STOP) Colon Cancer Implementation Guide,” Kaiser Permanente Center for Health Research, November 30, 2018, available at: https://www.careoregon.org/docs/default-source/providers/clinical-quality-metrics-toolkit/stop-crc-implementation-guide-rm-v05_final.pdf.
 National Colorectal Cancer Roundtable, “Improving Colorectal Cancer Screening Rates: Promising Practices for Medicaid Agencies,” available at: https://nccrt.org/resource/a-promising-practices-guide-for-state-medicaid-agencies/.
 New York State Department of Health, “2020 Quality Assurance Reporting Requirements,” April 24, 2020, available at: https://www.health.ny.gov/health_care/managed_care/qarrfull/qarr_2020/docs/qarr_specifications_manual.pdf.
 Materials and more information is available at: http://thecanceryoucanprevent.org/.
 Casey, Brian. “CMS opens review of expanded CT lung screening reimbursement”, available at: https://www.auntminnie.com/index.aspx?sec=ser&sub=def&pag=dis&ItemID=132432
 Whitney J. Palmer, “For Lung Cancer Screening, Geographic Location Matters,” Diagnostic Imaging, November 14, 2020, available at: https://www.diagnosticimaging.com/view/for-lung-cancer-screening-geographic-location-matters.
 UCLA Radiology, “New Project to Increase Lung Cancer Screening Adherence,” Spring 2021, available at: https://www.uclahealth.org/radiology/workfiles/Newsletter/2021S_IncreaseLungCancerScreeningAdherence.pdf.