PSE Change Real World Example: D.C. Policy Advances to Improve Medicaid Patient Access to Cancer Care

Problem

Medicaid patients in the nation’s capital have historically faced delayed and fragmented cancer care across a variety of health care providers and systems and could not always access chemotherapy services (Price, Blanchard, Harris, Ruder, & Gresenz, 2013).

PSE Solution

The GW Cancer Center has engaged a coalition of stakeholders over two and a half years to incrementally address the most challenging barriers to cancer care for Medicaid patients (Step 1: Engage). Starting in fall of 2014, staff at the GW Cancer Center’s Institute for Patient-Centered Initiatives and Health Equity (formerly the GW Cancer Institute) identified key stakeholders including the DC Department of Health Care Finance (DHCF), leadership at Medicaid managed care organizations, the DC Department of Health, cancer care clinicians, patient navigators, patient advocacy organizations, cancer survivors and caregivers. Sponsors for this effort included several pharmaceutical foundations and health insurance plans.

Actions/Results

Actions

The GW Cancer Center conducted a series of meetings with DHCF and convened two summits to gather input from nearly 60 stakeholders on May 11, 2015 and September 8, 2016. Staff at the GW Cancer Center reviewed published literature to identify trends in access to care challenges for Medicaid beneficiaries across the nation, as well as publicly available information on coverage, benefits and provider network of Medicaid beneficiaries in Washington, D.C. (Step 2: Scan; Step 3: Assess). The result was a needs assessment that was shared with stakeholders convened at the inaugural policy summit in May 2015.

A third meeting was hosted by DHCF on March 10, 2017. Each meeting resulted in tangible improvements to Medicaid patient access to care.

Results

On May 11, 2015, the group achieved consensus on the top challenge impeding access to cancer care for Medicaid patients: limited providers participating in the Medicaid network.

On May 1, 2016, adjustments to DC Medicaid chemotherapy reimbursement rates to match those of Medicare were formalized through a State Plan Amendment approved by the Centers for Medicare and Medicaid Services (CMS). The GW Cancer Center communicated the policy change internally to administration and tested new reimbursement processes in medical oncology with a handful of Medicaid patients. After initial success, changes were communicated more broadly within the GW Cancer Center and citywide (Step 5: Promote). As a result, this policy success has increased access to chemotherapy for Medicaid patients in the city because of an expansion in the number of medical oncologists who will accept Medicaid.

As a result of continued dialogue and identification of additional policy barriers, in July 2016, the largest Medicaid managed care organization eliminated the requirement of pre-authorizations and primary care referrals for pharmaceuticals for cancer treatment and supportive care for patients with a documented diagnosis of cancer, further improving timely access to treatment for Medicaid patients.

Effective April 1, 2017, another Medicaid managed care organization eliminated the need for primary care referrals for individuals needing to access specialists. This is anticipated to shorten time from adverse screening to diagnostic resolution by removing a major challenge in obtaining primary care referrals after a patient has already accessed radiology.

Success Factors and Key Questions Addressed

What was the ultimate purpose of the PSE change? What was your “ask”?

During the scan stage, our initial ask was simply convening as a group to identify what was impeding cancer care for patients in the District of Columbia. The GW Cancer Center initiated several meetings with leadership at DHCF to raise awareness of challenges, clarify root causes and propose solutions for Medicaid beneficiaries’ improved access to services.

What level of PSE change was necessary (local, state, federal or institutional)?

The needs assessment was shared with stakeholders convened at the first inaugural Access to Care Policy Summit in May in order to prioritize the most significant barrier to cancer care needing resolution in Washington, D.C. Outcomes resulted in District-wide systems change.

Who was already attempting PSE change efforts around the health issue?

There are many local and national organizations in Washington, D.C. working to improve cancer outcomes and reduce disparities. At the same time that we were assessing the breadth of the Medicaid provider network, DHCF was reviewing its pharmaceutical fee schedule and reviewing claims data to identify patterns within its network. This internal quality improvement work was instrumental and complemented the GW Cancer Center’s work. DHCF was the initiator of the State Plan Amendment to CMS.

Was the environment conducive to the PSE change? What challenges did the scan reveal (economic, political, social, legal, etc.)?

Each stakeholder came with a different perspective on Medicaid access to cancer care in Washington, D.C. This was a significant challenge, since awareness that there was a problem was the most important first step in solving the problem. The scan revealed that this PSE change effort would require ongoing commitment of leadership at the GW Cancer Center and DHCF to be successful. Critically, retaining federal support of Medicaid through continued Medicaid expansion under the Patient Protection and Affordable Care Act (2010) will be the determining factor regarding whether these PSE changes will be sustained.

The GW Cancer Center used the following steps in the PSE change process: engage, scan, assess, review, promote, implement, evaluate. These steps are not linear. The engage, scan and assess steps overlapped; and the review, implement and evaluate steps are ongoing and cyclical.

As a result of continuing review and evaluation (Step 7: Evaluate), we are currently addressing challenges as a coalition. In addition, DHCF, the GW Cancer Center, managed care organization leadership and other stakeholders continue to troubleshoot transportation challenges for Medicaid beneficiaries.

Related Resources

Read this report to learn more about the findings of the needs assessment. To learn more about the Access to Care Policy Summits, click here for the 2015 report and here for the 2016 report.

REFERENCES

Patient Protection and Affordable Care Act, 42 U.S.C. § 18001 (2010).

Price, R.A., Blanchard, J.C., Harris, R., Ruder, T., & Gresenz, C.R. (2013). Monitoring cancer outcomes across the continuum: Data synthesis and analysis for the District of Columbia. Rand Health Quarterly, 2(4), 6. Retrieved from https://www.rand.org/pubs/periodicals/health-quarterly/issues/v2/n4/06.html.