Public Health and Cancer: A New Treatment Linkage.

Cancer is the second leading cause of death in the United States. Each year, more than 1.2 million new cases occur and 552,000 individuals die [1]--almost 45,000 of these deaths are from breast and cervical cancer. More than 182,000 cases of breast cancer will occur this year with more than 40,800 deaths. Cervical cancer will affect another 12,800 women and kill 4,600. In many cases, these deaths are preventable with early identification and effective treatment. Between 1955 and 1992, the death rate from cervical cancer fell 74 percent. This significant reduction in mortality was due to the effectiveness of early screening from the Pap Smear.

Low-income, uninsured, older, and minority women are at extreme risk of not receiving early screening services. Ten years ago, the U.S. Congress passed the Breast and Cervical Prevention Act of 1990, which established the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). [2] This program was enacted to ensure that underserved women had access to needed prevention services. The program, which is managed through States, Territories and Tribes/Tribal Organizations, has provided more than 2.5 million screening tests to women in need of early preventive care in all 50 states and the District of Columbia, as well as six territories and 15 tribal organizations. [3]

Ensuring access to cancer screening

The program has several components, including:

* Screening low income women for breast and cervical cancer

* Educating at-risk populations and the provider community

* Increasing the use of screening services

* Developing linkages to other needed public health services 

* Offering needed diagnostic and treatment services, such as: pelvic examinations, Pap Smears (FDA approved screens), colposcopies, cervical biopsies, breast examinations, mammograms, breast ultrasounds, fine needle aspirations, and breast biopsies.

While referrals for further treatment and diagnostic services were expected, the program was not authorized to pay for these services. This left health departments and providers scrambling to find ways to provide treatment to the women diagnosed with cancer.

Despite its success, the program reaches only 15 percent of the eligible population, according to Centers for Disease Control Director Jeffrey P. Koplan, MD, MPH. [4] While these are generally hard to reach populations, the lack of a clear mechanism to pay for treatment further complicates providing screening services.

Ensuring access to treatment

This Fall, Congress and the President passed H.R. 4386 (Public Law 106-354). This measure provides a state option to expand Medicaid eligibility to women under age 65 who have been screened by the NBCCEDP, need treatment for breast and/or cervical cancer, and are uninsured. The parameters of the program, effective October 1, 2000, are:

* States will receive an enhanced match rate equal to that used for their children's health insurance program.

* A system of presumptive eligibility will be used. Providers must notify the state agency within five working days of the patient's diagnosis. The patient must fill out an application for eligibility by the last day of the month following the month when the determination was made.

* Medicaid eligibility is only during the period of treatment for breast and cervical cancer.

This legislation creates a linkage between public health and Medicaid that corrects a service delivery problem of immense proportions. It also resolves a policy debate in the public health community concerning the appropriateness of screening for a disease without an assured mechanism to pay for treatment. Public health programs often find themselves in this dilemma when they screen for diseases and then have to craft partnerships to ensure treatment. In many cases, these partnerships involve pro bono arrangements with the treatment teams and caps on the number of patients that can be served.

Conclusion

Adding a Medicaid option for uninsured women screened through the NBCCEDP corrects a vital program flaw. Physicians and other health providers should work with their state Medicaid and public health agencies to ensure this important program is implemented.

Georges Benjamin, MD, FACP, is the Secretary of the Department of Health and Mental Hygiene in Baltimore, Maryland.

Note

The stated views are those of the author and do not represent those of the State of Maryland or the Department of Health and Mental Hygiene.

References

1. American cancer Society Fact Sheet (www.cancer.org).

2. www.cdc.gov/cancer/nbccedp/law.htm.

3. www.cdc.gov/cancer/nbccedp/anniversary.htm.

4. www.cdc.gov/cancer/nbccedp/index.htm.

KEY CONCEPTS

* National Breast and Cervical Cancer Early Detection Program (NBCCEDP)

* Categorical Medicaid Eligibility

* H.R. 4386; Public Law 106-354

* Public Law 101-354

* Linking Public Health and Medicaid

Congress established the National Breast and Cervical Cancer Early Detection Program in 1990 to offer cancer screening to underserved women. The program, run by the U.S. Centers for Disease Control and Prevention, has been a phenomenal success, screening more than 2.5 million women. But the program was not authorized to pay for treatment services, leaving providers scrambling to find ways to provide care for newly diagnosed cancer patients. Last Fall, Congress and the President passed H.R. 4386 to correct this problem, which allows states to enroll women screened by the NBCCEDP and found to have cancer in their Medicaid program. This legislation creates a badly needed linkage between a successful public health program and Medicaid that will ensure a seamless system of care for women found to have this life threatening illness.

National Breast and Cervical Cancer Early Detection Program

* More than 2.5 million screening examinations

* More than 1.1 million mammograms

* More than 1.3 million Pap Screens

* More than 7,300 breast cancers diagnosed

* More than 37,000 pre-cancerous cervical lesions found

* More than 600 cervical cancers diagnosed

American Cancer Society Fact Sheet