Improving Adjuvant Hormone Therapy Use in Medicaid Managed Care–Insured Women, New York State, 2012–2014

Abstract

IntroductionIn 2010, national guidelines recommended that women with nonmetastatic, hormone receptor–positive breast cancer take adjuvant hormone therapy for 5 years. As results from randomized clinical trials became available, guidelines were revised in 2014 to recommend 10 years of therapy. Despite evidence of its efficacy, low initiation rates have been documented among women insured by New York State Medicaid. This article describes a coordinated quality improvement pilot conducted by a state department of health and Medicaid managed care plans to engage women in guideline-concordant adjuvant hormone therapy.MethodsWomen enrolled in Medicaid managed care with nonmetastatic, hormone receptor–positive breast cancer and who had surgery from May 1, 2012, through November 30, 2012, were identified using linked Medicaid and Cancer Registry data. Adjuvant hormone therapy status was determined from Medicaid pharmacy data. Contact information for nonadherent women was supplied to health plan care managers who conducted outreach activities. Adjuvant hormone therapy status in the 6 months following outreach was evaluated.ResultsIn the 6 months postoutreach, 61% of women in the contacted group filled at least 1 prescription, compared with 52% in the noncontacted group. Among those with at least 1 filled prescription, 50% of the contacted group were adherent, compared with 25% in the noncontacted group.ConclusionThis pilot suggests outreach conducted by health plan care managers, facilitated by linked Medicaid and Cancer Registry data, is an effective method to improve adjuvant hormone therapy initiation and adherence rates in Medicaid managed care–insured women.

Breast cancer patients' insurance status and residence zip code correlate with early discontinuation of endocrine therapy: An analysis of the ECOG‐ACRIN TAILORx trial

“…Our results for economic factors associated with early discontinuation are mostly consistent with prior studies, with self‐pay and Medicaid insurance and residence in neighborhoods with higher deprivation levels associated with higher rates of early discontinuation 27‐29 . The uninsured face barriers for prescription medications due to high out‐of‐pocket responsibilities.…”

“…The average out‐of‐pocket cost for a month's supply of ET ranges from $70 (tamoxifen) to $505 (aromatase inhibitors) for self‐pay patients without coupons or prescription assistance 39 . As the literature has established, the Medicaid population is also at higher risk for early discontinuation because of lesser coverage of routine care, heterogeneous coverage of costs of clinical trial participation, 40 and potentially lower financial or other reserves among this population 27‐29 …”

“…Several factors have been suggested as predictors of nonadherence and early discontinuation of ET, including extremes of age, 18,19 African American race, 20‐24 greater comorbidities, 18,19,25 postmenopausal status, 12 cognitive impairment, disease‐related and treatment‐related factors (eg, type of surgery, receipt of adjuvant chemotherapy, 26 and greater treatment side effects), 18,19 low recurrence risk perception, 19 lack of provider communication regarding the importance of ET, 18,19 follow‐up care with a general practitioner versus a cancer specialist, 18,19 increased out‐of‐pocket costs, 18 low social support, 18,19,25 and low socioeconomic status (SES) 27‐29 . Social determinants of health incorporate economic stability (eg, income and insurance), the built environment (eg, zip code/geography), and health system factors (access to and quality of care) 30 .…”

Women’s Beliefs on Early Adherence to Adjuvant Endocrine Therapy for Breast Cancer: A Theory-Based Qualitative Study to Guide the Development of Community Pharmacist Interventions

“…Few interventions designed to enhance AET adherence have been developed and their evaluation in randomized controlled trials has provided inconclusive results [ 12 , 13 , 14 , 15 , 16 , 17 ]. Most of these interventions were limited to the provision of information and reminders by mail or telephone.…”

Factors associated with longer endocrine therapy use by South Carolina Medicaid-insured breast cancer survivors

“…The following subgroups have been highlighted as at-risk: low socioeconomic status, [4][5][6] low social support, 3,7,8 greater comorbidity, 7,8 greater drug cost, 3,7 greater side-effects, 3,8 lack of provider communication regarding the importance of ET, 3,8 extremes of age, 3,8 and follow-up care with a general practitioner versus a cancer specialist. 3,8 As literature has established, the Medicaid population is at high risk for poor ET usage, [4][5][6] with a lack of interventions targeted at this population. [9][10][11][12] Qualitative studies reveal that side-effects, primarily menopausal symptoms and/or joint pain, emerge as the major barrier to continuing ET for the recommended duration.…”