Meeting the Needs of Cancer Survivors in North Carolina: Assessing and Improving the Medicaid Medical Home Model

The patient-centered medical home model represents an innovative effort to improve "whole-person" health by enhancing coordination of health services through the medical home (MH). This comprehensive health services model has been shown to improve population health outcomes for diseases such as diabetes and asthma, but has not been applied or evaluated in the context of improving cancer care. Community Care of North Carolina (CCNC) initiated an innovative medical home (MH) program in the early 1990s focused on improving primary care in vulnerable populations insured by Medicaid. An opportunity exists, therefore, to explore how best to enhance the existing Medicaid MH program to meet the specific needs of cancer survivors.

This study used North Carolina Central Cancer Registry data linked with Medicaid claims data to assess whether patterns of cancer survivorship care among Medicaid beneficiaries with a history of breast cancer are consistent with evidence-based guidelines and whether surveillance and follow-up practices differ by extent of patient engagement in the medical home program. Additionally this study identified appropriate provider, government, and patient advocate stakeholders throughout the state to help guide the development of cancer survivor-specific protocols and best practice recommendations for Medicaid medical homes in North Carolina.

This study addressed three Specific Aims: (1) to assess whether patterns of survivorship care among Medicaid beneficiaries with breast cancer are consistent with guidelines; (2) to examine extent of engagement in MHs among breast cancer survivors; and (3) to engage appropriate stakeholders in NC to help enhance the Medicaid MH program to further benefit cancer survivors. This study employed existing data for persons diagnosed with cancer in NC since 2003 and enlisted community stakeholders in reviewing the evidence and assessing future MH needs for low-income breast cancer survivors in NC. The study, serving Buncombe, Cumberland, Guilford, New Hanover and Wake counties, helped demonstrate the feasibility and usefulness of linked state cancer registry and claims data in supporting targeted improvement in cancer care in NC. Furthermore, the community-based approach to engaging stakeholders ensures that any intervention developed from these pilot efforts will be sufficiently vetted and collaboratively produced by those who stand to benefit most from the study.

Findings:  Results suggest that primary care medical home enrollment is associated with higher quality breast cancer survivorship care among women insured by Medicaid. Results also indicate that primary care providers have an important role to play in cancer survivorship; as such, personalized survivorship care plans should be distributed not only to survivors and their families, but also should be tailored for use in primary care settings.  

The study also looked at endocrine therapy use in a low-income Medicaid-insured population in North Carolina. Long-term use of endocrine therapy (ET) is important because it reduces risk of HR+ breast cancer recurrence by 40% and risk of death by one-third. Using Medicaid claims data matched to state registry records for survivors of stage 0-II HR+ breast cancer aged 18-64, Dr. Wheeler discovered that only 50% filled a prescription for ET during the study period.  Additionally, involvement in the Breast and Cervical Cancer Control Program and earlier year of diagnosis were significantly associated with higher odds of initiating guideline-recommended ET (p<0.05).   The implications for cancer survivors are that low-income survivors should be counseled on the importance of ET and offered support services to promote initiation and long-term adherence.

Geographic area(s) served: Buncombe, Cumberland, Guilford, New Hanover, and Wake Counties

Research team:
Stephanie Wheeler, PhD, assistant professor of health policy and management (principal investigator); Marisa Domino, PhD, professor of health policy and management; Kristen Hassmiller, PhD, assistant professor, health policy and management; Cathy Melvin, PhD, Paul Brown, Professor of Health Economics and Public Health at University of California-Merced; Claire Lin, PhD, Alexis Moore, MPH, and Tim Smith, MPA, study staff.

For more information about this pilot research study, contact Dr. Stephanie Wheeler, principal investigator, at Stephanie_Wheeler@unc.edu.