AHIP Coverage (Nov/December 2007)
Making Mammograms a Priority
Health plans find ways to encourage women to get recommended screening amid a recent decline in rates.
By Lisette Hilton
Government statistics indicate that mammography rates in recent years have steadily declined for the first time since the late 1980s. From outreach programs at local churches to multipronged communication strategies, health plans are doing their part to reverse this dangerous trend and increase mammography rates.
Breast cancer is the most commonly diagnosed cancer and the second leading cause of cancer-related death, after lung cancers, among U.S. women, according to government statistics. The Centers for Disease Control and Prevention (CDC) reports that screening mammography can reduce breast cancer mortality by about 20 percent to 35 percent in women between ages 50 and 69 and about 20 percent in women ages 40 to 49.
In its Jan. 26, 2007, Morbidity and Mortality Weekly Report, the CDC cites a study of health maintenance organizations that reported declining screening rates for mammography between 1999 and 2002. Data from the Behavioral Risk Factor Surveillance System—according to CDC, the world’s largest ongoing telephone health survey system—indicate a statistically significant drop in the proportion of women ages 40 years and older during 2000 to 2005 who self-reported having had a mammogram in the preceding two years. In that report, mammography rates went from 76.4 percent in the 2000 survey year to 74.6 percent in the 2005 survey.
Reasons for the decline in mammography rates are unclear. CDC suggests that one force fueling the trend could be that breast imaging practices themselves face significant challenges, including shortages of key personnel, malpractice concerns, and financial constraints. Health plan experts cite other reasons, including confusion among some members about mammogram efficacy because of conflicting news reports on recent studies.
Taking Action
Concerned that declining mammography rates could result in an increase in late-diagnosed and harder-to-treat breast cancers, health plans are looking at overcoming mammography barriers and challenges, educating members, creating a sense of need, and following up until women actually have the screening. Some health plans—especially those catering to the Medicaid and Medicare populations—are noting the declining rate of breast screening within their own memberships and are taking steps to reverse the trend. But even plans that are reporting upswings in mammography are implementing programs to keep the numbers high.
“Mammogram screening is pivotal to basic health maintenance. Breast cancer, if caught early, is a highly treatable disease,” says Julie Kozlowski, corporate program coordinator for case and disease management, HealthNow Inc., which does business in New York as BlueCross/BlueShield of Western New York and BlueShield of Northeastern New York.
An Important Phone Call
Affinity Health Plan, which serves about 206,000 members and focuses on Medicaid managed care and Medicare Advantage programs in New York City and surrounding counties, launched a program to increase mammography rates in 2000. “The statewide HEDIS (Health Plan Employer Data and Information Set—now the Healthcare Effectiveness Data and Information Set) average [for mammography rates in 2000] was 64 percent; our rate was 65 percent. But there was a big difference between the rate at [Affinity’s] original health plan in the Bronx (at 73 percent) and a health plan that we had purchased in the outer counties (at 52 percent),” says Barbara Hurley, director of quality management at Affinity Health Plan.
That low percentage prompted Affinity to launch a clinical specialist outreach program. Affinity specialists phone members who, according to their claims, have not had a mammography in the past two years. The plan’s callers speak with women about the need for the screening and inquire about barriers that might be preventing them from getting a mammogram. The callers even make mammogram appointments and call members back if they don’t follow through with the screening. A final call to members “is to verify that they did have the appointment and got their mammography and, if they did, [each member gets] a $25 gift certificate,” Hurley says.
From 2000 to 2004, Affinity Health Plan’s mammography rates went from 65 percent to 76 percent, according to HEDIS reports, surpassing the New York statewide average, which went from 64 percent to 69 percent in that period. Hurley and colleagues attribute the progress to the call program.
The Art of Mammography Reminders
While Fallon Community Health Plan’s breast cancer screening rate remains high at 82.5 percent for commercial and 86.5 percent for Medicare members, the plan has seen about a 1.5 percent drop in mammography rates in its HEDIS 2005 and 2007 reports, according to Beth Foley, Fallon’s director of health services. The Worcester, Massachusetts-based regional plan, offering commercial, Medicare, and Medicaid products, has about 189,000 members.
To reverse the trend, Fallon is stepping up communication with providers and members. The plan sends providers yearly clinical reminder lists, letting providers know when women have not had their mammograms. “We think this is important because sometimes it’s difficult for providers [to track mammograms] if they don’t have their own registry or they don’t have an electronic medical record system,” Foley says.
The plan does outreach to members to ensure that they get preventive physical exams and doesn’t charge a co-pay for them, which is an incentive, according to Foley. Members also receive personalized mailers. Mailers aren’t anything new for the plan, but the way Fallon crafts mammography communication to members is unique. “We want to engage the member, not prescribe to the member,” she explains.
The personalized message on the mailers includes questions asking how long it has been since a member’s last mammogram, rather than bluntly stating: “Our records indicate that you’re due for a mammogram.” Foley explains, “That’s shaming and stops them from becoming involved. We want to help [members] envision a healthy or stronger self as opposed to an inadequate, neglectful self.”
Foley and her colleagues changed the tone and language of their mammography messages to members only this year. While the plan doesn’t yet have hard numbers to back the program’s changes, the response from members who have received the mailings has been positive. “I got a letter from a woman who said she was scheduled to have a mammogram but she wanted me to know how much she appreciated our letter.”
Uncovering Gaps in Care
To combat a downward trend in mammography similar to national figures, HealthNow is talking one-on-one with members, says Kozlowski. Last year, HealthNow called about 200 women in its New York State Medicaid program who, according to claims, had not had mammograms in the last 12 months. Plan callers asked members why they hadn’t had the screening and educated them about the screening. It was a powerful reminder for members, Kozlowski says, and it revealed that many didn’t want to get their mammograms for fear of the result.
In those cases, HealthNow’s nurse caller tries to engage the member in a conversation about the importance to that member of a mammogram. For example, explains Kozlowski, “if the registered nurse hears a small child in the background, she would suggest having the mammogram in order to stay healthy to care for the child.”
HealthNow also implemented a member wellness checklist. “It’s basically a gap report,” Kozlowski says. She explains that HealthNow sends female members 40 and older who have not had a mammogram in the last 12 months customized letters notifying them of the gap and recommending that they talk with their primary care doctors or gynecologists about the issue. Individual PCPs and OB/GYNs also get a list of members who are their patients who have not had mammograms in the last 12 months.
The wellness checklist was first sent out last May and goes out to members and providers twice a year. “We have seen an increase in our commercial population (our HMO, PPO) for breast cancer screening. We still have challenges with our Medicaid and Medicare populations,” Kozlowski says.
To encourage provider participation, HealthNow offers a physician financial incentive program. “We go through claims…and when physicians meet the threshold [of a high number of mammograms among their eligible patients], they get a portion of payout; when they exceed the threshold, they get a full payout,” she says. “We have just recently increased our threshold, which means the quality of care has met the state guidelines—so, we’ve raised the bar” for physicians.
Building Trust Among Medicaid Members
Keystone Mercy Health Plan, the largest Medicaid managed care plan in Southeastern Pennsylvania, experienced a dip in mammography rates during HEDIS years 2005 and 2006, says Maria Pajil Battle, senior vice president of public affairs and marketing at Keystone. Battle says the plan’s challenge is to overcome members’ generalized mistrust of the health care system as well as their fears of having cancer detected. “We’re doing that by actually going to the community and taking the health care system to the community, as opposed to [having members] going to the hospital” for screenings, Battle says.
The outreach, in its eighth year, includes working with Philadelphia’s African-American churches. The plan’s health ministries program addresses the need for screening for all kinds of disease, including breast cancer. In one initiative, called the “40-Day Journey,” Keystone Mercy Health Plan coordinates a six-week program in churches, bringing health experts to speak, offering educational materials, and doing onsite screenings. In September, the plan hosted its “empowerment tour” at five churches—each with a different health focus, including breast health.
Keystone Mercy Health Plan also uses a local mobile mammography unit. When the van is available for the plan’s outreach events, it’s always filled to capacity, Battle says. The staff also works with women to overcome transportation or child care challenges so that women can get their mammograms.
A Series of Efforts
Kaiser Foundation Health Plan’s mammography rates are bucking the national trend. Rates are rising consistently throughout the organization, reports Mark Littlewood, director of risk management and patient safety for The Permanente Federation, which provides national support for regional Permanente medical groups, the care delivery partners of the Kaiser Foundation Health Plan.
“If you look at the HEDIS 2007 data for 2006 performance, our scores show, for example, a year-over-year increase in our Northern California region of about 79 percent
to 83 percent for our commercial [members]. The Medicare age group in that same region is 84 percent to 88 percent. In Southern California, they went from roughly 84 percent to 85 percent…for the commercial screening ages 52 to 69,” Littlewood says.
He attributes part of the plan’s success to being proactive with outreach to members and providers. For example, one of the plan’s star facilities in Southern California, Riverside Medical Center, took steps to increase mammography rates in 2003, when it was reporting mammography rates of 79 percent.
Riverside Medical Center set up a call center with trained personnel to follow up with members who had not scheduled a mammogram after having received a mammography reminder postcard. Staff at the call center are trained to counsel women about mammography. Although they are not licensed medical personnel, the callers are proficient at explaining why it’s important to receive a mammogram and convincing women to schedule one, Littlewood says.
If callers are unsuccessful in scheduling a mammogram, then the next step in a series of efforts involves individuals who have experience with “hard-to-reach women,” he says. The Riverside Medical staff use a combination of in-reach (to providers) and outreach.
“They’ll look ahead and see if [a woman] is coming in for an appointment, and if she is they’ll either work with the physician that she’s coming to see or even have somebody actually come and meet her in the waiting room,” Littlewood says. Members who agree to a mammogram at that point can walk to Riverside’s mammography unit and get their mammograms right then and there. “We have walk-in slots available [for that purpose],” he says.
Riverside Medical Center staff also recognized a pocket in the center’s service area that was particularly resistant to mammography. Residents of a nearby town wanted to receive their services close to home, rather than having to travel to Riverside.
“We didn’t have an in-house mammography unit up there, so we hired a vendor to take a mobile mammography unit into that town a couple of times a month,” Littlewood says. “Our own radiologist would still be reading the films and doing the follow-up.”
He adds, “That one intervention brought the entire area up a couple of percentage points.” The combination of interventions worked to boost current screening rates at the medical center to 92 percent.
Multipronged Approach
Noting decreases in mammography rates in its 2005 and 2006 HEDIS reports, Health Net of California has implemented a multipronged approach to boost those rates. Peggy Haines, vice president for quality management at Health Net of California in Woodland Hills, suspects that the decline of about six percentage points (depending on the product line) was largely due to data collection changes—specifically the change by the National Committee for Quality Assurance (NCQA) requiring plans to use only administrative data and not patients’ charts for measurement purposes. NCQA made the change to eliminate the time-consuming chart collection and review process.
Still, the plan has embarked on three initiatives aimed at increasing mammography rates. “One initiative is focused on partnering with providers to equip them with information and tools to help them at their practice sites,” Haines says. Since April 2007, the plan’s primary care and OB/GYN providers have received tear-off pads, reminding them of when health screenings, including mammography, should occur.
“The bottom half of this one-page information sheet is a tear-off that the doctor can give to the member so that she can put in [her] own dates and record it,” Haines says. The bilingual (English and Spanish) pad has been a hit among providers, many of whom have asked for additional pads, she notes.
This year, Health Net also contracted with an auto-dialogue vendor, which makes scripted automated calls to members during their birthday months to remind them to get their mammograms. The interactive call asks questions and, based on members’ answers, offers appropriate information. “We’ve used this technology for other screenings and have found really good success rates,” Haines says. Preliminary data from the automated call program indicates that between 47 percent and 55 percent of Health Net of California’s Medicare members who were contacted agreed to schedule a mammogram within the next 30 days, compared with about 39 percent of the plan’s commercial members who received a call.
In yet another move to reach patients with the mammography message, Health Net has partnered with WebMD, which provides members with educational and online tools. “If [members] take a health risk assessment through WebMD on our Web site and say that they haven’t received a mammography in the recommended timeframe, [based on their risk assessment], then they will get periodic e-mail messages” reminding them to schedule the screening, Haines says.
Members can also update their online personal health records, which remind them when to get a mammogram. If a woman gets the screening, Health Net automatically populates her health record with the information. Time will tell whether these initiatives are effectively increasing mammography rates.
Some experts believe—as does Haines—that it’s not so much that rates are going down, but reporting has changed, making rates appear lower. Affinity was well into a trend of increasing rates before its 2005 HEDIS report, which reflected the new reporting system without the use of charts and instead relying on claims data. “Our rates [with the new measuring system] went from 76 percent to 66 percent,” Hurley says. “The state rate went from 69 percent to 66 percent.”
Regardless of the cause, downward trends in mammography are always a concern to health plans, says Susan J. Beane, M.D., senior vice president and chief medical officer at Affinity Health Plan. Carol H. Lee, M.D., chair of the American College of Radiology Breast Imaging Commission, agrees.
“The death rate from breast cancer in the United States has dropped by 24 percent since 1990, and a large part of this decline is due to early detection through mammography,” Lee notes. “If women do not get regular screening mammograms, we could see a reversal of this significant trend.”
Lisette Hilton is a freelance writer based in Florida who has been covering health care for 17 years.
