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Access to Quality Care

Susan G. Komen for the Cure is working with policymakers to ensure patient access to quality care for all patients, not just those who can afford it. Komen for the Cure is supporting a number of policy initiatives in this area, including patient access to state-of-the-art cancer treatments for Medicare beneficiaries and support for nurse education.

Breast and Cervical Cancer Prevention and Treatment Act
Nurse Reinvestment Act
Patient Navigator Services
Breast Cancer Patient Protection Act

Breast and Cervical Cancer Prevention and Treatment Act

Equal Access to Breast Cancer Treatment
Susan G. Komen for the Cure is committed to changing policy related to the Breast and Cervical Cancer Prevention and Treatment Act of 2000 (BCCPTA). A flaw in the implementation of the BCCPTA prevents certain low-income and uninsured women from receiving Medicaid-funded breast cancer treatment based solely on where they were screened. The BCCPTA allows states to provide full Medicaid coverage to women who otherwise would not have health care coverage for breast and/or cervical cancer, for the duration of their treatment. To qualify for Medicaid coverage under the BCCPTA, a woman must be under age 65, not already eligible for Medicaid, without creditable health care coverage, and in need of treatment for breast and/or cervical cancer or pre-cancerous conditions.

The BCCPTA was an important first step in providing Medicaid-funded treatment to low-income women who were screened under the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) and found to have breast or cervical cancer. When it was enacted, states were given different options for defining BCCPTA eligibility. At a minimum, states offer Medicaid coverage to women who meet the above conditions and were screened through their state NBCCEDP-funded screening program. However, states were given the option to cover additional low-income women who meet the above eligibility requirements but who were not screened through the state program. Regrettably, less than a third of states are utilizing this more equitable coverage model. Many women are therefore denied BCCPTA coverage, based simply on where they were screened. Below are the three categories of state BCCPTA options.

  • Under Option 1, the most restrictive option, women are considered eligible for Medicaid treatment only if their screening services were provided by the state’s NBCCEDP-funded program. Twenty-one states and the District of Columbia have implemented Option 1.
  • Under Option 2, women are considered eligible for Medicaid treatment even if their particular clinical service was not provided by the State’s NBCCEDP-funded program, but the service was within the scope of a grant, sub-grant or contract under the NBCCEDP state program. Fifteen states have implemented Option 2.
  • Only 14 states have implemented Option 3, the least restrictive and most fair option, which allows women who qualify to receive Medicaid treatment regardless of where they were originally screened.

The current BCCPTA system is inherently unjust. Due to funding constraints, NBCCEDP-funded programs reach less than 20 percent of eligible women. Accordingly, at least four out of five eligible women must be screened outside of the program. In Option 1 and 2 states, many of these women are not eligible for Medicaid-funded breast cancer treatment under current law. Susan G. Komen for the Cure, whose Affiliates around the country provided $70 million last year in grants for screening, treatment, and education, has been outspoken about this treatment gap since the inception of the BCCPTA. In testimony before Congress in 1999, Komen for the Cure raised concerns that the BCCPTA would not cover many women who were otherwise eligible for the program but not screened through NBCCEDP.

The current law leaves patients and providers with two unattractive options. Either the provider must deny Medicaid coverage to a woman screened outside of an NBCCEDP-funded program, or the woman must be re-screened by an NBCCEDP-funded program to meet the Medicaid eligibility criteria.

  • If the woman is denied coverage, she must choose whether to forgo treatment; attempt to secure charity care if she has the ability to navigate the health care system; or incur devastating financial burdens. Any delays in treatment can affect the woman’s prognosis and chances for survival. It is unethical and immoral to screen a woman and then provide her no viable options for treatment.
  • If the woman is re-screened by an NBCCEDP program, she must go through the psychological and physical trauma of a second mammogram and a second biopsy. Re-screening results in inefficiencies and unnecessary delays. Furthermore, her treatment is delayed by critical months, and valuable resources that could be put toward treatment or screening of additional women are wasted.

Susan G. Komen for the Cure has advocated tirelessly at the state level to correct this problem, successfully working with policymakers in states including Illinois and South Carolina to expand BCCPTA eligibility. At minimal cost, women in these states may now receive Medicaid treatment, regardless of where they were screened. Working in conjunction with Komen’s Pennsylvania Affiliates, legislators in that state have also introduced a bill that would move Pennsylvania to the more equitable Option 3. However, 21 states still implement the most restrictive option, which result in women being denied treatment based solely on where they were screened.

The cost for states to move from Option 1 to Option 3 is manageable.

  • Illinois budgeted $4 million to move from Option 1 to Option 3, estimating treatment of an additional 400 women annually.
  • Researchers from the George Washington University Center for Health Services Research & Policy studied early results of the BCCPTA implementation and reported that the cost is approximately 1 percent of state Medicaid budgets.
  • Furthermore, early treatment, before the cancer has spread to lymph nodes, is almost one third less than treatment for later stage cancer, which may require more extensive surgeries and drug therapies.

Susan G. Komen for the Cure is challenging the states and the nation to change policies by eliminating the gap in the current BCCPTA and providing equal access to treatment. Government can start saving lives now. Susan G. Komen for the Cure has already invested $1 billion in breast cancer research and community outreach programs, making it the world’s largest provider of funds behind the federal government, and it has pledged to invest another $2 billion by 2017.

Without a cure, over the next 25 years one out of eight American women will be diagnosed with breast cancer, and approximately one million will die from the disease. To save more lives, and advance the fight against breast cancer we must correct the treatment gap to allow all eligible women access to quality treatment under state Medicaid programs.

Nurse Reinvestment Act

Oncology nurses play a vital role in the delivery of quality care for patients with breast cancer and other forms of cancer. These dedicated professionals are involved in the administration of chemotherapy and supportive medications, patient education, health promotion, pain and symptom management, psychosocial care, survivorship, end-of-life care and other essential services. However, our nation currently faces a critical shortage of qualified nurses and inadequate numbers of nursing school faculty to train the next generation of nurses. In the field of oncology nursing, this is particularly critical, given the aging of our population.

The Nurse Reinvestment Act, designed to address current and expected nursing shortages, was signed into law on August 1, 2002. The law includes several important initiatives to ensure an adequate nursing workforce well into the 21st century:

  • A scholarship program for nursing students who agree to work in a shortage area for at least two years after completing their degree;
  • Grants to develop and implement programs to train nurses who provide geriatric care;
  • Student loan funds for Masters or Doctoral students who agree to serve as full-time nursing faculty after completion of their degree

Komen supports continuing the progress being made in addressing our nation’s nursing workforce shortage. In effort to continue educating and training additional nurses for the healthcare workforce of the future, Komen is urging Congress in 2007 to increase levels of funding as appropriate for the Nurse Reinvestment Act programs.

Patient Navigator Services

Susan G. Komen for the Cure is committed to ensuring that all breast cancer patients have access to a qualified patient navigator to help guide them through the complicated structure of the American health care system. Through its Affiliates, Komen has funded numerous programs across the country that provide these critical services to breast cancer patients.

Patient navigators are trained, culturally sensitive health care workers who provide support and guidance to breast cancer patients through the cancer care continuum. They help "navigate" the patients through the maze of doctors' offices, clinics, hospitals, outpatient centers, insurance and payment systems, patient-support organizations and other segments of the health care system. For breast cancer patients, a patient navigator can provide personalized education on breast surgery options, chemotherapy and radiation therapy. Navigators can facilitate communication with physicians and other health care professionals.

Patient Navigation Services are critical to address the barriers to quality cancer care, particularly for minority and underserved patients who often do not speak English, have low literacy skills, are uninsured, and/or live long distances from treatment centers. These patients may have difficulty assessing quality care and have trouble coordinating their cancer care. Without patient navigators, these patients experience disjointed treatment, inadequate patient-doctor communication, difficulty with follow-up appointments and poor adherence to treatment regimes.

The Patient Navigator Outreach and Chronic Disease Prevention Act of 2005 (Patient Navigator Act) established a competitive grant program through the Health Resources and Service Administration to provide patient navigators to those in need. In June 2005, the bill passed by a voice vote in the House and by unanimous consent in the Senate. Representatives Robert Menendez (D-NJ) and Deborah Pryce (R-OH) sponsored the bill in the United States House of Representatives and Senators Kay Bailey Hutchison (R-TX) and Jeff Bingaman (D-NM) sponsored the companion bill in the Senate. President Bush signed the bill into law on June 29, 2005.

The legislation authorized $25 million over five years to fund the Patient Navigator grant program. However, no funds were appropriated from these critical services until this year, when Congress appropriated $2.9 million. Susan G. Komen for the Cure asks Congress to appropriate $18.6 million for the Patient Navigator grant program in 2009, which includes unappropriated funds that were authorized by the Patient Navigator Act.

Komen continues support efforts to increase and enhance patient navigator programs in the 110th Congress.

Breast Cancer Patient Protection Act

Komen continues to educate Members of Congress about the importance of strong protections for breast cancer patients in managed care and other settings. In recent years, there has been growing concern about "drive-through" mastectomies reportedly resulting from managed care plans' refusal to cover adequate inpatient hospital stays subsequent to mastectomy, lumpectomy, and lymph node dissection. In response, a number of states have enacted legislation requiring insurers and health plans to cover an inpatient post-mastectomy hospital stay of at least 48 hours, unless the patient chooses a shorter length of stay.

In the 110th Congress, Representative Rosa DeLauro (D-CT), Representative Jo Ann Davis (R-VA), and Senator Olympia Snowe (R-ME) have introduced "Breast Cancer Patient Protection Act of 2007" bills in the United States House of Representatives and the United States Senate. The legislation attempts to ensure that decisions are made jointly by physicians and patients when concerning the length of hospital stay subsequent to mastectomy, lumpectomy or lymph node dissection for the treatment of breast cancer. The legislation mandates coverage for secondary consultations to confirm or refute the diagnosis of breast cancer. It also prohibits health plans and insurers from covering inpatient hospital stays of less than 48 hours post-mastectomy or breast conveying surgery (such as lumpectomy) or less than 24 hours after lymph node dissections (unless the patient chooses a shorter length of stay).

Representative Davis has also introduced the "Women's Health and Cancer Rights Conforming Amendments of 2007." This legislation requires group health plans to provide coverage for reconstructive surgery following mastectomy for all stages of reconstruction of the breast on which the mastectomy was performed. It also requires group health plans to cover surgery and reconstruction of the other breast to produce a symmetrical appearance as well as prostheses and physical complications of mastectomy, such as lymphedemas.

Komen supports efforts to ensure an adequate length of hospital stay as an important component of quality breast cancer care.