by Susan Logan and Yu-Hong Lin
For full report click here.
Prostate cancer is the most common cancer diagnosis, and second leading cause of cancer death, among men in the United States. Every year in California, an estimated 1,200 low-income, uninsured men are diagnosed with prostate cancer. On average, these men are younger than most U.S. men diagnosed with prostate cancer, present with moderate to highly aggressive tumors, and present at a later stage of disease than patients in the general population. Without treatment, these patients are at high risk of cancer progression and excess mortality from prostate cancer.
Because prostate cancer treatment is highly specialized, and provided by a relatively scarce group of subspecialty physicians, low-income, uninsured men face substantial barriers accessing prostate cancer treatment in their local communities. To improve access to treatment for this patient population, the California legislature passed a law establishing a statewide prostate cancer treatment program. The contract for this program has been administered by UCLA-IMPACT since April 2001. In its short 5-year history, IMPACT has experienced five budget cuts, two enrollment suspensions and, on two occasions, threats to terminate program funding altogether. Decreased funding and enrollment suspensions have led to long waitlists for patient services, undermining the ability of the program to provide low-income, uninsured Californians with access to quality prostate cancer care.
Citing high administrative expense and unproven program effectiveness, the governor line-item vetoed funding for the program in the FY2005-2006 State Budget. The legislature restored program funding with the passage of SB 650, but as a requirement for continued funding have requested a full program evaluation. This report presents the results of an independent analysis of the IMPACT program, including a cost-effectiveness analysis, which is a necessary component of the full program evaluation.
In our analysis of the IMPACT program, we did not find evidence of high administrative costs. In FY 2004-2005, true administrative expenses accounted for only 11% of the program’s budget, and clinical staff expenses accounted for 23% of the total budget. The ratio of fixed costs to patient treatment costs was also distorted by the lengthy enrollment suspension in that fiscal year. Clinical staff are essential to meeting the objectives of the IMPACT program, which include not only improving access to treatment, but also reducing disparities in treatment outcomes for low-income, uninsured Californians with prostate cancer.
From a societal standpoint, IMPACT is a cost-effective strategy for providing low-income, uninsured Californian’s with reasonable access to prostate cancer-specific treatment. This is true whether we compare IMPACT to the county safety net, or to a hypothetical prostate cancer treatment program modeled after the state component of the Medi-Cal Breast and Cervical Cancer Treatment Program. Although in theory a Medi-Cal prostate cancer program would be cost-effective, in practice there are too few specialty providers who both treat prostate cancer and accept new Medi-Cal fee-for-service patients for such a program to be practical.
In order to decrease prostate cancer-related disparities among low-income, uninsured Californians, we recommend that the State:
• Establish stable and consistent funding for the IMPACT program.
• Allow IMPACT to use a provider reimbursement scheme that will encourage adequate provider participation in the program.
• Increase program funding to a level adequate to support the primary goals and objectives of the IMPACT program, which are consistent with California’s own comprehensive cancer control objectives.
• Require and support IMPACT’s data collection and analysis activities. The information generated by these activities is important for program quality assurance, and essential for quantifying how effectively the “value added” program services reduce cancer-related disparities among low-income, uninsured men with prostate cancer.