The Efficacy of Direct Mail, Patient Navigation, and Incentives for Increasing Mammography and Colonoscopy in the Medicaid Population: A Randomized Controlled Trial

Abstract

Background: Despite lower cancer screening rates and survival rates in the Medicaid population compared with those with private insurance, there is a dearth of population-based, evidence-based interventions targeting Medicaid clients to address this problem.Methods: This study reports results of a population-based randomized controlled trial (RCT) among all individuals enrolled in Minnesota's Medicaid program who were overdue for breast cancer (n = 22,113) and/or colorectal cancer (n = 94,294) screening. Individuals were randomized to intervention or control groups. The intervention group received persuasive and innovative direct mail materials coupled with a $20 incentive for using their Medicaid benefit to get screened. Direct mail materials provided a phone number to a call center staffed by patient navigators who addressed barriers and scheduled appointments via three-way calls. The control group received the intervention 15 months later. Primary outcomes were completion of mammography or colonoscopy within 12 weeks of the intervention. Billing claims served as evidence of screening.Results: Multivariate logistic regression showed significant differences for both breast cancer (P < 0.001) and colorectal cancer (P < 0.01). The odds of receiving a mammogram for the treatment group were significantly higher than the control group [OR = 1.30; 95% confidence interval (95% CI) = 1.16-1.46], and the treatment group was more likely to receive a colonoscopy than the control group (OR = 1.12; 95% CI = 1.04-1.21).Conclusions: This population-based intervention increased breast cancer and colorectal cancer screening in a Medicaid population overdue for screening.Impact: These findings may have broad application for reaching individuals who generally remain outside the health care system despite having public health insurance. Cancer Epidemiol Biomarkers Prev; 27(9); 1047-56. ©2018 AACR.

Figure 1. CONSORT flow diagram depicting study recruitment and retention

a. Includes all persons in Minnesota Health Care Programs (MHCP) that serve adults with low incomes. Programs include Medicaid (MA), MinnesotaCare, Minnesota Family Planning Program, and others. b. The target population was restricted to MA enrollees. As a condition of being allowed to conduct this research, the MN Department of Human Services’ (MDHS) IRB stipulated that we could not discriminate among MHCP enrollees on the basis of MA status in terms of their having an equal chance of being offered the intervention. Consequently, all age- and gender- eligible individuals in the MHCPs had to be randomized to treatment or delayed treatment even though they were excluded a priori from the study. The n’s reported are MA enrollees only. c. Although originally intended to be in the study, women ages 40-49 became ineligible prior to randomization at the request of the MN Medicaid Medical Director / IRB Chair and therefore were excluded. He felt that the lack of national consensus on promoting screening to women in this age group paralleled a lack of consensus among MN health care providers and health plans. Under these circumstances, he did not want it to appear that MDHS was endorsing screening in this age group.