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Late-stage melanoma patients have most expenses for treatment. About 90 percent of the total annual direct cost for treating melanoma, a deadly form of skin cancer, is spent on those with advanced disease -- less than 20 percent of all melanoma patients, say researchers from the School of Medicine. The staggering medical expense in treating these late-stage patients provides an incentive for better skin cancer surveillance and prevention programs. The study was published in the May 1998 issue of the Journal of the American Academy of Dermatology.

According to lead author Dr. Gary Rogers, associate professor of surgery at the School of Medicine and codirector of the Skin Oncology Program at Boston Medical Center, the annual direct cost of treating newly diagnosed melanoma in 1997 was estimated to be at least $560 million, and it may exceed $1 billion. "The actual cost of treating melanoma includes factors such as the risks of complications and time lost from work. Our study looked strictly at the cost of the actual treatment. If these other factors were added in, the cost would be several times higher," he says.

Melanoma, which afflicts nearly 40,000 people and kills nearly 7,000 annually, is the most virulent form of skin cancer. When discovered early, melanoma can often be treated effectively, but is more deadly when discovered at an advanced stage.

"The screening efforts of groups like the American Academy of Dermatology facilitate early detection of melanoma, which increases patients' survival rate. Our study shows that early detection saves both lives and money," Rogers says.

State regulation and reimbursement policies and the certified nurse-midwife. State regulatory and reimbursement policies exert a strong -- and possibly counterproductive -- influence on health-care practitioners, according to two School of Public Health associate professors, Eugene Declercq and Lisa Paine. Their study was published in the March/April 1998 issue of Health Affairs.

Declercq and Paine examined the impact of state regulation on the supply and practice of certified nurse-midwives (CNMs). Their findings show that a greater number of CNMs work -- and work more effectively -- in states with supportive regulatory environments.

At the turn of the century, government regulations eliminated midwifery -- at the time an unlicensed profession -- partly because midwives competed with doctors for patients. In the 1920s, nurse-midwifery became a regulated profession. "Despite a broadening of Medicaid benefits and recent national legislation, women and children have persistent barriers to health care," says Declercq. "One solution is the expanded use of CNMs, who can ease the problems of access for women, newborns, and families with children." However, the team found strong obstacles to this solution.

The researchers studied the regulation of CNM practice, the nature of barriers CNMs face, and the impact of those barriers on their practices and on women's access to their services. Licensing for CNMs varies widely among states; they usually must work under a physician's supervision and often can write only limited prescriptions. "There's also a lack of understanding by both the public and the policy-makers of what CNMs do," says Paine. For example, they found that while most nurse-midwives are regulated by a state board of registration in nursing, in 1995 only eight states had a CNM on the regulatory board.

Reimbursement policies that vary from state to state and insurer to insurer strongly discourage access to CNMs, the study found. Although federal Medicaid coverage is available in all states, there is considerable variation in services covered and levels of reimbursement. The team also found that in 1995 only 31 states mandated that private insurers cover some CNM services. Another complication is whether CNMs can bill for their services or have to be reimbursed as an employee of a physician or institution. "All these barriers get in the way of patient care," says Declercq.

According to Declercq and Paine, it's clear that nurse-midwives can increase health-care access while reducing costs. But the dilemma faced by CNMs is a common one for nonphysician practitioners. "They want to provide direct services to mothers and children, not waste their time in state politics," says Paine. "However, while regulatory control will likely remain up to the states, leveling the playing field for CNMs in terms of federal reimbursement could really help women get access to these services."

"Research Briefs" is written by Joan Schwartz in the Office of the Provost. To read more about BU research, visit


15 May 2003
Boston University
Office of University Relations