The impact of Medicaid coverage and reimbursement on access to diagnostic mammography

BACKGROUND:

Women of low socioeconomic status are at risk for delayed evaluation of abnormal mammograms and later stage presentations of breast cancer. Medicaid reimbursement for clinical services is lower than Medicare reimbursement, yet it is unclear whether low Medicaid reimbursement is a barrier to accessing mammography. The objective of the current study was to determine the association between reported insurance type (Medicaid vs Medicare), Medicaid reimbursement rate, and access to diagnostic mammography (DM).

METHODS:

Standardized patients (SPs) called 521 mammography facilities in defined geographic regions of 11 states in 2005. Facilities were divided between high, middle, and low reimbursing states based on the state's relative Medicaid‐to‐Medicare reimbursement rate for DM. SPs contacted each facility twice to schedule a DM using the same clinical vignette but switching insurance status (Medicaid vs Medicare). The authors measured the proportion of SPs who were offered 1) any appointment and 2) a timely appointment, defined as a third available appointment within 20 business days.

RESULTS:

SPs with Medicaid were less likely to receive an appointment than SPs with Medicare (91% vs 99.1%; difference, 8.1%; 95% confidence interval, 5.3%‐10.9% [P < .001]). Among facilities that offered appointments to both callers, the proportion of timely appointments did not differ between Medicaid (93.7%) and Medicare (92.9%; P = .51). States' Medicaid reimbursement rates for DM were not associated with the percentage of SPs with Medicaid who were offered any appointment (P = .50) or a timely appointment (P = .69).

CONCLUSIONS:

Callers with Medicaid were offered appointments for DM less frequently than callers with Medicare, although both were widely accepted. State Medicaid reimbursement rates did not affect access to mammography. Cancer 2009. © 2009 American Cancer Society.     

Use of colonoscopy for polyp surveillance in Medicare beneficiaries

BACKGROUND:

Professional society guidelines recommend follow‐up colonoscopy for patients with resected colonic adenomas. However, adherence to guideline recommendations in routine clinical practice has not been well characterized.

METHODS:

The authors used a population‐based sample of Medicare beneficiaries to identify all patients aged ≥70 years who had a claim for colonoscopy with polypectomy or hot biopsy during the period from 2001 to 2004. Medicare claims through 2009 identified colonoscopy within the following 5 years as well as fecal occult blood testing, sigmoidoscopy, and barium enema.

RESULTS:

In total, 12,771 patients were included. At 5 years, 45.7% of patients underwent another colonoscopy, and 32.3% of procedures included a polypectomy. The rates of fecal occult blood testing, flexible sigmoidoscopy, and barium enema at 5 years were 54%, 3.8%, and 2.9%, respectively. There was a marked decrease in repeat colonoscopy at 1 year, 3 years, and 5 years with more recent years of index procedures. Other predictors of undergoing repeat colonoscopy were younger age, African American race, and a colonoscopy before the index examination. There was no association with physician specialty. The decreasing use of colonoscopy with time was maintained in a multivariable analysis.

CONCLUSIONS:

In a sample of elderly Medicare beneficiaries, there was under use of follow‐up colonoscopy at 5 years after polypectomy, and <50% of patients received a repeat examination. In particular, the use of this procedure decreased over the 4‐year study period. Coupled with other data indicating the overuse of follow‐up colonoscopy in patients without polyps, there appeared to be significant discordance between guidelines and actual practice. Cancer 2013. © 2013 American Cancer Society.     

Geographic variation of racial/ethnic disparities in colorectal cancer testing among medicare enrollees

BACKGROUND:

The Medicare population has documented racial/ethnic disparities in colorectal cancer (CRC) screening, but it is unknown whether these disparities differ across geographic regions.

METHODS:

Among Medicare enrollees within 8 US states, we ascertained up‐to‐date CRC screening on December 31, 2003 (fecal occult blood testing in the prior year or sigmoidoscopy or colonoscopy in the prior 5 years). Logistic regression models tested for regional variation in up‐to‐date status among white versus different nonwhite populations (blacks, Asian/Pacific Islanders [APIs], Hispanics). We estimated regression‐adjusted region‐specific prevalence of up‐to‐date status by race/ethnicity and compared adjusted white versus nonwhite up‐to‐date prevalence across regions by using generalized least squares regression.

RESULTS:

White versus nonwhite up‐to‐date status varied significantly across regions for blacks (P = .01) and APIs (P < .001) but not Hispanics (P = .62). Whereas the white versus black differences in proportion up‐to‐date were greatest in Atlanta (Georgia), rural Georgia, and the San Francisco Bay Area of California (range, 10%‐16% differences, blacksP < .001). White versus Hispanic differences were substantial but homogeneous across regions (range, 8%‐16% differences, Hispanics CONCLUSIONS: Significant geographic variation in up‐to‐date status among black and API Medicare enrollees is associated with heterogeneous racial/ethnic disparities for these groups across US regions. Cancer 2011. © 2011 American Cancer Society.     

The costs of centralisation: a systematic review of the economic impact of the centralisation of cancer services

While evidence suggests that within specific cancer sites centralisation of services improves outcomes and quality of care, the economic impact of centralisation is unclear. This systematic review identified 19 studies that have investigated whether or not the centralisation of cancer services results in economies of scale, or is cost-effective, or increases the costs of accessing care for patients and their carers. Evidence from 13 studies suggests that increasing surgeon volumes are associated with cost reductions, although one study suggested that this relationship is U-shaped and the evidence is not consistent for hospital volumes and costs. Only one study demonstrated that centralisation was cost-effective with an incremental cost utility ratio of $5029 (€3616) per quality-adjusted life year gained. Consistent evidence from four studies suggested that centralised services increase the costs of accessing care for patients and their carers. Current evidence on the economic impact of centralisation of cancer services is limited and of poor quality. Therefore, it remains unclear whether centralisation results in economies of scale and is cost-effective. Future research should be based on a clear definition of the different components of centralisation in order to determine which aspects of centralisation are efficient and for which cancer subgroups.     

Inequity in Telemedicine Use Among Patients with Cancer in the Deep South During the COVID-19 Pandemic

BackgroundTelemedicine use has increased significantly during the COVID-19 pandemic. It remains unclear if its rapid growth exacerbates disparities in healthcare access. We aimed to characterize telemedicine use among a large oncology population in the Deep South during the COVID-19 pandemic.Materials and MethodsA retrospective cohort study was performed at the only National Cancer Institute designated-cancer center in Alabama March 2020 to December 2020. With a diverse (26.5% Black, 61% rural) population, this southeastern demographic uniquely reflects historically vulnerable populations. All non-procedural visits at the cancer center from March to December 2020 were included in this study excluding those with a department that had fewer than 100 visits during this time period. Patient and clinic level characteristics were analyzed using t-test and Chi-square to compare characteristics between visit types (in-person versus telemedicine, and video versus audio within telemedicine). Generalized estimating equations were used to identify independent factors associated with telemedicine use and type of telemedicine use.ResultsThere were 50 519 visits and most were in-person (81.3%). Among telemedicine visits, most were phone based (58.3%). Black race and male sex predicted in-person visits. Telemedicine visits were less likely to have video among patients who were Black, older, male, publicly insured, and from lower income areas.ConclusionsTelemedicine use, specifically with video, is significantly lower among historically vulnerable populations. Understanding barriers to telemedicine use and preferred modalities of communication among different populations will help inform insurance reimbursement and interventions at different socioecological levels to ensure the continued evolution of telemedicine is equitable.     

Timeliness and quality of diagnostic care for medicare recipients with chronic lymphocytic leukemia

BACKGROUND:

Little is known about the patterns of care relating to the diagnosis of chronic lymphocytic leukemia (CLL), including the use of modern diagnostic techniques such as flow cytometry.

METHODS:

The authors used the SEER‐Medicare database to identify subjects diagnosed with CLL from 1992 to 2002 and defined diagnostic delay as present when the number of days between the first claim for a CLL‐associated sign or symptom and SEER diagnosis date met or exceeded the median for the sample. The authors then used logistic regression to estimate the likelihood of delay and Cox regression to examine survival.

RESULTS:

For the 5086 patients analyzed, the median time between sign or symptom and CLL diagnosis was 63 days (interquartile range [IQR] = 0‐251). Predictors of delay included age ≥75 (OR 1.45 [1.27‐1.65]), female gender (OR 1.22 [1.07‐1.39]), urban residence (OR 1.46 [1.19 to 1.79]), ≥1 comorbidities (OR 2.83 [2.45‐3.28]) and care in a teaching hospital (OR 1.20 [1.05‐1.38]). Delayed diagnosis was not associated with survival (HR 1.11 [0.99‐1.25]), but receipt of flow cytometry within thirty days before or after diagnosis was (HR 0.84 [0.76‐0.91]).

CONCLUSIONS:

Sociodemographic characteristics affect diagnostic delay for CLL, although delay does not seem to impact mortality. In contrast, receipt of flow cytometry near the time of diagnosis is associated with improved survival. Cancer 2011. © 2010 American Cancer Society.     

Methadone initiation and rotation in the outpatient setting for patients with cancer pain

BACKGROUND:

Methadone is an effective and inexpensive opioid for cancer pain treatment. It has been reported as difficult to use in the outpatient setting because of its variable relative potency and long half‐life. The purpose of this study was to determine the outcome of methadone initiation or rotation for cancer pain treatment in outpatient settings.

METHODS:

Chart review was done of 189 consecutive patients who underwent methadone initiation or rotation at the authors' palliative care outpatient center. Data were collected regarding demographic and clinical characteristics, symptoms, and opioid side effects at baseline and for 2 follow‐up visits (F1, F2). Failure was defined as methadone discontinuation by the palliative care physician or patient's hospitalization for uncontrolled pain or methadone‐related side effects at F1.

RESULTS:

One hundred (53%) initiations and 89 (47%) rotations were conducted. Success rates for methadone initiation and rotation were 82 of 89 (92%) and 85 of 100 (84%), respectively. Mean (standard deviation) age was 60 (11) years. One hundred (53%) patients were women, 138 (73%) were white, and 182 (96%) had solid cancers. The main reason for rotation was pain (65 of 89 patients, 47%). Median (interquartile range, IQR) pain scores (Edmonton Symptom Assessment Scale/0‐10) were 6 (5‐8), 4 (3‐6), and 3 (2‐5) at baseline, F1, and F2, respectively (P < .0001). Median (IQR) daily methadone dose for initiation and rotation was 10 (5‐15) mg and 15 (10‐30) mg at F1 (P < .0001) and 10 (8‐15) mg and 18 (10‐30) mg at F2 (P < .0001), respectively. Constipation and nausea improved (P < .005) after initiation/rotation to methadone. Frequency of sedation, hallucinations, myoclonus, and delirium did not increase after initiation/rotation to methadone.

CONCLUSIONS:

Outpatient methadone initiation and rotation for cancer pain treatment were safe, with high success rates and low side effect profiles. Cancer 2010. © 2010 American Cancer Society.     

Equity-Oriented Healthcare: What It Is and Why We Need It in Oncology

Alarming differences exist in cancer outcomes for people most impacted by persistent and widening health and social inequities. People who are socially disadvantaged often have higher cancer-related mortality and are diagnosed with advanced cancers more often than other people. Such outcomes are linked to the compounding effects of stigma, discrimination, and other barriers, which create persistent inequities in access to care at all points in the cancer trajectory, preventing timely diagnosis and treatment, and further widening the health equity gap. In this commentary, we discuss how growing evidence suggests that people who are considered marginalized are not well-served by the cancer care sector and how the design and structure of services can often impose profound barriers to populations considered socially disadvantaged. We highlight equity-oriented healthcare as one strategy that can begin to address inequities in health outcomes and access to care by taking action to transform organizational cultures and approaches to the design and delivery of cancer services.     

Underutilization of therapy for hepatocellular carcinoma in the medicare population

BACKGROUND:

The incidence of hepatocellular carcinoma (HCC) is increasing in the United States, and the care of these patients remains highly specialized and complex. Multiple treatment options are available for HCC but their use and effectiveness remain unknown.

METHODS:

Using Surveillance, Epidemiology, and End Results (SEER)‐Medicare linked data, 8730 patients who were diagnosed with HCC between 1991 and 2005 were identified. Therapy included surgical resection (8.7%), liver transplantation (1.4%), ablation (3.6%), or transarterial chemoembolization (16%). Patients who received no or palliative‐only treatment were grouped together (NoTx; 70.3%). Patient, disease, and tumor factors were examined as determinants of therapy.

RESULTS:

HCC is increasing in the Medicare population. The median age at diagnosis was 75.1 years and 73.6% of patients were coded as white, 17.2% as Asian, 8.3% as black, and 0.9% as other race. The rate of therapy increased over time, but only 29.7% of patients overall underwent therapy. In patients with early stage HCC, only 43.1% underwent therapy. In the NoTx group, 49.4% did not have cirrhosis, 36.0% had tumors that measured <5 cm, and 39.8% were diagnosed with stage I or II disease when variables were complete. The use of therapy for all HCC patients increased over time, correlating with a commensurate increase in median survival. In multivariate regression analysis, patients who received any modality of treatment achieved significant benefit compared with the NoTx group (odds ratio, 0.41; 95% confidence interval, 0.39‐0.43).

CONCLUSIONS:

In the Medicare population, HCC patients who received therapy experienced a substantial survival advantage over their nonoperative peers (NoTx). Despite evidence that many patients had favorable biological characteristics, <30% of patients diagnosed with HCC received any treatment. Cancer 2011. © 2010 American Cancer Society.     

Prevalence and predictors of interval colorectal cancers in medicare beneficiaries

BACKGROUND:

After a colonoscopy that is negative for cancer, a subset of patients may be diagnosed with colorectal cancer, also termed interval cancer. The frequency and predictors have not been well studied in a population‐based US cohort.

METHODS:

The authors used the linked Surveillance, Epidemiology, and End Results (SEER)‐Medicare database to identify 57,839 patients aged ≥69 years who were diagnosed with colorectal cancer between 1994 and 2005 and who underwent colonoscopy within 6 months of cancer diagnosis. Colonoscopy performed between 6 and 36 months before cancer diagnosis was a proxy for interval cancer.

RESULTS:

By using the case definition, 7.2% of patients developed interval cancers. Factors that were associated with interval cancers included proximal tumor location (distal colon: multivariable odds ratio [OR], 0.42; 95% confidence interval [CI], 0.390‐0.46; rectum: OR, 0.47; 95% CI, 0.42‐0.53), increased comorbidity (OR, 1.89; 95% CI, 1.68 2.14 for ≥3 comorbidities), a previous diagnosis of diverticulosis (OR, 6.00; 95% CI, 5.57‐6.46), and prior polypectomy (OR, 1.74; 95% CI, 1.62‐1.87). Risk factors at the endoscopist level included a lower polypectomy rate (OR, 0.70; 95% CI, 0.63‐0.78 for the highest quartile), higher colonoscopy volume (OR, 1.27; 95% CI, 1.13‐1.43), and specialty other than gastroenterology (colorectal surgery: OR, 1.45; 95% CI, 1.16‐1.83; general surgery: OR, 1.42; 95% CI, 1.24‐1.62; internal medicine: OR, 1.38; 95% CI, 1.17‐1.63; family practice: OR, 1.16; 95% CI, 1.00‐1.35).

CONCLUSIONS:

A significant proportion of patients developed interval colorectal cancer, particularly in the proximal colon. Contributing factors likely included both procedural and biologic factors, emphasizing the importance of meticulous examination of the mucosa. Cancer 2012;118: 3044–52. © 2011 American Cancer Society.     

The development of an outpatient treatment system for cancer chemotherapy

It is necessary to develop a system of treatment to provide cancer chemotherapy on an outpatient basis. Facilities needed include treatment service sites, outpatient laboratories, and chemotherapy pharmacies where safety cabinets are available. Medical oncologists, chemotherapy nurses and pharmacists should conduct cancer chemotherapy after obtaining informed consent from the patient. Chemotherapy protocols, ordering systems and risk management for medical errors must also be established in the agreement to perform chemotherapy. The problems encountered in the experiences at the Outpatient Treatment Service of National Cancer Center Hospital East are discussed.