Research comparing the effect of health maintenance organizations and Medicaid on early cancer detection associates HMO coverage with a more favorable stage at diagnosis. It also indicates that Medicaid recipients and the uninsured are more likely to be diagnosed with cancer at a later stage.
"I was pretty much expecting those findings from previous research and my own personal experience," said Richard Roetzheim, M.D., of the University of South Florida Department of Family Medicine and the H. Lee Moffitt Cancer Center, who conducted the research. He anticipated that people who did not have health insurance or who were covered by Medicaid have poor outcomes.
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When looking at skin cancer, breast cancer, and prostate cancer, Roetzheim found that having Medicaid or having no health insurance at all were both associated with higher likelihood of late-stage diagnosis.
Roetzheim was surprised that patients with no health insurance and those with Medicaid had such similar results. He noted that, on paper, Medicaid provides very good insurance coverage, but he said there may be differences in types of physicians who see patients covered by Medicaid and physicians who work in HMOs. In addition, there may be differences in the facilities that accept Medicaid payments versus those serving HMOs.
"In some sense we have a very different type of health care system for Medicaid probably as a result of lower reimbursement as compared to private insurance," Roetzheim said.
However, it may be a mistake to generalize, because HMOs and other insurance types all vary depending on the specific plan, Roetzheim said. "We need more detailed, specific information about the patients themselves, such as what kinds of doctors they saw and where they received treatment," said Roetzheim. "We need to track them through the health care system and see how it differs among patients."
In a 1993 study on HMOs, Medicaid, and breast cancer, John Z. Ayanian, M.D., of the Harvard Medical School, Boston, came to a similar conclusion. In the study, Ayanian determined that uninsured patients and those covered by Medicaid have more advanced breast cancer at diagnosis than privately insured patients.
"Weve got a vulnerable group of patients out there that are at high risk of having their cancer diagnosed at late stage and having poor outcomes, and I dont get a sense that we are doing anything to solve that problem," said Roetzheim. "If anything, the problem is going to get worse as insurance rates go up and as Medicaid gets squeezed."
Differences in care and overall outcome have also been found between HMOs and fee-for-service insurance plans. In a recent study, Arnold Potosky, Ph.D., of the National Cancer Institute, concluded that survival outcomes for breast cancer patients in HMOs were equal to if not better than those in fee-for-service plans. Potosky also found that a recommended therapy for early-stage breast cancerbreast-conserving surgery plus adjuvant radiotherapywas used more frequently in the HMOs he studied.
Gerald F. Riley, of the Health Care Financing Administration, examined breast cancer stage at diagnosis and treatment patterns among elderly women in HMO and fee-for-service settings. Riley found that patients with HMO coverage were less likely to have breast cancer diagnosed at a late stage than their fee-for-service counterparts. Riley also found that HMO enrollees were more likely to receive the indicated radiation therapy. However, for breast-conserving surgery, rates were similar for both HMOs and fee-for-service.
Roetzheim found the opposite diagnosis pattern in HMOs and fee-for-service settings when studying colon cancer care and treatment. For colon cancer, patients in Medicare HMOs tended to have later stage diagnosis, and patients enrolled in private HMOs tended to have higher mortality rates.
Although these differences can be tracked through the health care system, more information is still needed. "If you want to figure out how to affect quality of care provided by health plans, you have to first understand which financial and non-financial incentives health plans use to affect provider behavior actually result in quality of care differences in cancer," said Matthew Maciejewski, Ph.D., of the Northwest Center for Outcomes Research in Older Adults and the University of Washington, Seattle.
"Once you know that, you can identify providers or centers of excellence and the health plan incentives that differentiate them from other providers and centers. Only then will any policy recommendations result in better outcomes," he added.
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