Patients with cancer are more likely to be diagnosed at an advanced stage of disease and are less likely to receive recommended treatment if they are enrolled in Medi-Cal, California’s Medicaid program, or if they are dually eligible for Medicare and Medi-Cal, according to a study by the University of California Davis Institute for Population Health Improvement. Looking at data recorded in the California Cancer Registry (CCR) between 2004 and 2012, researchers found disparities in cancer survival as well as quality of care among persons with different sources of health insurance, and the study found substantial opportunities existed for improved quality of care among all patients.
The study compared the care received by patients with Medicare, patients with Medicaid (Medi-Cal), dual eligible patients, patients with Department of Defense (DOD) insurance (grouping together TRICARE and care provided at military treatment facilities such as military hospitals and clinics), patients with Veterans Assistance (VA) insurance, patients with private insurance, and patients with no insurance.
Patients with DOD insurance, private insurance, or Medicare coverage most likely to receive a breast cancer diagnosis at stage 0 or 1 (62.3, 61.4, and 60.4 percent). Comparatively, those with Medi-Cal were found to be least likely to be diagnosed at an early stage (39 percent), followed by uninsured patients (44 percent), dual eligible patients (50 percent), and those with VA insurance (55 percent). Uninsured patients were most likely to be diagnosed with breast cancer at stage IV (13.7 percent).
VA patients were most likely to receive radiotherapy for positive regional lymph nodes following mastectomy (93.8 percent), and Medicare and dual eligible patients were least likely to receive this recommended treatment (49.6 and 46.8 percent). These percentages were similar to those of uninsured patients. Patients at stage 0-II covered by Medicare were significantly more likely (61.1 percent) to receive breast-conserving surgery than patients at stage 0-II with any other source of insurance, with Medi-Cal, VA, and uninsured patients being much less likely (52.2 percent for Medi-Cal) to receive breast-conserving surgery. Patients with stage III breast cancer covered by DOD or private insurance had the best 5-year relative survival rate (80.3 and 79.6 percent), and dual eligible and uninsured patients at stage III had the lowest 5-year relative survival rate (59.4 and 62.5 percent).
Among patients with colon cancer, Medi-Cal and uninsured patients were significantly less likely to be diagnosed at an early stage than patients all other types of insurance, and were found to be most likely to be diagnosed at stage IV. Stage III patients with DOD, VA, and private insurance were significantly more likely (83 and 82.4 percent) than Stage III dual eligible and Medicare patients to receive adjuvant chemotherapy (51.1 and 53.7 percent). DOD, VA, and private insurance patients with stage III colon cancer also had the highest 5-year relative survival rates (76.9, 75.3, and 70.9 percent), while Medi-Cal patients in stage III had lower survival rates (56.6 percent) than all but Medicare patients.
Among patients with the types of insurance studied, Medi-Cal patients were the least likely to have rectal cancer diagnosed at stage 0 or I (25.2 percent). Although patients with private insurance were most likely to be diagnosed at an early stage, the difference was only significant when compared to those with Medi-Cal and uninsured patients. Dual eligible and Medicare patients under age 80 were significantly less likely to receive recommended radiation therapy than patients with VA insurance. Medi-Cal patients were also more than twice as likely to be diagnosed with rectal cancer at stage IV than patients with private insurance (30.9 percent compared to 14.4 percent). Among patients with early stage rectal cancer, dual eligibles had the lowest 5-year relative survival rate (65 percent) compared to all other types of insurance studied.
Patients with DOD and VA insurance were most likely to have lung cancer diagnosed at stage I (26.5 and 24.5 percent). Medi-Cal and uninsured patients were found to be significantly less likely to be diagnosed at an early stage (11.6 and 7.6 percent) and were found to be more likely to receive a stage IV diagnosis (68.5 and 61.5 percent) than patients with any other type of insurance. The 5-year relative survival rate was significantly lower for Medi-Cal and dual eligible patients with early stage lung cancer (48 and 46.1 percent) compared to patients with DOD or private insurance (75.4 percent and 64.8 percent).
Patients with Medi-Cal were more than three times as likely to be diagnosed with stage IV prostate cancer than patients with private or DOD coverage. For patients with cancer at this stage, the 5-year relative survival rate was significantly lower for Medi-Cal patients (36.7 percent) than those with VA, DOD, or private insurance.
The researchers recommended that, given the magnitude in differences in outcome and quality of care between Medi-Cal members and patients with other types of health insurance, “it would be prudent for the Department of Health Care Services, which administers the Medi-Cal program, to give priority to further investigating the quality and outcomes of cancer care among Medi-Cal members through the linkage of CCR and Medi-Cal enrollment and paid claims data, and possibly other relevant state health care databases. This would allow for more detailed evaluation of the many factors which influence treatment and outcomes.”