Medi-Cal, uninsured patients less likely to receive quality cancer care

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.

Breast cancer

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).

Colon cancer

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.

Rectal cancer

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.

Lung cancer

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).

Prostate cancer

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.”

Cover your constituents! Study says Medicaid ‘is clearly better than no coverage’

Medicaid coverage improves awareness of treatment options, chronic disease management, utilization of preventive care services, and access to health care, according to a study published in the American Journal of Public Health (AJPH). The study supports the premise that Medicaid expansion under the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) does in fact lead to better health.

AJPH Study

The study was based upon data gathered from national surveys conducted by the Centers for Disease Control and Prevention (CDC). It looked at the care received by 4,460 poor Americans. Researchers found that Medicaid leads to significant improvements in health. For example, individuals with Medicaid were 69 percent more likely to be aware of having high blood pressure and 62 percent more likely to have control of their high blood pressure than people without coverage. The study’s researchers noted that awareness and treatment of high blood pressure is a critical preventive measure, calling it the “key to preventing strokes and heart attacks.”

Oregon study

The study’s lead researcher believes the findings point out flaws in the Oregon Health Insurance Experiment, a study which is regularly used as evidence that Medicaid doesn’t improve health. While the Oregon study determined that Medicaid is effective at reducing rates of depression, the Oregon experiment found that Medicaid did not improve physical health. The lead researcher of the AJPH study suggested that the Oregon study may not be representative for much of the country because it was conducted in Portland where uninsured patients “have much better access to safety-net care than do uninsured Americans elsewhere.”


A co-author of the study, an associate professor of medicine at Harvard Medical School, said that “we need to get everyone covered in a single-payer system, but until we do, Medicaid is clearly better than no coverage.” He also asked “With mounting proof that Medicaid improves health, why are politicians refusing to cover their constituents?”

CMS, New York State testing new model of coordinated care for dual eligibles

Individuals who are eligible for both Medicare and Medicaid are often faced with challenges when navigating through the programs’ various rules, benefits, and providers. Some such individuals, known as “dual eligibles,” may also have intellectual or developmental disabilities and require access to various health care providers. In the attempt to provide a “more coordinated, person-centered experience” for such enrollees, CMS and New York State are teaming up to test a new model of providing care that focuses on coordinating acute care and long-term care needs.

New Model

CMS announced its partnership with the New York State Department of Health (NYSDOH) and the Office for People with Developmental Disabilities (OPWDD), that will create the Fully Integrated Duals Advantage for Individuals with Intellectual and Developmental Disabilities (FIDA-IDD), which will be a demonstration project aimed at better serving dual eligible enrollees who have intellectual and developmental disabilities. According to CMS, the FIDA-IDD Demonstration will provide more opportunities for individuals to be involved in directing their own services and care planning while living as independently as possible in their communities.

Under the FIDA-IDD model, 20,000 dual eligible enrollees in the downstate New York region will be offered the opportunity to participate in the voluntary program. The program will be offered through Partners Health Plan in New York City, Long Island, and Rockland and Westchester Counties. Voluntary enrollment will begin after April 1, 2016.


Section 2602 of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) established the Federal Coordinated Health Care Office, known as the Medicare-Medicaid Coordination Office (MMCO) to better coordinate the Medicare and Medicaid programs to ensure that dual eligibles receive the benefits to which they are entitled. The MMCO partners with states through CMS’ Financial Alignment Initiative to create demonstration projects to test methods of providing integrated benefits to dual eligibles. Demonstrations such as FIDA-IDD that are approved under the Financial Alignment Initiative are intended to provide better care through a person-centered, integrated care approach.


The new model shares the general structure and goals with the Fully Integrated Duals Advantage (FIDA) Demonstration project, which is already in operation in New York, but it involves different populations and Medicare-Medicaid plans. Additionally, the new model (FIDA-IDD) does not allow for passive enrollment and includes benefits that are tailored to providing support to individuals who have intellectual and developmental disabilities.

The FIDA-IDD is operated under the Capitated Model, through which states and CMS contract with health plans that receive prospective, blended payments in exchange for providing dual eligibles with coordinated care. In order to participate in the FIDA-IDD Demonstration, plans must meet core Medicare and Medicaid requirements and must pass a comprehensive readiness review.

How it Works

The FIDA-IDD Plan will provide enrollees with an interdisciplinary care team, which will be based on the enrollees’ individual preferences and goals so as to ensure that enrollees’ medical, behavioral health, long-term services and supports, and social needs are integrated. The demonstration will include performance metrics established by CMS and New York to ensure high quality care. The plan also includes continuity of care requirements so that enrollees can continue to see their current providers as they transition into the FIDA-IDD Plan. Additionally, New York created the Independent Consumer Advocacy Network (ICAN), which is a free Ombudsman program intended to assist enrollees with appeals and other plan issues. The program will support individual advocacy and will provide New York and CMS with feedback on the plan’s performance relating to community integration, independent living, and person-centered care.

External Evaluation

Each demonstration under CMS’ Financial Alignment Initiative, including the FIDA-IDD, will be externally evaluated to measure its quality, beneficiary care experience, care coordination, costs, and support of community living. FIDA-IDD will also have a specific evaluation that will use a comparison group to analyze the demonstration’s impact.

Kusserow on Compliance: OIG 2016 Work Plan highlights investigative priorities and accomplishments

The HHS Office of Inspector General (OIG) Work Plan for fiscal year 2016 describes audits, evaluations, and certain continuing legal and investigative initiatives and forecasts areas for which the OIG anticipates planning and/or beginning work. With regards to investigations, the OIG noted that it receives and investigates thousands of complaints involving the scores of programs wherein it provides oversight. The most resources are devoted to oversight of the Medicare and Medicaid programs, many of which involve allegations of billing for services not rendered, services considered medically unnecessary, misrepresented services, and patient harm. This also includes issues related to illegal billing with regard to the sale, diversion, and off-label marketing of prescription drugs; solicitation and receipt of kickbacks, including illegal payments to patients for involvement in the fraud scheme; and illegal referral arrangements between physicians and medical companies.

In fiscal year (FY) 2015, the OIG brought criminal actions against 925 individuals or entities; it brought 682 civil actions. These included false claims actions, civil monetary penalty settlements, and administrative recoveries. During this period, 4,112 individuals and entities were excluded from participation in federal health care programs. The agency also reported expected recoveries of more than $3 billion, consisting of nearly $1.13 billion in audit receivables and about $2.22 billion in investigative receivables, which include about $286.6 million in non-HHS investigative receivables resulting from its work in Medicaid restitution cases. The OIG also identified about $21 billion in savings estimated on the basis of prior-period legislative, regulatory, or administrative actions on OIG recommendations.

Further details of investigative interest are noted throughout the Work Plan in specific planned work areas. It is worth reviewing these projects as they often telegraph situations that eventually blossom into national initiatives.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

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Copyright © 2015 Strategic Management Services, LLC. Published with permission.