Project description:BackgroundEarly treatment of hepatocellular carcinoma (HCC) is associated with improved survival, but many patients with HCC do not receive therapy. We aimed to examine factors associated with HCC treatment and survival among incident patients with HCC in a statewide cancer registry.Materials and methodsAll patients with HCC from 2003 through 2013 were identified in the North Carolina cancer registry. These patients were linked to insurance claims from Medicare, Medicaid, and large private insurers in North Carolina. Associations between prespecified covariates and more advanced HCC stage at diagnosis (ie, multifocal cancer), care at a liver transplant center, and provision of HCC treatment were examined using multivariate logistic regression. A Cox proportional hazards model was developed to assess the association between these factors and survival.ResultsOf 1,809 patients with HCC, 53% were seen at a transplant center <90 days from diagnosis, with lower odds among those who were Black (adjusted odds ratio [aOR], 0.54; 95% CI, 0.39-0.74), had Medicare insurance (aOR, 0.35; 95% CI, 0.21-0.59), had Medicaid insurance (aOR, 0.46; 95% CI, 0.28-0.77), and lived in a rural area; odds of transplant center visits were higher among those who had prediagnosis alpha fetoprotein screening (aOR, 1.74; 95% CI, 1.35-2.23) and PCP and gastroenterology care (aOR, 1.66; 95% CI, 1.27-2.18). Treatment was more likely among patients who had prediagnosis gastroenterology care (aOR, 1.68; 95% CI, 0.98-2.86) and transplant center visits (aOR, 2.42; 95% CI, 1.74-3.36). Survival was strongly associated with age, cancer stage, cirrhosis complications, and receipt of HCC treatment. Individuals with Medicare (adjusted hazard ratio [aHR], 1.58; 95% CI, 1.20-2.09) and Medicaid insurance (aHR, 1.55; 95% CI, 1.17-2.05) had shorter survival than those with private insurance.ConclusionsIn this population-based cohort of patients with HCC, Medicare/Medicaid insurance, rural residence, and Black race were associated with lower provision of HCC treatment and poorer survival. Efforts should be made to improve access to care for these vulnerable populations.

Project description:Policy Points Patients with low socioeconomic status (SES) experience poorer survival rates after diagnosis of breast cancer, even when enrolled in Medicare and Medicaid. Most of the difference in survival is due to more advanced cancer on presentation and the general poor health of lower SES patients, while only a very small fraction of the SES disparity is due to differences in cancer treatment. Even when comparing only low- versus not-low-SES whites (without confounding by race) the survival disparity between disparate white SES populations is very large and is associated with lower use of preventive care, despite having insurance.ContextDisparities in breast cancer survival by socioeconomic status (SES) exist despite the "safety net" programs Medicare and Medicaid. What is less clear is the extent to which SES disparities affect various racial and ethnic groups and whether causes differ across populations.MethodsWe conducted a tapered matching study comparing 1,890 low-SES (LSES) non-Hispanic white, 1,824 black, and 723 Hispanic white women to 60,307 not-low-SES (NLSES) non-Hispanic white women, all in Medicare and diagnosed with invasive breast cancer between 1992 and 2010 in 17 US Surveillance, Epidemiology, and End Results (SEER) regions. LSES Medicare patients were Medicaid dual-eligible and resided in neighborhoods with both high poverty and low education. NLSES Medicare patients had none of these factors.Measurements5-year and median survival.FindingsLSES non-Hispanic white patients were diagnosed with more stage IV disease (6.6% vs 3.6%; p < 0.0001), larger tumors (24.6 mm vs 20.2 mm; p < 0.0001), and more chronic diseases such as diabetes (37.8% vs 19.0%; p < 0.0001) than NLSES non-Hispanic white patients. Disparity in 5-year survival (NLSES - LSES) was 13.7% (p < 0.0001) when matched for age, year, and SEER site (a 42-month difference in median survival). Additionally, matching 55 presentation factors, including stage, reduced the disparity to 4.9% (p = 0.0012), but further matching on treatments yielded little further change in disparity: 4.6% (p = 0.0014). Survival disparities among LSES blacks and Hispanics, also versus NLSES whites, were significantly associated with presentation factors, though black patients also displayed disparities related to initial treatment. Before being diagnosed, all LSES populations used significantly less preventive care services than matched NLSES controls.ConclusionsIn Medicare, SES disparities in breast cancer survival were large (even among non-Hispanic whites) and predominantly related to differences of presentation characteristics at diagnosis rather than differences in treatment. Preventive care was less frequent in LSES patients, which may help explain disparities at presentation.

Project description:ImportanceMedicare beneficiaries with disabilities aged 18 to 64 years face barriers accessing ambulatory care. Past studies comparing Medicare Advantage (MA) with traditional Medicare (TM) have not assessed how well these programs meet the needs of beneficiaries with disabilities.ObjectiveTo compare differences in enrollment rates, ambulatory care access, and ambulatory care quality for beneficiaries with disabilities in MA vs TM.Design setting and participantsThis cohort study included a nationally representative, weighted sample of 7201 person-years for beneficiaries aged 18 to 64 years with disability entitlement in the Medicare Current Beneficiary Survey from 2015 through 2018. Differences in program enrollment and in measures of access and quality by program enrollment were compared after adjusting for demographic, insurance, social, health, and area characteristics and after reweighting the sample by propensity to enroll in MA as estimated by observed confounders. Data analyses were conducted between November 1, 2020, and November 11, 2021.ExposuresMedicare Advantage vs TM program enrollment.Main outcomes and measuresSix patient-reported measures of ambulatory care access (usual source of care, primary care usual source of care, specialist visit) and quality (cholesterol screening, influenza vaccination, colon cancer screening).ResultsThe mean (SD) age of the overall study population was 52.1 (11.0) years; 49.5% were female and 50.5% were male; 1.6% were Asian/Pacific Islander; 17.4%, Black; 10.2% Hispanic; 1.4%, Native American; 65.1%, White, and 4.2%, multiracial. Among all beneficiaries living in the community, individuals with disability entitlement were less likely to enroll in MA than other beneficiaries (34.8% vs 41.2%). The final sample of beneficiaries with disabilities included 2444 person-years in MA and 4757 person-years in TM. Beneficiaries with disabilities in MA vs TM were more likely to be of a minority race or ethnicity (35.7% vs 27.6%) and less likely to be enrolled in private insurance (11.9% vs 25.0%). Comparing MA with TM among beneficiaries with disabilities, those in MA had significantly better rates of access to a usual source of care (90.2% vs 84.9%; adjusted propensity-weighted marginal difference [APWMD], 2.9%; 95% CI, 0.2%-5.7%), access to specialist visits (53.2% vs 44.8%; APWMD, 5.5%; 95% CI, 0.6%-10.5%), cholesterol screenings (91.1% vs 86.4%; APWMD, 3.8%; 95% CI, 0.9%-6.7%), influenza vaccinations (61.4% vs 51.5%; APWMD, 10.4%; 95% CI, 5.3%-15.5%), and colon cancer screenings (68.4% vs 54.6%; APWMD, 10.3%; 95% CI, 4.8%-15.8%).Conclusions and relevanceIn this cohort study, Medicare beneficiaries with disabilities were enrolled in MA at significantly lower rates than those without disabilities. However, MA was associated with significantly better ambulatory care access and quality for these beneficiaries on 5 of 6 measures compared with TM.

Project description:ImportancePostpartum Medicaid eligibility extensions are likely to shift enrollees from commercial to Medicaid coverage in the postpartum year; however, the potential implications for health care use and spending are unknown.ObjectiveTo compare health care use and spending among individuals with a Medicaid-paid birth who had continuous Medicaid vs continuous commercial insurance during months 3 to 12 post partum.Design, setting, and participantsCross-sectional study using linked all-payer claims, birth records, and income data for Medicaid-paid births in the Colorado All Payer Claims Database from 2014 to 2019 to estimate the association between continuous Medicaid vs commercial insurance and health care use and spending during months 3 to 12 post partum.ExposureContinuous enrollment in Medicaid vs commercial insurance during months 3 to 12 post partum.Main outcomes and measuresPrimary outcomes were the rate and number of primary care and outpatient visits, and total out-of-pocket spending during months 3 to 12 post partum. Secondary outcomes were the rate and number of emergency department visits and hospitalizations during months 3 to 12 post partum.ResultsThe 44 471 individuals in the sample had a mean (SD) age of 26.8 (5.50) years. Self-reported race and ethnicity included 1279 (2.9%) Asian individuals, 4028 (9.1%) Black individuals, 33 534 (75.4%) White individuals, as well as 5630 (12.7%) individuals of other race and ethnicity (American Indian or Alaskan Native; Other Pacific Islander; and unspecified). Of these, 19 337 (43.5%) self-identified as Hispanic individuals. The sample included 42 989 individuals continuously enrolled in Medicaid and 1482 individuals continuously enrolled in commercial insurance during months 3 to 12 post partum. Compared with those continuously enrolled in Medicaid, commercially insured enrollees were older (32.2% of commercial enrollees were between the ages of 30-39 vs 27.5% of Medicaid enrollees, P < .001), less likely to be Hispanic (38.9% in commercial vs 43.7% in Medicaid, P < .001) or born in the US (15.6% in commercial vs 19.6% in Medicaid, P < .001), and more likely to be married (62.8% in commercial vs 54.8% in Medicaid, P < .001), have completed college (32.9% in commercial vs 16.5% in Medicaid, P < .001), and initiated early prenatal care (79.7% in commercial vs 72.5% in Medicaid, P < .001). In multivariable models, individuals with commercial insurance were 2.46 percentage points (95% CI, 2.12-2.79 percentage points; P < .001) more likely to attend a primary care visit and had 0.81 (95% CI, 0.70-0.92; P < .001) additional primary care visits total during months 3 to 12 post partum. Individuals enrolled in commercial insurance were 7.92 percentage points (95% CI, -8.44 to -7.40 percentage points; P = .006) less likely to visit an emergency department compared with those enrolled in Medicaid. Total adjusted per person spending was $1110 (95% CI, $509-$1710; P < .001) higher, and total out-of-pocket spending per person was $796 (95% CI, $754-$838; P < .001) higher for those enrolled in commercial insurance vs Medicaid.Conclusions and relevanceIn this study, primary care use was higher and emergency department use was lower among those continuously enrolled in commercial vs Medicaid insurance during months 3 to 12 post partum. Medicaid rather than commercial insurance was associated with decreased exposure to out-of-pocket costs during months 3 to 12 postpartum for individuals with low income.

Project description:ObjectivesPolicymakers have increasingly focused on emergency department (ED) utilization for primary care-treatable conditions as a potentially avoidable source of rising health care costs. The objective was to determine the association of health insurance type and arrival time, as indicators of limited availability of primary care, with primary care-treatable classification of ED visits.MethodsThis was a retrospective analysis of a nationally representative sample of 241,167 ED visits from the 1997 to 2009 National Hospital Ambulatory Medical Care Surveys (NHAMCS). Probabilities of ED visits being primary care-treatable were categorized based on the primary International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code. The association of health insurance type and arrival time was determined with the average probability of the primary diagnosis being primary care-treatable using multivariable linear regression.ResultsCompared to privately insured visits, Medicaid visits had a 1.7% (95% confidence interval [CI] = 1.2% to 2.2%) and uninsured visits a 2.4% (95% CI = 1.9% to 3.0%) higher probability of primary care-treatable classification, while Medicare visits had a 1.4% (95% CI = 0.7% to 2.0%) lower probability during the overall study period. Compared to business hours, weekend visits had a 1.5% (95% CI = 1.0% to 2.0%) higher probability of being primary care-treatable during the overall study period. From 1997 to 2009, the overall adjusted probability of ED visits being primary care-treatable increased by 0.19% (95% CI = 0.10 to 0.28) per year. This probability increased at a rate of 0.52% per year for Medicare visits (95% CI = 0.38% to 0.65%), more than double that of Medicaid visits (0.25% per year, 95% CI = 0.13% to 0.37%). By contrast, there was no significant change from 1997 to 2009 in the average probability of ED visits being primary care-treatable by privately insured (0.05% per year, 95% CI = -0.07 to 0.16) or uninsured (0.00% per year, 95% CI = -0.12 to 0.13) individuals.ConclusionsThese findings add to prior work that implicates insurance type and arrival time in the variation of primary care-treatable ED visits. Although primary care-treatable classification of ED visits was most associated with uninsured or Medicaid visits, this classification increased most rapidly among Medicare visits during the study period.

Project description:BackgroundHead and neck cancers are of particular interest to health care providers, their patients, and those paying for health care services, because they have a high morbidity, they are extremely expensive to treat, and of the survivors only 48% return to work. Consequently the economic burden of oral cavity, oral pharyngeal, and salivary gland cancer (OC/OP/SG) must be understood. The cost of these cancers in the U.S. has not been investigated.MethodsA retrospective analysis of administrative claims data for 6,812 OC/OP/SG cancer patients was undertaken. Total annual health care spending for OC/OP/SG cancer patients was compared to similar patients without OC/OP/SG cancer using propensity score matching for enrollees in commercial insurance, Medicare, and Medicaid. Indirect costs, as measured by short term disability days were compared for employed patients.ResultsTotal annual health care spending for OC/OP/SG patients during the year after the index diagnosis was $79,151 for the Commercial population. Health care costs were higher for OC/OP/SG cancer patients with Commercial Insurance ($71,732, n = 3,918), Medicare ($35,890, n = 2,303) and Medicaid ($44,541, n = 585) than the comparison group (all p < 0.01). Commercially-insured employees with cancer (n = 281) had 44.9 more short-term disability days than comparison employees (p < 0.01). Multimodality treatment was twice the cost of single modality therapy. Those patients receiving all three treatments (surgery, radiation, and chemotherapy) had the highest costs of cost of care, from $96,520 in the Medicare population to $153,892 in the Commercial population.ConclusionsIn the U.S., the cost of OC/OP/SG cancer is significant and may be the most costly cancer to treat in the U.S. The results of this analysis provide useful information to health care providers and decision makers in understanding the economic burden of head and neck cancer. Additionally, this cost information will greatly assist in determining the cost-effectiveness of new technologies and early detection systems. Earlier identification of cancers by patients and providers may potentially decrease health care costs, morbidity and mortality.

Project description:ImportanceThe Affordable Care Act created 2 new coverage options for uninsured adults: Medicaid expansion, which in most states provides comprehensive coverage without premiums and deductibles; and private marketplace coverage, which requires a premium contribution and cost-sharing, though with generous federal subsidies at lower incomes. How enrollment rates compare in the marketplace vs Medicaid is an important policy question as states continue to weigh alternative coverage options such as Medicaid buy-in programs, enrolling Medicaid-eligible populations into marketplace plans, or creating a public option.ObjectiveTo assess the association between income eligibility for Medicaid vs marketplace coverage and insurance enrollment among low-income adults in Colorado.Design setting and participantsUsing 2014 and 2015 all-payer claims data from Colorado and detailed income eligibility information, we used a regression discontinuity design to assess the difference in Medicaid and marketplace enrollment just below and just above 138% of the federal poverty level (FPL), the eligibility threshold between the 2 programs. The sample included nonpregnant adults aged 19 to 64 years with incomes between 75% to 400% FPL. We stratified our analysis by age, sex, chronic condition status, and urban vs rural residence. Analysis was conducted from January to October 2020.Main outcome and measuresThe main outcome was total enrollment in either Medicaid or marketplace coverage during marketplace's Open Enrollment period. Income-based health insurance eligibility was assessed as a percentage of FPL at the time of initial application for coverage.ResultsThe primary analytical sample included 32 091 enrollees in 2014 and 55 451 in 2015, with incomes ranging from 120% to 156% FPL. Most enrollees were women (59.26% in 2014, 59.20% in 2015), resided in urban areas (70.36% in 2014, 73.08% in 2015), and had no chronic conditions (74.66% in 2014, 76.11% in 2015). For age, in 2014 and 2015, respectively, 13.22% and 13.93% were aged 19 to 25 years, 27.85% and 28.54% were aged 26 to 34 years, 23.58% and 24.34% were aged 35 to 44 years, 18.35% and 17.75% were aged 45 to 54 years, and 17.00% and 15.44% were aged 55 to 64 years. Marketplace enrollment was 81.3% (95% CI, -86.0% to -75.0%) lower than Medicaid enrollment in 2014 and 88.6% (95% CI, -90.8% to -86.0%) lower in 2015 among those close to the 138% FPL eligibility threshold. The drop-off in marketplace enrollment was largest among younger adults, aged 26 to 34 and 35 to 44 years: relative drop off -88.7% (95% CI, -93.3% to -80.8%) and -87.8% (95% CI, -90.8% to -83.9%) in 2014, and relative drop off -91.9% (95% CI, -94.5% to -87.9%) and -93.0% (95% CI, -94.5% to -91.1%) in 2015, respectively.Conclusions and relevanceIn this cross-sectional study using a regression-discontinuity analysis, meaningful gaps in insurance enrollment may have existed for those with incomes just above the eligibility threshold for Medicaid expansion, especially among younger adults. Policies expanding Medicaid income eligibility or zero-dollar premium marketplace plans are likely to be more effective at inducing enrollment than subsidized private plans with premium requirements.

Dataset Information

Evaluation of Online Patient Portal vs Text-Based Blood Pressure Monitoring Among Black Patients With Medicaid and Medicare Insurance Who Have Hypertension and Cardiovascular Disease.

Publications

Evaluation of Online Patient Portal vs Text-Based Blood Pressure Monitoring Among Black Patients With Medicaid and Medicare Insurance Who Have Hypertension and Cardiovascular Disease.

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