Study Looked Specifically at Insurance Status
Click to Enlarge: Source: Cancer Medicine
BETHESDA, MD — Cancer patients treated within the MHS generally receive their diagnoses earlier than members of the general U.S. population covered by employee-provided insurance, Medicaid or without insurance.
“The presented findings provide evidence that patients in the MHS had diagnosis of common cancers at an earlier stage, compared to various insurance types in the general U.S. population,” wrote researchers from Walter Reed National Military Medical Center, the Uniformed Services University of the Health Sciences, the Henry M. Jackson Foundation for the Advancement of Military Medicine Inc., and the Uniformed Services University of the Health Sciences, all in Bethesda, MD. “This difference was largest compared to the uninsured and Medicaid groups, while it was minimal for the SEER-insured groups.”
The study team pointed out that the largest difference was seen with lung cancer.
A key difference, according to the Cancer Medicine study, is that individuals, retirees and their families have free care or minimal out-of-pocket costs in the military health system (MHS). It noted that out-of-pocket costs in the United States general population can vary substantially.1
For the study, patients were identified from the DoD Automated Central Tumor Registry (ACTUR) and the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) program. Using the categories “insured,” “insured-no specifics,” “any Medicaid” and “uninsured,” tumor stage at diagnosis of breast, prostate, lung and colon cancers during 2007-2013 was compared among ACTUR and SEER categories. Included in the analysis were 18,440 eligible patients identified from ACTUR and 831,959 patients identified from SEER.
“For all cancer types, patients in the SEER-insured/no specifics, Medicaid, and uninsured groups had significantly greater likelihood of late stage diagnosis compared to ACTUR patients,” according to the authors. “The adjusted ORs were greatest among uninsured and Medicaid patients. The SEER-insured group also had a significantly higher odds of advanced stage disease than ACTUR patients for prostate cancer and lung cancer.”
The researchers concluded that MHS patients with universal access to healthcare were diagnosed at an earlier stage than those in the general population, especially when compared to Medicaid and uninsured groups.
Decreased Mortality
“Early detection of cancer results in decreased mortality, and in order for a malignancy to be detected and diagnosed, a person must have access to medical care,” the study pointed out. “At present, the United States remains without a means in which to provide effective healthcare for its entire population.”
The study team advised that annual premiums for a typical employer sponsored plan were more than $4,000 in 2012 and have increased since. In that year, about half of Americans were covered by an employer-sponsored plan, 18% received coverage through Medicaid, and 15% were uninsured. By 2019, the percentage of uninsured had decreased to 9% in 2019, while other categories increased with commensurate increases in other categories.
The MHS provides primary care, cancer screening, diagnostic imaging and cancer treatment. Beneficiaries include active duty members, retirees and their family members.
“The MHS provides universal health care to its beneficiaries,” the authors noted. “Our previous studies showed that MHS beneficiaries had earlier stages of colon, breast, and lung cancers compared to the population in the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) registry. However, these studies did not subdivide the SEER population by insurance status category. Comparison of each insurance status to the MHS can offer more nuanced evidence of its association with stage at diagnosis.”
The researchers reported that their results showed a later stage at diagnosis for breast, prostate, colon and lung cancers in Medicaid and uninsured groups compared to the MHS, across age groups. With prostate and lung cancer, the study also found a later stage at diagnosis with privately insured groups compared to the MHS.
“The most striking system-related difference between ACTUR and SEER and between SEER insurance groups is the costs and fee schedules,” the authors pointed out. “Costs for uninsured patients are often prohibitive, which likely explains why odds of later stage diagnosis were highest among uninsured patients. Costs for privately insured patients are highly variable. Some have very low out-of-pocket costs, whereas some face higher costs through high-deductible health plans or other plans. On average, out-of-pocket costs for privately insured beneficiaries were at least $4000 more when compared to those in the MHS.Out-of-pocket costs thus may contribute to the differences observed in stage at diagnosis between the MHS and SEER-insured groups.”
While later diagnosis among Medicaid patients could not be explained by cost sharing, since those patients have very low out-of-pocket costs, “uninsured patients are often enrolled in and classified under Medicaid shortly after a new cancer diagnosis. This may also contribute to later stage diagnosis in this group,” the study noted.
The researchers suggested that Medicaid patients “face more barriers in finding physicians who accept their insurance and are more likely to have delays in care due to cost, all of which could possibly lead to a delay in diagnosis. Delays in time to appointments could also be a factor affecting stage at diagnosis between ACTUR and SEER-insured groups, especially in the case of lung cancer; waiting times for appointments in the MHS are shorter than that reported in a separate survey among civilian physicians.”
Also contributing were factors such as time to initial presentation, time to specialist referral, time to diagnostic testing and time to definitive treatment.
Another issue is screening, “an important path” to diagnosis for breast, colon and prostate cancers, the study authors wrote. “Higher utilization of screening services in the ACTUR population may contribute to earlier stage at diagnosis,” they explained. “While breast cancer screening rates may be similar among patients with military insurance and private insurance, screening rates are lower among patients with Medicaid and especially for uninsured patients. For colon cancer, reported rates of screening are higher among patients with military insurance, whereas screening is less common among patients with Medicaid and least common among uninsured patients.”
They added that their findings for prostate cancer might also be associated with cancer screening, pointing out that early stage prostate cancer, which is almost always detected via screening, had a higher incidence in the military population. The situation was different with lung cancer because there was no standardized screening regimen during the time of the study.
The authors also emphasized that their study was performed before the ACA eliminated out-of-pocket costs for cancer screening for those not previously covered.
- Flanary JT, Lin J, Shriver CD, Zhu K. Cancer stage at diagnosis: Comparison of insurance status in SEER to the Department of Defense Cancer Registry. Cancer Med. 2023 Oct 30. doi: 10.1002/cam4.6655. Epub ahead of print. PMID: 37902129.