Guaranteed Healthcare

Disparities within the U. S. health care system result in serious impacts on access to care for patients with cancer at all stages from screening and prevention to treatment and survival. Access barriers further lead to disparities in the quality of care received. These concerns led the American Cancer Society to launch a national effort in 2007 calling for system reform that will provide “4 As coverage”:

Disparities within the U. S. health care system result in serious
impacts on access to care for patients with cancer at all stages from
screening and prevention to treatment and survival. Access barriers
further lead to disparities in the quality of care received. These
concerns led the American Cancer Society to launch a national effort in
2007 calling for system reform that will provide “4 As coverage”:

•  Adequate—timely access to the full range of evidence-based health care including prevention and early detection.
•  Affordable—costs are based on the person’s ability to pay.
•  Available—coverage available regardless of health status or prior claims.
•  Administratively simple—processes are easy to understand and navigate. (1) (Sack, K. Cancer society focuses its ads on the uninsured. New York Times, August 31, 2007)

Access barriers take a wide variety of forms and affect many
disadvantaged groups within the U. S. population. The single most
important aspect of access is the status of the patient’s health
insurance coverage. (2) (Siminoff, LA, Ross, L. Access and equity to cancer care in the USA: a review and assessment.
Postgrad Med J 81: 674, 2005) For all types of cancer, the uninsured
are 1.6 times more likely to die within five years compared to cancer
patients with insurance. (3) (Ward, E, Halpern, M Schrag, N et al. Association of insurance with cancer care utilization and outcomes. CA Cancer J Clin 58: 19-20, 2008) 8/1/9

The lack of health insurance is much more common among racial and
ethnic minorities than among whites. According to the U. S. Census
Bureau, when 15.9 percent of the population was uninsured in 2005, the
uninsurance rate for whites was 11.3 percent compared to 19.6 percent
for non-Hispanic blacks and 32.7 percent for Hispanics. (4) (Income, poverty, and health insurance coverage in the United States: 2005, update.)

These examples illustrate how the lack of insurance adversely impacts patients with cancer across the entire spectrum of care:
•  Women aged 40 to 64 without insurance are only half as likely to
have had a mammogram within the last two years as those with insurance.
(5) (Ibid #3)
•  One in four uninsured cancer patients delay or forego care because of cost. (6) (Ibid #3)
•  Uninsured African-American women with breast cancer have a
five-year survival rate of only 63 percent compared to 89 percent for
insured Caucasian women. (7) (Ibid # 3)
•  Cancer has become a chronic disease for the estimated 12 million
cancer survivors in this country, many of whom have co-morbidities such
as heart disease, diabetes and arthritis as well as under-recognized
and under-treated anxiety and depression. A 2008 national study found
that uninsured cancer patients were three times more likely than their
insured counterparts to have not seen health professional in the last
year, twice as likely to have no regular source of care, and five times
more likely to use the emergency room for care. (8) (Wilper, AP,
Woolhandler, S, Lasser, KE et al. A national study of chronic disease prevalence and access to care in uninsured U. S. adults. Ann Intern Med 149: 170-76, 2008)

Under-insurance is another big problem for many patients with
cancer, since many insurance policies provide little protection against
the rapidly rising costs of cancer care. Two examples illustrate the
financial burdens placed on cancer patients and their families even
when insured:

•  Despite being consistently insured, a 2006 study by the Kaiser
Family Foundation and the Harvard School of Public Health found that
almost one-half of cancer patients used up most or all of their life
savings, while 8 percent were turned away or unable to get a specific
treatment because of insurance issues and 3 percent ended up declaring
bankruptcy. (9) (Kaiser Family Foundation. Survey of families affected
by cancer shows people with and without health insurance suffer serious
financial hardships. USA Today/Kaiser Family Foundation/Harvard School of Public Health National Survey of Households Affected by Cancer, November 20, 2006)
•  Some “insurance” policies are ludicrous in the extent of their
undercoverage—one example is the limited-benefit basic cancer policy
marketed by AllState, starting at $420 a year for family “coverage”,
which pays a one-time benefit of $2,000 if diagnosed for the first time
with cancer (other than skin cancer). (10) (McQueen, MP. The shifting calculus of workplace benefits. Wall Street Journal, January 16, 2007: D1)

Do patients with cancer covered by Medicare and Medicaid fare any
better than their counterparts with or without private insurance? Here
again, their access to care falls far short of their needs. An
increasing number of physicians will not accept new patients on
Medicare or Medicaid because of low reimbursement. Medicare Advantage
plans may impose high cost burdens on patients who are referred to
out-of-network physicians and facilities for cancer care, sometimes
leading to disenrollment. (11) (Medicare Rights Center. Why consumers
disenroll from Medicare private health plans. Summer 2010) Medicaid
remains an underfunded porous safety net with many restrictions on
coverage varying from state to state. (12) (Ramirez de Arrelano, AB,
Wolfe, SM. Unsettling Scores: A Ranking of State Medicaid Programs.
Washington, D.C. Public Citizen Health Research Group, April 2007) 
Medicaid enrollees are more likely to have late-stage cancers when
diagnosed, resulting in worse outcomes. (13) (Halpern, MT, Ward, EM,
Pavluck, AL et al. Association of insurance status and ethnicity with
cancer stage at diagnosis for 12 cancer sites: A retrospective
analysis. Lancet Oncol 9 (3): 222-31, 2008) Many oncologists refuse to
provide chemotherapy for Medicaid patients in their offices due to low
reimbursement, sending them on to hospitals. (14) (Lung Cancer
Connections. Caring 4Cancer. An introduction to Medicaid. Web site accessed October 31, 2008)

Because of access barriers to care and other factors in our
market-based system of care (based as it is on ability to pay, not
medical need), the quality of care for cancer patients in our present
system leaves much to be desired for these kinds of reasons:

•  Perverse financial incentives pervade our business-oriented
health care system. Hospitals and physicians make higher revenues by
providing services that are often unnecessary, inappropriate or even
harmful. When Medicare reduced reimbursement rates for outpatient
chemotherapy drugs in 2005, oncologists switched from drugs that were
most reduced in profitability to other high-margin drugs at increased
cost but without good evidence of improved outcomes. (15) (Jacobson, M,
Earle, CC, Price, M, Newhouse, JP. How Medicare’s payment cuts for cancer chemotherapy drugs changed patterns of treatment. Health Affairs
29 (7): 1391-99, 2010)  A 2008 study by United Health found that
Procrit, a very expensive anti-anemia drug also highly remunerative to
prescribing oncologists, was being prescribed for about one-third of
patients who were not anemic at all. (16) (Culliton, BJ. Interview: Insurers and ‘targeted biologics’ for cancer: A conversation with Lee N Newcomer.
Health Affairs Web Exclusive 27 (1): W 41-W51, 2008)  More than 30
million full-body CT scans are performed each year for screening
purposes despite the lack of evidence of benefit or the approval by
the FDA or the American College of Radiology. (17) (Brenner, DJ, Hall,
EJ. Computed tomography—An increasing source of radiation exposure. N Engl J Med
357: 2277-84, 2007)  Over-screening, over-diagnosis and over-treatment
of prostate cancer are endemic in this country, without evidence of
improved outcomes. A 2009 report of a randomized ten-year trial of
76,000 American men found that widespread screening does not lower the
death rate from the disease. (18)  (Andriole, GL, Grubb, RL, Buys, SS
et al. Mortality results from a randomized prostate-cancer screening trial. N Engl J Med
online. March 18, 2009).  Dr. Peter Bach, oncologist at Sloan-Kettering
Cancer Center and former senior advisor on health care quality at the
Centers for Medicare and Medicaid Services (CMS), estimates that 30 to
40 percent of spending on cancer care is of marginal value. (19) (Bach,
P, as quoted in McNeil, C. Sticker shock sharpens focus on biologics. News. J Natl. Cancer Inst 99 (12): 911, 2007)
•  We have an industry-friendly system of deciding what services
and treatments will be covered. Coverage policies are not rigorously
evidence-based, and the use of cost-effectiveness as a criterion for
coverage decisions is vigorously opposed by industry. Many expensive
and toxic drugs are used for indications beyond FDA approval—so-called
“off label” use. In 2009, Medicare coverage of off-label cancer drugs
was expanded despite the lack of clinical evidence for effectiveness.
(20) (Abelson, R, Pollack, A. Medicare widens drugs it accepts for cancer care: More off-label uses. New York Times, January 27, 2009)
•  Quality of care breaks down at the interface between primary care
and oncology-related subspecialty care. A just-published monograph by
the National Cancer Institute documents the scope and magnitude of this
serious problem, ranging from lack of communication and collaboration
to overlapping and ambiguous roles. (National Cancer Institute.
Division of Cancer Control and Population Sciences. Toward Improving the Quality of Cancer Care: Addressing the Interfaces of Primary and Oncology-Related Subspecialty Care.
Number 40, 2010)  For the best quality of care, cancer patients need to
be followed by both groups of physicians working together in their
areas of expertise. One study of almost 15,000 survivors of colorectal
cancer, for example, found that patients followed by oncologists were
less likely to receive influenza vaccination, cervical screening and
bone densitrometry, while those followed by primary care physicians
reported less screening by colonoscopy and mammography. (21) (Earle,
CC, Neville, BA. Under-use of necessary care among cancer
survivors. Cancer 101 (8): 1712-19, 2004) Continuity of primary care
throughout the care of cancer from screening to survivorship is
essential to the best outcomes. We cannot expect subspecialists to care
for co-morbidities so common among cancer patients, and treatment
decisions often require consideration of co-morbidities, personal and
family considerations.

As is clear from the above, access and quality of care are closely
entwined and multi-dimensional. Addressing these problems is a complex
challenge since they are embedded in a dysfunctional health care
system. But that is the subject of our next post, which will consider
to what extent the new health care reform law, the Patient Protection
and Affordable Care Act of 2010, can remedy these problems.

Adapted in part from The Cancer Generation: Baby Boomers Facing a Perfect Storm, 2009, with permission of the publisher, Common Courage Press.