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The American Journal of Managed Care June 2014
Comparison Between Guideline-Preferred and Nonpreferred First-Line HIV Antiretroviral Therapy
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Martin Zalesak, MD, PhD; Joyce S. Greenbaum, BA; Joshua T. Cohen, PhD; Fotios Kokkotos, PhD; Adam Lustig, MS; Peter J. Neumann, ScD; Daryl Pritchard, PhD; Jeffrey Stewart, BA; and Robert W. Dubois, MD
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Health Insurance and Breast-Conserving Surgery With Radiation Treatment
Askal Ayalew Ali, MA; Hong Xiao, PhD; and Gebre-Egziabher Kiros, PhD
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Ateev Mehrotra, MD; Ruopeng An, PhD; Deepak N. Patel, MBBS; and Roland Sturm, PhD
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Gregory B. Steinberg, MB, BCh; Bruce W. Church, PhD; Carol J. McCall, FSA, MAAA; Adam B. Scott, MBA; and Brian P. Kalis, MBA
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Abby Swanson Kazley, PhD; Annie N. Simpson, PhD; Kit N. Simpson, DPH; and Ron Teufel, MD
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Removing a Constraint on Hospital Utilization: A Natural Experiment in Maryland
Noah S. Kalman, MD; Bradley G. Hammill, MS; Robert B. Murray, MA, MBA; and Kevin A. Schulman, MD
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A Systematic Review of Value-Based Insurance Design in Chronic Diseases
Karen L. Tang, MD; Lianne Barnieh, PhD; Bikaramjit Mann, MD; Fiona Clement, PhD; David J.T. Campbell, MD, MSc; Brenda R. Hemmelgarn, MD, PhD; Marcello Tonelli, MD, SM; Diane Lorenzetti, MLS; and Braden J. Manns, MD, MSc

Health Insurance and Breast-Conserving Surgery With Radiation Treatment

Askal Ayalew Ali, MA; Hong Xiao, PhD; and Gebre-Egziabher Kiros, PhD
Type of health insurance plays a significant role in the likelihood of receiving the recommended treatment among women diagnosed with early-stage breast cancer.
In the privately insured and Medicare-insured groups, compared with married women, being single was significantly associated with less utilization of BCS with RT; divorced women and widows did not significantly differ from married women across all health insurance types. Financial considerations35 related to the amount of copay and reimbursement schedules among single women, and better access to social support and social networks21 among married women, are likely to contribute to the differences between single and married women in using BCS with RT in the privately insured and Medicare groups.

The most provocative findings of this study were that race/ethnicity and poverty were unique significant factors among Medicaid-insured women. Among women insured by Medicaid, non-Hispanic black women were more likely to receive the recommended treatment compared with non-Hispanic white women. In addition, among the same group of women, an increase in poverty rate was associated with the use of the recommended treatment. Additional thorough analyses were done to be sure that this finding was not related to some issues about the data and to get some insights behind the unexpected findings concerning the effects of race/ethnicity and poverty among women insured by Medicaid. Among Medicaid-insured women, the average age of non-Hispanic white and non- Hispanic black women were similar. Examination of the time trends in the receipt of the recommended treatment using year of diagnosis by race/ethnicity in the period of 1997 to 2002 showed no change for 1 particular group. Interaction effects of race/ethnicity by age, poverty level, and education were not significant. Excluding either of the census tract variables poverty or education from the models did not change the ORs in any significant manner. Hence, among women insured by Medicaid, it does not appear that the finding that non-Hispanic black patients were more likely to use BCS with RT compared with non-Hispanic white women is an artifact of some model misspecification. Our result is also similar to a study by Koehlmoos28 which reported that non-Hispanic black patients on Medicaid in Florida in 2001 had the highest rate of RT use. We are unsure why non-Hispanic black women and residents in neighborhoods with a high percentage of poor people were associated with an increased likelihood of receiving the recommended treatment. It is possible that interventions that targeted non-Hispanic black residents and poor neighborhoods or low socioeconomic classes regarding early breast cancer diagnosis and treatment during or before the study period may have created an informed community that is more likely to seek the recommended treatment. Government and non-governmental programs and interventions that aim to reduce racial/ ethnic disparities in breast cancer mortality by targeting minorities and women from low socioeconomic status may have contributed toward closing or surpassing the racial/ethnic gap in cancer treatment among Medicaidinsured women by creating awareness and disseminating vital information about the importance of early cancer screening and treatment. For example, the National Breast and Cervical Cancer Early Detection Program that was created in response to the Breast and Cervical Cancer Mortality Prevention Act of 1990 and administered by the CDC funds the Florida Breast and Cervical Cancer Early Detection Program (FBCCEDP).38 Through funding from the CDC, the FBCCEDP is administered via the state Medicaid program and has provided breast cancer screening and diagnostic services since 1994. Since mid-2001, the program has been providing paid breast and cervical cancer treatment through Medicaid for eligible women.38 As this funding is administered via state Medicaid programs, including Florida, this program is hopefully having a significant effect among minorities and low-income women in expanding early breast cancer screening and treatment services. It is also expected that the ACA will significantly expand the health insurance coverage of Americans regardless of pre-existing conditions and hence provide access to low-income women to get early screening and recommended treatments without delay.

Two separate studies6,37 have analyzed Medicaidinsured data separately and both have documented the ORs of black versus white patients in the receipt of BCS with RT. Bradley, Given, and Roberts7 reported that among women who were insured by Medicaid, black women were more likely to have BCS for cancer (OR = 1.63, 95% CI, 1.33-1.98) than white women. The comparison for BCS with RT was not significant (OR = 1.07, 95% CI, 0.82-1.37), although black women were 7% more likely to receive BCS with RT compared with white women. A study by Kimmick and colleagues37 also reported a nonsignificant difference in the receipt of BCS with RT (OR = 0.75, 95% CI, 0.40-1.40) between black and white patients in the use of BCS with RT. Consequently, racial/ethnic differences in the receipt of recommended treatment requires further investigation because longer waiting time to receive an appropriate treatment, including delays in getting timely radiation, were documented to be more prevalent among minority women and women of low socioeconomic status.39

Patterns of BCS With RT

BCS in combination with RT is the recommended treatment for early-stage breast cancer. Still, there is a concern that use of mastectomy in the United States has been increasing in the past 10 years.28,30 This is particularly alarming in an era where individualized medicine and patient-oriented decision making have been accepted as appropriate models of care. The increased trend in the use of mastectomy raises several questions, including whether accurate information has been communicated to patients. It is crucial to educate patients earlier about the pros and cons of each treatment option and to develop strategies that help to communicate available treatment choices to women and their families facing the stress of a new cancer diagnosis. BCS with RT rather than mastectomy is a form of individualized care that provides local control and survival equal to those seen after mastectomy, and an increasing body of evidence suggests that it is the biology of the cancer rather than the type of local therapy that determines risk of local recurrence, whether treated with mastectomy or BCS with RT.17

It is not easy to predict how recently passed laws, especially the ACA, and new advances in radiation technology developed to treat early-stage breast cancer will affect surgical treatment for affected women. With recent advances in radiation technology and novel treatment approaches including targeted and shorter treatments, one may expect that the patterns of early-stage breast cancer treatment will trend toward receiving the recommended treatment. Over the past 2 decades, evidence from several randomized trials have shown that women diagnosed with early-stage breast cancer who underwent BCS with RT had equivalent overall survival rates compared with women who underwent mastectomy with the advantage that breast tissue could safely be preserved.27,30,40 Additional advantages of BCS with RT are the provision of short-term physical functioning and better quality of life while minimizing complications. 27 However, there has been a concern about the rate of local recurrence after receiving BCS with RT and concerns about the inconvenience and costs associated with daily treatments that are administered over a 3-to-6-week period. Recently, advances in modern radiation technologies such as breast imaging, and the addition of adjuvant RT as well as innovative approaches and treatment techniques to early-stage cancer treatments, have resulted in a substantial decrease in the rates of local recurrence after receiving the recommended treatment.40 In addition, RT is well-tolerated and, when delivered using modern technologies, carries a low risk of serious morbidity.

The ACA, which enables all Americans to have access to healthcare at an affordable cost, is understood to change the patterns of healthcare in the United States enormously when fully implemented. The expansion of Medicaid to cover low-income individuals and families is estimated to cover 16 million new Medicaid enrollees,33 which is very significant on its own in terms of breast cancer treatment among low-income women. Therefore, the implementation of this new law is more likely to favor more use of BCS in combination with RT, regardless of types of health insurance, by encouraging eligible or appropriate patients to receive the recommended treatment without delay. The role of physician preference is equally important to that of patient preference in earlystage breast cancer treatment choices and outcomes; however, how US healthcare reform will affect surgeons is not clear. On the one hand, an increase in the number of patients with health insurance creates more insured customers for surgeons. On the other hand, as suggested by Adepoju and colleagues,33 surgeons may not be incentivized properly for providing less-invasive procedures of equal efficacy. For example, for early-stage breast cancer treatment, surgeons are reimbursed 40% less for BCS with RT than they are for mastectomy,33 which shows reimbursement is associated with the type of surgery that is performed.

Strengths and Limitations of the Study

The strengths of our study include the following: (1) we compared surgical breast cancer treatment that was received within and between health insurance types; (2) we used multilevel modeling to account for the fact that women living in a community share common factors and exposure to treatment facilities and health services; (3) we fitted insurance-specific regression models to identify predictors that are common or unique to each type of health insurance; (4) our data cover more years than previous studies20,28 and the sample size is large enough to allow for insurance-specific analysis; and (5) in addition to age at diagnosis, we included age-squared to our models and were able to capture the nonlinear relationship between age and the likelihood of receiving the recommended treatment.

This study also has a number of limitations. First, information about radiation therapy can be underreported if treatment was delivered in a facility other than a reporting facility such as a free-standing center or a physician office. FCDS recognized this problem, and beginning in January 2003, it initiated the Florida Statewide Free- Standing Radiation Therapy Centers Cancer Case Identification Program to identify patients seen in free-standing ambulatory patient care centers using RT modalities in addition to the continued reporting of all cases of cancer diagnosed and/or treated as an inpatient or outpatient in any of the reporting facilities.

 
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