Abstract PR07: Primary care utilization, late-stage diagnosis, and timeliness of treatment among Medicaid cancer patients: Early signals following the ACA expansion
Authors: Tsui Jennifer , DeLia Derek , Nova Jose , David Rotter , Aishwarya Kulkarni , Kitaw Demissie , Antoinette Stroup , Cantor Joel C. 
Published: February 2019

Background: Low-income and racial/ethnic minority cancer patients in the United States, particularly those with Medicaid coverage, are more likely to be diagnosed with later-stage cancer and experience worse survival compared to other groups. Recent national and state Medicaid policy initiatives, including the Medicaid eligibility expansion, aim to increase access to care, improve quality, and reduce costs. It is unclear, however, whether these non-cancer specific system-level efforts will have an impact on cancer care quality for Medicaid-insured patients. Currently, few cancer-specific analyses are available from early Medicaid redesign implementation periods (2012 and beyond) to inform possible care improvement strategies for vulnerable cancer patients.

Methods: Through a recent linkage of New Jersey State Cancer Registry (NJSCR), one of twenty SEER regions, and Medicaid claims/encounter/enrollment data, we examined the effect of primary care (PC) utilization on late-stage diagnosis (stage III/IV) and treatment delays for breast (BC), colorectal (CRC), or invasive cervical cancer (ICC) diagnosed from 2012-2014. We compared late-stage diagnosis and treatment delays (&gt; 90 days) by PC utilization (one or more visits 2-12 months prior to diagnosis), Medicaid-related factors (eligibility category, enrollment days prediagnosis, coverage gaps, managed care enrollment), and tumor and demographic characteristics. Adjusted logistic regression models were used to identify factors independently associated with improved timeliness of treatment and late-stage disease.

Results: A total of 1,919 BC, 1,068 CRC, and 256 ICC non-elderly, Medicaid-insured adults were identified in the linked dataset. Nearly half of cancer patients (49%) in the linked cohort were African American or Hispanic. Compared to non-Medicaid cases, significantly higher proportions of linked Medicaid cases were diagnosed with later-stage disease (BC: 21% vs. 10%, p&lt;0.001; CRC: 49% vs. 42%, p&lt;0.001; ICC: 40% vs. 28%, p 0.04) and experienced longer than 90 days to first treatment (All cases: 22% vs 16%, p&lt; 0.001). For patients enrolled in a managed care plan (67%), the proportion of late-stage cases varied significantly from 38% to 54% by plan (p&lt;0.001). Only 26% of Medicaid cancer patients had 1 or more PC visits prediagnosis. In adjusted models, Medicaid patients with no PC visits (OR 2.13, 95% CI 1.63-2.77), enrolled in Medicaid ≤ 3 months prediagnosis (OR 1.50, 95% CI 1.20-1.88), or were FFS for the majority of their enrolled days in the year prior to diagnosis were more likely to have late-stage cancer. In cancer site-specific models, Medicaid patients diagnosed with CRC during the expansion year (2014 vs 2012-2013) were more likely to have late-stage disease (OR 2.05, 95% CI 1.42-2.93). Not having a PC visit was also significantly associated with treatment delays (OR 2.71, 95% CI 1.67-4.40).

Conclusions: These findings indicate that Medicaid cancer patients diagnosed in the early ACA implementation period continue to be composed of significantly higher proportions of later-stage cases, thus requiring more aggressive treatment, leading to potential complications, worse outcomes, and higher overall costs of care. Targeted strategies to improve continuity of care and access to primary care within safety-net settings prior to a cancer diagnosis are needed to reduce late-stage cancer burden in this population. More detailed monitoring of cancer-related quality metrics across managed care organizations may also be warranted. Cancer care providers must also plan for high levels of late-stage diagnosis among newly enrolled Medicaid patients with cancer.

Citation Format: Jennifer Tsui, Derek DeLia, Jose Nova, Rotter David, Kulkarni Aishwarya, Demissie Kitaw, Stroup Antoinette, Joel C. Cantor. Primary care utilization, late-stage diagnosis, and timeliness of treatment among Medicaid cancer patients: Early signals following the ACA expansion [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr PR07.