Dual-Eligibility Status: A Marker of Vulnerability and Cancer-Related Disparities

The study by Warren et al that accompanies this editorial highlights important differences in receipt of chemotherapy across subgroups of the Medicare population according to type of supplemental insurance. Not surprisingly, the findings show that dually eligible Medicare beneficiaries with select cancers were significantly less likely than Medicare beneficiaries with private insurance to receive chemotherapy, even after adjusting for patient age, race, marital status, cancer site and stage, Charlson comorbidity score, and prediagnosis nursing home status. There is a dearth of studies on cancer care and outcomes in the Medicare population by type of supplemental insurance. The authors should be commended for their innovative approach to identify private supplemental insurance status by using a unique database, the National Cancer Institute’s Patterns of Care Studies and linked SEERMedicare data. Individuals who are dually eligible for Medicare and Medicaid comprise the sickest and the poorest individuals who are covered by either Medicare or Medicaid. As a public supplemental health insurance program, Medicaid helps with payments for Medicare’s premium and cost sharing, and most dually eligible patients qualify for full Medicaid benefits, including long-term care. Dually eligible patients represent 21% of the Medicare population, but incur 31% of total Medicare costs. Compared with nondually eligible patients, a greater percentage of those with dual eligibility has cognitive or mental impairment (58% v 25%) or three of more chronic conditions (55% v 44%), reports being in fair or poor health (50% v 22%), requires assistance with at least one activity of daily living (44% v 26%), or is a resident in a long-term care facility (13% v 1%). These data, which translate into much greater complexity of health care needs in patients who are dually eligible than in those who are not, also imply greater susceptibility to receive poorly coordinated care, as reflected in the high rates of hospitalization for potentially preventable conditions. The findings in the study by Warren et al raise important questions, especially as we examine the individual factors that may have contributed to the observed disparities. First, patients with dual eligibility have low incomes, and even in countries that provide universal health care coverage, low socioeconomic status contributes to disparities in cancer care. In addition, an earlier study comparing cancer treatment patterns between dually eligible patients and non-dual lowincome Medicare beneficiaries did not show an advantage to having Medicaid as supplemental insurance. This may be a result of the fact that, although Medicaid reduces financial barriers to health services, at least to some extent, there remain many types of barriers, including access to specialist care. Indeed, as noted by Warren et al, low levels of reimbursement imply less willingness by physicians to treat Medicaid patients. Second, greater complexity of health care needs implies greater difficulty in navigating a fragmented health care system, and a higher likelihood of receiving disparate care, especially when coupled with poor psychosocial support. Hence, the authors rightly highlight the importance of patient navigators, particularly with the expansion of the Medicaid population, as expected with the Affordable Care Act. Just as important, a more complex clinical presentation reflects difficulties in clinical decision making, especially given the significant lack of information on the safety and efficacy of cancer treatment in older and/or frail patients. In fact, because care guidelines are developed mostly from clinical trials in which older and sicker patients are underrepresented, treatment recommendations are made on the basis of data from younger and healthier patients. Warren et al adjust for both comorbidities and nursing home status, but not for claims-based measures for disability status, as proposed by Davidoff et al, to approximate the Eastern Cooperative Oncology Group (ECOG) performance status. This would have allowed for a more nuanced approach to risk adjustment. Indeed, as shown recently, disability status was a significant independent predictor of cancer-directed treatment, although accounting for it did not improve model fit. In addition, findings from an earlier study on patients with cancer receiving home health care showed the importance of accounting for functional limitations and geriatric syndromes, in addition to chronic conditions, when studying patterns of cancer treatment and survival in older adults. Thus, a lower rate of chemotherapy in dually eligible patients may well reflect a heightened level of patient vulnerability and a greater reluctance on the part of clinicians to provide care according to guidelines, possibly to avoid potential chemotoxicity and decline. Moving forward, our approach to address disparities needs to be multipronged, focusing on patient care as well as on care and payment models that improve access to better coordinated care. First, the advances made thus far, along with ongoing research in geriatric oncology, will help clinicians to better discern between patients who will tolerate treatment and those who are more likely to experience decline as a result of cancer treatment. This will require the design of clinical JOURNAL OF CLINICAL ONCOLOGY E D I T O R I A L VOLUME 33 NUMBER 4 FEBRUARY 1 2015