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Cancer screening has long been considered a worthy public health investment. Health economics offers the theoretical foundation and research methodology to understand the demand- and supply-side factors associated with screening and evaluate screening-related policies and interventions. This article provides an overview of health economic theories and methods related to cancer screening and discusses opportunities for future research. We review 2 academic disciplines most relevant to health economics research in cancer screening: applied microeconomics and decision science. We consider 3 emerging topics: cancer screening policies in national as well as local contexts, “choosing wisely” screening practices, and targeted screening efforts for vulnerable subpopulations. We also discuss the strengths and weaknesses of available data sources and opportunities for methodological research and training. Recommendations to strengthen research infrastructure include developing novel data linkage strategies, increasing access to electronic health records, establishing curriculum and training programs, promoting multidisciplinary collaborations, and enhancing research funding opportunities.

To examine the relationship between federally qualified health center (FQHC) use and hospital-based care among individuals dually enrolled in Medicare and Medicaid.Data were obtained from 2012 to 2018 Medicare claims.We modeled hospital-based care as a function of FQHC use, person-level factors, a Medicare prospective payment system (PPS) indicator, and ZIP code fixed effects. Outcomes included emergency department (ED) visits (overall and nonemergent), observation stays, hospitalizations (overall and for ambulatory care sensitive conditions), and 30-day unplanned returns. We stratified all models on the basis of eligibility and rurality.Our sample included individuals dually enrolled in Medicare and Medicaid for at least two full consecutive years, residing in a primary care service area with an FQHC. We excluded individuals without primary care visits, who died, or had end-stage renal disease.After the Medicare PPS was introduced, FQHC use in rural counties was associated with fewer ED and nonemergent ED visits per 100 person-years among both age-eligible (-14.8 [-17.5, -12.1]; -6.6 [-7.5, -5.6]) and disability-eligible duals (-11.3 [-14.4, -8.3]; -6 [-7.4, -4.6]) as well as a lower probability of observation stays (-0.8 pp age-eligible; -0.4 pp disability-eligible) and unplanned returns (-2.1 pp age-eligible; -1.9 pp disability-eligible). In urban counties, FQHC use was associated with more ED and nonemergent ED visits per 100 person-years (10.6 [8.4, 12.8]; 4.0 [2.6, 5.4]) among disability-eligible duals (a decrease of more than 60% compared with the pre-PPS period) and increases in the probability of hospitalization (1.1 pp age-eligible; 0.8 pp disability-eligible) and ACS hospitalization (0.5 pp age-eligible; 0.3 pp disability-eligible) (a decrease of roughly 50% compared with the pre-PPS period).FQHC use is associated with reductions in hospital-based care among dual enrollees after introduction of the Medicare PPS. Further research is needed to understand how FQHCs can tailor care to best serve this complex population.

State central cancer registries are an essential component of cancer surveillance and research that can be enriched through linkages to other databases. This study identified and described state central registry linkages to external data sources and assessed the potential for a more comprehensive data infrastructure with registries at its core.We identified peer-reviewed papers describing linkages to state central cancer registries in all 50 states, Washington, DC, and Puerto Rico, published between 2010 and 2020. To complement the literature review, we surveyed registrars to learn about unpublished linkages. Linkages were grouped by medical claims (public and private insurers), medical records, other registries (eg, human immunodeficiency virus/acquired immunodeficiency syndrome registries, birth certificates, screening programs), and data from specific cohorts (eg, firefighters, teachers).We identified 464 data linkages with state central cancer registries. Linkages to cohorts and other registries were most common. Registries in predominately rural states reported the fewest linkages. Most linkages are not ongoing, maintained, or available to researchers. A third of linkages reported by registrars did not result in published papers.Central cancer registries, often in collaboration with researchers, have enriched their data through linkages. These linkages demonstrate registries' ability to contribute to a data infrastructure, but a coordinated and maintained approach is needed to leverage these data for research. Sparsely populated states reported the fewest linkages, suggesting possible gaps in our knowledge about cancer in these states. Many more linkages exist than have been reported in the literature, highlighting potential opportunities to further use the data for research purposes.

Objective To evaluate the quality of a multiyear linkage between the Colorado All-Payers Claims Database (ACPD) and the Colorado Central Cancer Registry. Data sources Secondary 2012-2017 data from the APCD and the Colorado cancer registry. Study design Descriptive analysis of the proportion of cases captured by the linkage in relation to the cases reported by the registry. Data collection/extraction methods We used probabilistic linkage to combine records from both data sources for all patients diagnosed with cancer. Results We successfully linked 93% of the 146,884 patients in the registry. Approximately 63% of linked patients were perfect matches on five identifiers. Of partial matches, 81.6% were matched on four identifiers with missing or partial Social Security Numbers. The linkage rate was lower for uninsured patients at diagnosis (74.7%) or patients with private plans (89.4%) but close to 100% for Medicare and Medicaid enrollees. Most of the 29% of patients who did not have claims at the time of diagnosis were covered by private plans that may not submit claims. Conclusions APCD-registry linkages are a promising source of data to conduct population-based research from multiple payers. However, not all payers submit claims, and the quality of the data may vary by state. This article is protected by copyright. All rights reserved.

Background Safety-net hospitals serve a vital role in society by providing care for vulnerable populations. Existing data regarding oncologic outcomes of patients with colon cancer treated at safety-net hospitals are limited and variable. The objective of this study was to delineate disparities in treatment and outcomes for patients with colon cancer treated at safety-net hospitals. Methods This retrospective cohort study identified 802,304 adult patients with colon adenocarcinoma from the National Cancer Database between 2004-2016. Patients were stratified according to safety-net burden of the treating hospital as previously described. Patient, tumor, facility, and treatment characteristics were compared between groups as were operative and short-term outcomes. Cox proportional hazards regression was utilized to compare overall survival between patients treated at high, medium, and low burden hospitals. Results Patients treated at safety-net hospitals were demographically distinct and presented with more advanced disease. They were also less likely to receive surgery, adjuvant chemotherapy, negative resection margins, adequate lymphadenectomy, or a minimally invasive operative approach. On multivariate analysis adjusting for patient and tumor characteristics, survival was inferior for patients at safety-net hospitals, even for those with stage 0 (in situ) disease. Conclusion This analysis revealed inferior survival for patients with colon cancer treated at safety-net hospitals, including those without invasive cancer. These findings suggest that unmeasured population differences may confound analyses and affect survival more than provider or treatment disparities.

PURPOSE: Responses to the opioid epidemic in the United States, including efforts to monitor and limit prescriptions for noncancer pain, may be affecting patients with cancer. Oncologists' views on how the opioid epidemic may be influencing treatment of cancer-related pain are not well understood. METHODS: We conducted a multisite qualitative interview study with 26 oncologists from a mix of urban and rural practices in Western Pennsylvania. The interview guide asked about oncologists' views of and experiences in treating cancer-related pain in the context of the opioid epidemic. A multidisciplinary team conducted thematic analysis of interview transcripts to identify and refine themes related to challenges to safe and effective opioid prescribing for cancer-related pain and recommendations for improvement. RESULTS: Oncologists described three main challenges: (1) patients who receive opioids for cancer-related pain feel stigmatized by clinicians, pharmacists, and society; (2) patients with cancer-related pain fear becoming addicted, which affects their willingness to accept prescription opioids; and (3) guidelines for safe and effective opioid prescribing are often misinterpreted, leading to access issues. Suggested improvements included educational materials for patients and families, efforts to better inform prescribers and the public about safe and appropriate uses of opioids for cancer-related pain, and additional support from pain and/or palliative care specialists. CONCLUSION: Challenges to safe and effective opioid prescribing for cancer-related pain include opioid stigma and access barriers. Interventions that address opioid stigma and provide additional resources for clinicians navigating complex opioid prescribing guidelines may help to optimize cancer pain treatment.

Study objective More than 17 million people have gained health insurance coverage through the Patient Protection and Affordable Care Act’s Medicaid expansion. Few studies have examined heterogeneity within the Medicaid expansion population. We do so based on time-varying patterns of emergency department (ED) and ambulatory care use, and characterize diagnoses associated with ED and ambulatory care visits to evaluate whether certain diagnoses predominate in individual trajectories. Method We used group-based multitrajectory modeling to jointly estimate trajectories of ambulatory care and ED utilization in the first 12 months of enrollment among Pennsylvania Medicaid expansion enrollees from 2015 to 2017. Results Among 601,877 expansion enrollees, we identified 6 distinct groups based on joint trajectories of ED and ambulatory care use. Mean ED use varied across groups from 3.4 to 48.7 visits per 100 enrollees in the first month and between 2.8 and 44.0 visits per 100 enrollees in month 12. Mean ambulatory visit rates varied from 0.0 to 179 visits per 100 enrollees in the first month and from 0.0 to 274 visits in month 12. Rates of ED visits did not change over time, but rates of ambulatory care visits increased by at least 50% among 4 groups during the study period. Groups varied on chronic condition diagnoses, including mental health and substance use disorders, as well as diagnoses associated with ambulatory care visits. Conclusion We found substantial variation in rates of ED and ambulatory care use across empirically defined subgroups of Medicaid expansion enrollees. We also identified heterogeneity among the diagnoses associated with these visits. This data-driven approach may be used to target resources to encourage efficient use of ED services and support engagement with ambulatory care clinicians.

ImportancePrior research has reported undertreatment among patients with cancer who are insured by Medicaid, but this finding may be due, in part, to incomplete data in cancer registries.ObjectiveTo compare disparities in radiation and hormone therapy between women with breast cancer covered by Medicaid and those with private insurance using the Colorado Central Cancer Registry (CCCR) and CCCR data supplemented with All Payer Claims Data (APCD).Design, Setting, and ParticipantsThis observational cohort study included women aged 21 to 63 years who received breast cancer surgery. We linked the CCCR and Colorado APCD to identify Medicaid and privately insured women who were newly diagnosed with invasive, nonmetastatic breast cancer between January 1, 2012, and December 31, 2017. In the radiation treatment analysis, we narrowed the sample to women who received breast-conserving surgery (Medicaid, n = 1408; private, n = 1984) and in the hormone therapy analysis, we selected women who were hormone-receptor positive (Medicaid, n = 1156; private, n = 1667).Main Outcomes and MeasuresWe used logistic regression to estimate the likelihood of treatment within 12 months to assess whether the results varied between data sources.ResultsThere were 3392 and 2823 participants in the radiation and hormone therapy cohorts, respectively. The mean (SD) age was 51.71 (8.30) years in the radiation therapy cohort, and 52.00 (8.16) years in the hormone therapy cohort. Among the participants, there were 140 (4%) and 105 (4%) who were Black non-Hispanic, 499 (15%) and 406 (14%) who were Hispanic, 2602 (77%) and 2190 (78%) were White, and 151 (4%) and 122 (4%) were other/unknown in the radiation and hormone therapy cohorts, respectively. A higher percentage of women were aged 50 years or younger in the Medicaid samples (40% vs 34% in the privately insured sample) and identified as non-Hispanic Black (about 7%) or Hispanic (approximately 24%). Treatment was underreported in both sources, but to a lesser extent in the APCD (2.5% and 2.0% for Medicaid and private insurance, respectively) compared with CCCR (19.5% and 13.3% for Medicaid and private insurance, respectively). Using CCCR data, Women with Medicaid insurance were 4 (95% CI, −8 to −1; P = .02) and 10 (95% CI, −14 to −6; P Conclusions and RelevanceAmong women with breast cancer covered by Medicaid vs private insurance, cancer treatment disparities may be overestimated if based solely on cancer registry data.

ImportanceDisruptions in cancer surgery during the COVID-19 pandemic led to widespread deferrals and cancellations, creating a surgical backlog that presents a challenge for health care institutions moving into the recovery phase of the pandemic.ObjectiveTo describe patterns in surgical volume and postoperative length of stay for major urologic cancer surgery during the COVID-19 pandemic.Design, Setting, and ParticipantsThis cohort study identified 24 001 patients 18 years or older from the Pennsylvania Health Care Cost Containment Council database with kidney cancer, prostate cancer, or bladder cancer who received a radical nephrectomy, partial nephrectomy, radical prostatectomy, or radical cystectomy between the first quarter (Q1) of 2016 and Q2 of 2021. Postoperative length of stay and adjusted surgical volumes were compared before and during the COVID-19 pandemic.Main Outcomes and MeasuresThe primary outcome was adjusted surgical volume for radical and partial nephrectomy, radical prostatectomy, and radical cystectomy during the COVID-19 pandemic. The secondary outcome was postoperative length of stay.ResultsA total of 24 001 patients (mean [SD] age, 63.1 [9.4] years; 3522 women [15%], 19 845 White patients [83%], 17 896 living in urban areas [75%]) received major urologic cancer surgery between Q1 of 2016 and Q2 of 2021. Of these, 4896 radical nephrectomy, 3508 partial nephrectomy, 13 327 radical prostatectomy, and 2270 radical cystectomy surgical procedures were performed. There were no statistically significant differences in patient age, sex, race, ethnicity, insurance status, urban or rural status, or Elixhauser Comorbidity Index scores between patients who received surgery before and patients who received surgery during the pandemic. For partial nephrectomy, a baseline of 168 surgeries per quarter decreased to 137 surgeries per quarter in Q2 and Q3 of 2020. For radical prostatectomy, a baseline of 644 surgeries per quarter decreased to 527 surgeries per quarter in Q2 and Q3 of 2020. However, the likelihood of receiving radical nephrectomy (odds ratio [OR], 1.00; 95% CI, 0.78-1.28), partial nephrectomy (OR, 0.99; 95% CI, 0.77-1.27), radical prostatectomy (OR, 0.85; 95% CI, 0.22-3.22), or radical cystectomy (OR, 0.69; 95% CI, 0.31-1.53) was unchanged. Length of stay for partial nephrectomy decreased from baseline by a mean of 0.7 days (95% CI, −1.2 to −0.2 days) during the pandemic.Conclusions and RelevanceThis cohort study suggests that partial nephrectomy and radical prostatectomy surgical volume decreased during the peak waves of COVID-19, as did postoperative length of stay for partial nephrectomy.

Background: This study sought to determine if increased access to health insurance following the Affordable Care Act (ACA) resulted in an increased proportion of early-stage breast cancer diagnosis among women in Pennsylvania, particularly minorities, rural residents, and those of lower socioeconomic status. Materials and Methods: Data on 35,735 breast cancer cases among women 50–64 and 68–74 years of age in Pennsylvania between 2010 and 2016 were extracted from the Pennsylvania Cancer Registry and analyzed in 2019. Women 50–64 years of age were subdivided by race/ethnicity, area of residence, and socioeconomic status as measured by area deprivation index (ADI). We compared the proportions of early-stage breast cancer diagnosis pre-ACA (2010–2013) and post-ACA (2014–2016) for all women 50–64 years of age to all women 68–74 years of age. This comparison was also made between paired sociodemographic subgroups for women 50–64 years of age. Multivariable logistic regression models were constructed to assess how race, area of residence, ADI, and primary care physician (PCP) density interacted to impact breast cancer diagnosis post-ACA. Results: The proportion of early-stage breast cancer diagnosis increased by 1.71% post-ACA among women 50–64 years of age (p

Background: This analysis describes associations between area deprivation and patient-reported outcomes among patients with advanced cancer. Methods: This is a cross-sectional analysis of baseline data from a multisite primary palliative care intervention trial. Participants were adult patients with advanced cancer. Patient-level area deprivation scores were calculated using the Area Deprivation Index (ADI). Quality of life and symptom burden were measured. Uni- and multivariate regressions estimated associations between area deprivation and outcomes of interest. Results: Among 672 patients, ∼0.5 (54%) were women and most (94%) were Caucasian. Mean age was 69.3±10.2 years. Lung (36%), breast (13%), and colon (10%) were the most common malignancies. Mean ADI was 64.0, scale of 1 (low)–100 (high). In unadjusted univariate analysis, Functional Assessment of Cancer Therapy—Palliative (p=0.002), Edmonton Symptom Assessment Scale (p=0.025) and the Hospital Anxiety and Depression Scale anxiety (p=0.003) and depression (p=0.029) scores were significantly associated with residence in more deprived areas (p=0.003). In multivariate analysis, controlling for patient-level factors, living in more deprived areas was associated with more anxiety (p=0.019). Conclusion: Higher ADI was associated with higher levels of anxiety among patients with advanced cancer. Geographic information could assist clinicians with providing geographically influenced social support strategies.

Background: This study examines the association between Medicaid enrollment, including through the National Breast and Cervical Cancer Early Detection Program (NBCCEDP), and distant stage for three screening-amenable cancers: breast, cervical, and colorectal. Methods: We use the Surveillance, Epidemiology, and End Results Cancer Registry linked with Medicaid enrollment data to compare patients who were Medicaid insured with patients who were not Medicaid insured. We estimate the likelihood of distant stage at diagnosis using logistic regression. Results: Medicaid enrollment following diagnosis was associated with the highest likelihood of distant stage. Medicaid enrollment through NBCCEDP did not mitigate the likelihood of distant stage disease relative to Medicaid enrollment prior to diagnosis. Non-Hispanic Black patients had a greater likelihood of distant stage breast and colorectal cancer. Residing in higher socioeconomic areas was associated with a lower likelihood of distant stage breast cancer. Conclusions: Medicaid enrollment prior to diagnosis is associated with a lower likelihood of distant stage in screen amenable cancers but does not fully ameliorate disparities. Impact: Our study highlights the importance of health insurance coverage prior to diagnosis and demonstrates that while targeted programs such as the NBCCEDP provide critical access to screening, they are not a substitute for comprehensive insurance coverage.

Retention in HIV care remains a national challenge. Addressing structural barriers to care may improve retention. We examined the association between physician reimbursement and retention in HIV care, including racial differences.We integrated person-level administrative claims (Medicaid Analytic eXtract, 2008-2012), state Medicaid-to-Medicare physician fee ratios (Urban Institute, 2008, 2012), and county characteristics for 15 Southern states plus District of Columbia. The fee ratio is a standardized measure of physician reimbursement capturing Medicaid relative to Medicare physician reimbursement across states. Generalized estimating equations assessed the association between the fee ratio and retention (≥2 care markers ≥90 days apart in a calendar year). Stratified analyses assessed racial differences. We varied definitions of retention, subsamples, and definitions of the fee ratio, including the fee ratio at parity.The sample included 55,237 adult Medicaid enrollees with HIV (179,002 enrollee years). Enrollees were retained in HIV care for 76.6% of their enrollment years, with retention lower among non-Hispanic Black (76.1%) versus non-Hispanic White enrollees (81.3%, P0.001). A 10-percentage point increase in physician reimbursement was associated with 4% increased odds of retention (adjusted odds ratio 1.04, 95% confidence interval: 1.01 to 1.07). In stratified analyses, the positive, significant association occurred among non-Hispanic Black (1.08, 1.05-1.12) but not non-Hispanic White enrollees (0.87, 0.74-1.02). Findings were robust across sensitivity analyses. When the fee ratio reached parity, predicted retention increased significantly overall and for non-Hispanic Black enrollees.Higher physician reimbursement may improve retention in HIV care, particularly among non-Hispanic Black individuals, and could be a mechanism to promote health equity.

For many low-income Medicare beneficiaries, Medicaid provides important supplemental insurance that covers out-of-pocket costs and additional benefits. We examine whether Medicaid participation by low-income adults age 65 and up increased as a result of Medicaid expansions to working-age adults under the Affordable Care Act (ACA). Previous literature documents so-called “welcome mat” effects in other populations but has not explicitly studied older persons dually eligible for Medicare and Medicaid. We extend this literature by estimating models of Medicaid participation among persons age 65 and up using American Community Survey data from 2010 to 2017 and state variation in ACA Medicaid expansions. We find that Medicaid expansions to working-age adults increased Medicaid participation among low-income older adults by 1.8 percentage points (4.4 percent). We also find evidence of an “on-ramp” effect; that is, low-income Medicare beneficiaries residing in expansion states who were young enough to gain coverage under the 2014 ACA Medicaid expansions before aging into Medicare were 4 percentage points (9.5 percent) more likely to have dual Medicaid coverage relative to similar individuals who either turned 65 before the 2014 expansions or resided in non-expansion states. This on-ramp effect is an important mechanism behind welcome mat effects among some older adults.

Background Human immunodeficiency virus (HIV)–experienced clinicians are critical for positive outcomes along the HIV care continuum. However, access to HIV-experienced clinicians may be limited, particularly in nonmetropolitan areas, where HIV is increasing. We examined HIV clinician workforce capacity, focusing on HIV experience and urban–rural differences, in the Southern United States. Methods We used Medicaid claims and clinician characteristics (Medicaid Analytic eXtract [MAX] and MAX Provider Characteristics, 2009–2011), county-level rurality (National Center for Health Statistics, 2013), and diagnosed HIV cases (AIDSVu, 2014) to assess HIV clinician capacity in 14 states. We assumed that clinicians accepting Medicaid approximated the region’s HIV workforce, since three-quarters of clinicians accept Medicaid insurance. HIV-experienced clinicians were defined as those providing care to ≥ 10 Medicaid enrollees over 3 years. We assessed HIV workforce capacity with county-level clinician-to-population ratios, using Wilcoxon-Mann-Whitney tests to compare urban–rural differences. Results We identified 5012 clinicians providing routine HIV management, of whom 28% were HIV-experienced. HIV-experienced clinicians were more likely to specialize in infectious diseases (48% vs 6%, P Conclusions Significant urban–rural disparities exist in HIV-experienced workforce capacity for communities in the Southern United States. Policies to improve equity in access to HIV-experienced clinical care for both urban and rural communities are urgently needed.

Objectives This study investigated the relationship between state Medicaid co-payment policies and cancer screening for Medicaid-enrolled women. Study design Cross-sectional analysis of administrative claims and enrollment data. Methods Our data included Medicaid Analytic eXtract (MAX) outpatient claims files across 43 states in 2003, 2008, and 2010, the years for which both MAX data and state cost-sharing data were available. Data on enrollee demographics and screening services from enrollment and claims files were merged with state-year data on co-payment policies and county-level controls from the Area Health Resources File. Participants were nonelderly, nondisabled, nonpregnant women in the recommended age range for each screening service (50-64 years for mammograms; 21-64 years for Pap tests) enrolled in fee-for-service Medicaid. The main independent variable is whether an enrollee faced cost sharing for preventive services. We examined 3 categories of cost sharing: co-payments for all visits, including for preventive services; co-payments for outpatient visits but waived for preventive services; and no co-payments. The main outcome measure was receipt of mammogram or Pap test within a 12-month period. Results Medicaid enrollees with co-payments for preventive services were less likely to receive both screening mammograms and Pap tests than enrollees in states not requiring cost sharing for preventive services. Conclusions Co-payments for preventive services discourage breast and cervical cancer screening among Medicaid enrollees. The effect is larger for breast cancer screening, which is costlier and requires an additional visit. Considering this evidence, cost sharing for preventive services may lead to adverse health consequences and greater long-term costs.

Compared to urban populations, rural populations rank poorly on numerous health indicators, including cancer outcomes. We examined the relationship of rural residence with stage and treatment among patients with prostate cancer, the second most common malignancy in men.Using the Pennsylvania Cancer Registry we identified all men diagnosed with prostate cancer between 2009 and 2015. Patients were classified as residing in a rural area, a large town or an urban area using the Rural-Urban Commuting Area classification. Our primary outcomes included indicators of prostate cancer treatment and treatment types but we also examined disease stage and mortality. We used the chi-square tests to assess differences between groups and estimated multivariable logistic regression models to assess the association between rural residence and treatment.We identified 51,024 men diagnosed with localized or metastatic prostate cancer between 2009 and 2015. The overall incidence of prostate cancer decreased during the study period from 416 to 304/100,000 men while the incidence of metastatic disease increased from 336 to 538/100,000. Rural residents were less likely to undergo treatment than urban residents even when stratified by low, intermediate and high risk disease (aOR 0.77, 95% CI 0.64-0.91; aOR 0.71, 95% CI 0.58-0.89; and aOR 0.68, 95% CI 0.53-0.89, respectively). Rural status did not affect the receipt of radiation therapy compared to other treatment types.Prostate cancer treatment differs between urban and rural residents. Rural residents are less likely to receive treatment even when stratified by disease risk.

INTRODUCTION AND OBJECTIVE:An important consequence of the COVID-19 pandemic was a precipitous decline in elective outpatient encounters such as cancer screening. It is particularly important to ex...

INTRODUCTION AND OBJECTIVE:Radical cystectomy is associated with one of the highest readmission rates of any surgery, hovering around 25%. Readmissions occur both at the hospital at which patients ...

Fewer than 60% of Americans diagnosed with HIV are retained in care, with racial disparities. Addressing structural barriers to care may improve outcomes along the HIV care continuum, such as retention, and promote health equity. We examined the relationship between physician reimbursement and retention in HIV care, including racial differences. Data included person-level demographic information and administrative claims (Medicaid Analytic eXtract, 2008-12), state Medicaid-to-Medicare fee ratios (Urban Institute, 2008, 2012), and county characteristics for 15 Southern states plus District of Columbia. The fee ratio is a standardized measure of physician reimbursement capturing state variation in Medicaid relative to Medicare physician reimbursement, which is largely consistent across states. We used generalized estimating equations to assess the association between physician reimbursement ratio and retention in HIV care (≥2 claims for physician visits, antiretroviral prescriptions, or CD4 or HIV RNA viral load tests ≥90 days apart in a calendar-year). We also evaluated an increase in the fee ratio to parity, where Medicaid and Medicare physician reimbursement are equal. Stratified analysis assessed racial differences. The sample included 55,237 adult Medicaid enrollees living with HIV (179,002 enrollee-years). Enrollees were retained in HIV care for approximately three-quarters (76.8%) of their enrollment-years, with retention lower among non-Hispanic Black (76.2%) versus non-Hispanic White (81.3%, p

LAY SUMMARY Cancer has substantial economic impacts for patients, their families and/or caregivers, employers, and the health care system. However, there is only limited understanding of how economic issues can affect access to cancer care services and the receipt of high-quality cancer care. Health economics research in cancer is particularly timely due to the large and increasing number of patients with cancer and cancer survivors, but there are many factors that may create barriers to performing cancer health economics research. This commentary has identified important topics and questions in cancer health economics research and will assist in the development of this critical field.

Background This study examines the expansion of health insurance coverage in Massachusetts under state health reform as a natural experiment to investigate whether expanded insurance coverage reduced the likelihood of advanced stage colorectal cancer (CRC) and breast cancer (BCA) diagnosis. Methods Our study populations include CRC or BCA patients aged 50-64 years observed in the Massachusetts Cancer Registry and Surveillance Epidemiology and End Results (SEER) registries for 2001-2013. We use difference-in-differences regression models to estimate changes in the likelihood of advanced stage diagnosis after Massachusetts health reform, relative to comparison states without expanded coverage (Connecticut, New Jersey, Georgia, Kentucky, and Michigan). Results We find some suggestive evidence of a decline in the proportion of advanced stage CRC cases. Approximately half of the CRC patients in Massachusetts and control states were diagnosed at advanced stages pre reform; there was a 2 percentage-point increase in this proportion across control states and slight decline in Massachusetts post reform. Adjusted difference-in-difference estimates suggest a 3.4 percentage-point (P=0.005) or 7% decline, relative to Massachusetts baseline, in the likelihood of advanced stage diagnosis after the reform in Massachusetts, though this result is sensitive to years included in the analysis. We did not find a significant effect of reform on BCA stage at diagnosis. Conclusions The decline in the likelihood of advanced stage CRC diagnosis after Massachusetts health reform may suggest improvements in access to health care and CRC screening. Similar declines were not observed for BCA, perhaps due to established BCA-specific safety-net programs.

Objective To examine between-state differences in the socioeconomic and health characteristics of Medicare beneficiaries dually enrolled in Medicaid, focusing on characteristics not observable to or used by policy makers for risk adjustment. Data source 2010-2013 Medicare Current Beneficiary Survey. Study design Retrospective analyses of survey-reported health and socioeconomic status (SES) measures among low-income Medicare beneficiaries and low-income dual enrollees. We used hierarchical linear regression models with state random effects to estimate the between-state variation in respondent characteristics and linear models to compare the characteristics of dual enrollees by state Medicaid policies. Principal findings Between-state differences in health and socioeconomic risk among low-income Medicare beneficiaries, as measured by the coefficient of variation, ranged from 17.5 percent for an index of socioeconomic risk to 20.3 percent for an index of health risk. Between-state differences were comparable among the subset of low-income beneficiaries dually enrolled in Medicare and Medicaid. Dual enrollees with incomes below the Federal Poverty Level were in better health and had higher SES in states that offered Medicaid to individuals with relatively higher incomes. Duals' average incomes were higher in states with Medically Needy programs. Conclusions Characteristics of dual enrollees differ substantially across states, reflecting differences in states' low-income Medicare populations and Medicaid policies. Risk-adjustment methods using dual enrollment to proxy for poor health and low SES should account for this state-level heterogeneity.

Background: In January 2015, Pennsylvania expanded Medicaid eligibility to all legally present adults in the Commonwealth of Pennsylvania with household incomes up to 138 percent of the federal poverty level under the Affordable Care Act. Pennsylvania is the most populous state to expand Medicaid that did not previously have a large expansion of the program to adults, making it an ideal setting to study the impacts of the program. By March 2017, an estimated 716,000 people had enrolled in Pennsylvania's expanded Medicaid program. We aim to determine how Pennsylvania's Medicaid expansion has impacted breast cancer diagnosis and treatment in the state. Methods: The Pennsylvania Cancer Registry was queried for all women aged 18 to 64 years newly diagnosed with breast cancer between 2007 and 2015. Demographic, tumor, and treatment characteristics were evaluated for each year during this time span. In order to assess the impact that Medicaid expansion had on these variables, they were compared for the years 2007 to 2014 (before Medicaid expansion) and the year 2015 (after). Results: Between 2007 and 2015, 49,606 cases of invasive breast cancer were diagnosed among women aged 18-64 and residing in the state of Pennsylvania, 43,920 of which were diagnosed and treated between 2007 and 2014, and 5,686 of which were diagnosed and treated in 2015. Initial analysis indicates that more women were diagnosed with localized breast cancer (SEER summary stage 1) following Medicaid expansion in 2015 compared to the period of 2007 to 2014 (63.07% v. 60.62%, p = 0.0004). Meanwhile, the proportion of women diagnosed with metastatic breast cancer did not change before and after Medicaid expansion (6.52% v. 6.86%, p = 0.3298). Subsequent analysis will assess changes in treatment outcomes including time to treatment and receipt of guideline-concordant care. Conclusion: The expansion of Medicaid in Pennsylvania in 2015 under the Affordable Care Act resulted in an increase in the proportion of localized (SEER summary stage 1) breast cancer diagnoses, though there was no change in the proportion of metastatic cases in the first year following expansion. The results suggest a possible increase in earlier stage diagnosis associated with increased access to health insurance. Additional analysis will examine the impact on treatment-related outcomes. Citation Format: Spada N, Geramita E, van Londen G, Sabik L. Changes in breast cancer diagnosis and treatment after Medicaid expansion in Pennsylvania [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-08-06.

OBJECTIVES: To evaluate the impact of centralized surgical and nonsurgical care (i.e., radiation and chemotherapy) on travel distances and survival outcomes for patients with advanced bladder cancer. Bladder cancer is a disease with high mortality for which treatment access is paramount and survival is superior in patients receiving surgery at high-volume centers. METHODS: Using SEER-Medicare, we identified patients 66 years or older diagnosed with bladder cancer between 2004–2013. We categorized patients as treated with either surgical (i.e., radical cystectomy) or nonsurgical (i.e., radiation or chemotherapy) care. We fit a linear probability model to generate the predicted proportion of patients treated at the top quintile of volume over time and assessed travel distance, 1-year all-cause mortality, and 1-year bladder cancer-specific mortality over time. RESULTS: A total of 6,756 and 10,383 patients underwent surgical and nonsurgical care, respectively. The percentage of patients treated at high-volume centers increased over the study period for both surgical care (53% to 62%) and nonsurgical care (47% to 55%), (both p

BACKGROUND: Little is documented regarding objective financial metrics and their impact on subjective financial toxicity in head and neck cancer (HNC) survivors. METHODS: In a cross-sectional analysis, 71 survivors with available claims data for HNC-specific out-of-pocket expenses (OOPE) completed a survey including patient-reported, subjective financial toxicity outcome tools: the Comprehensive Score for financial Toxicity (COST) and the Financial Distress Questionnaire (FDQ). RESULTS: Worse COST scores were significantly associated with lower earnings at survey administration (coefficient = 3.79; 95% CI 2.63–4.95; p < 0.001); loss of earnings after diagnosis (coefficient = 6.03; 95% CI 0.53–11.52; p = 0.032); and greater annual OOPE as a proportion of earnings [log10(Annual OOPE: Earnings at survey): coefficient = −5.66; 95% CI −10.28 to −1.04; p = 0.017]. Similar results were found with FDQ. CONCLUSION: Financial toxicity is associated with particular socioeconomic characteristics which, if understood, would assist the development of pre-treatment screening tools to detect at-risk individuals and intervene early in the HNC cancer survivorship trajectory.

BACKGROUND Medicaid expansion under the Affordable Care Act has improved access to screening and treatment for certain cancers. It is unclear how this policy has affected the diagnosis and management of pancreatic cancer. METHODS Using a quasi-experimental difference-in-differences (DID) approach, we analyzed Medicaid and uninsured patients in the National Cancer Data Base during two time periods: pre-expansion (2011-2012) and postexpansion (2015-2016). We investigated changes in cancer staging, treatment decisions, and surgical outcomes. RESULTS In this national cohort, pancreatic cancer patients in expansion states had increased Medicaid coverage relative to those in nonexpansion states (DID = 17.49, p

Background Socioeconomic differences in receipt of adjuvant treatment contribute to persistent disparities in breast cancer (BCA) outcomes, including survival. Adjuvant endocrine therapy (AET) substantially reduces recurrence risk and is recommended by clinical guidelines for nearly all women with hormone receptor-positive non-metastatic BCA. However, AET use among uninsured or underinsured populations has been understudied. The health reform implemented by the US state of Massachusetts in 2006 expanded health insurance coverage and increased the scope of benefits for many with coverage. This study examines changes in the initiation of AET among BCA patients in Massachusetts after the health reform. Methods We used Massachusetts Cancer Registry data from 2004 to 2013 for a sample of estrogen receptor (ER)-positive BCA surgical patients aged 20–64 years. We estimated multivariable regression models to assess differential changes in the likelihood initiating AET after Massachusetts health reform by area-level income, comparing women from lower- and higher-income ZIP codes in Massachusetts. Results There was a 5-percentage point (p-value Conclusions The expansion of health insurance in Massachusetts was associated with a significant relative increase in the likelihood of AET initiation among women in low-income areas compared with those in high-income areas. Our results suggest that expansions of health insurance coverage and improved access to care can increase the number of eligible patients initiating AET and may ameliorate socioeconomic disparities in BCA outcomes.

Introduction: Rural populations routinely rank poorly on common health indicators including urologic cancer-specific mortality. While it is understood that rural residents face barriers to healthcare, the exact nature of these barriers has not been well described. In order to define these barriers, we performed a qualitative study to directly identify primary care physician perspective on healthcare access in rural areas. Methods: From January to August 2019, we conducted semi-structured interviews with 20 primary care physicians practicing in rural areas within western Pennsylvania. We purposively sampled primary care physicians in rural counties in Pennsylvania. We then recruited additional participants using a snowball recruitment strategy, in which the initial interviewees recommend other potential participants in their field. Data was then transcribed, coded, and analyzed via thematic analysis. Results: Participants identify the following as major healthcare barriers rural residents face: access to specialists, lack of transportation to medical centers, and financial burden. Financial barriers impact patients’ willingness to obtain screenings measures and attend specialist appointments secondary to co-pays. Primary care physicians report patients experience numerous hardships after being referred to a specialist, as they often have to travel long distances, lack means of transportation, are unwilling to skip work, have low healthcare literacy, and tend to be suspicious of medical treatment. Conclusion: Rural residents face numerous barriers to obtaining healthcare. Policy to rectify this disparity should focus on improving local access to care, transportation to tertiary care centers, and financial assistance for preventative screening measures.

Cost sharing in traditional Medicare can consume a substantial portion of the income of beneficiaries who do not have supplemental insurance from Medicaid, an employer, or a Medigap plan. Near-poor Medicare beneficiaries (with incomes more than 100 percent but less than 200 percent of the federal poverty level) are ineligible for Medicaid but frequently lack alternative supplemental coverage, resulting in a supplemental coverage "cliff" of 25.8 percentage points just above the eligibility threshold for Medicaid (100 percent of poverty). We estimated that beneficiaries affected by this supplemental coverage cliff incurred an additional $2,288 in out-of-pocket spending over the course of two years, used 55 percent fewer outpatient evaluation and management services per year, and filled fewer prescriptions. Lower prescription drug use was partly driven by low take-up of Part D subsidies, which Medicare beneficiaries automatically receive if they have Medicaid. Expanding eligibility for Medicaid supplemental coverage and increasing take-up of Part D subsidies would lessen cost-related barriers to health care among near-poor Medicare beneficiaries.

Medicaid is an important source of supplemental coverage for older Medicare beneficiaries with low income. Research has shown that Medicaid expansion under the Patient Protection and Affordable Care Act (ACA) was associated with increased Medicaid coverage for previously eligible older adults with low income, but there has been little research on whether their health care use increased or whether such changes differed by beneficiaries' health status.To assess whether the ACA Medicaid expansion to working-age adults was associated with increased Medicaid enrollment and health care use among older adults with low income with and without chronic condition limitations.This cross-sectional study used data from the National Health Interview Survey from 2010 to 2017 for adults 65 years or older with low income (≤100% of the federal poverty level). Data were analyzed from November 2020 to March 2022.Residence in a state with Medicaid expansion for working-age adults.The main outcomes were Medicaid coverage and health care use, measured by physician office visits and inpatient hospital care. Survey weights were used in calculating descriptive statistics and regression estimates. In multivariate analysis, difference-in-differences models were used to compare changes in outcomes over time between respondents in Medicaid expansion states and respondents in nonexpansion states.Of 21 859 adults included in the study, 7153 had chronic condition limitations (4983 [70.1%] female; mean [SD] age, 76.0 [0.1] years) and 14 706 did not have chronic condition limitations (9609 [66.3%] female; mean [SD] age, 74.85 [0.08] years). Of those with chronic condition limitations, 2707 (36.7%) were enrolled in Medicaid, 2816 (39.4%) had an office visit in the past 2 weeks, and 2152 (30.7%) used inpatient hospital care in the past year. Medicaid expansion was associated with differential increases in the likelihood of having Medicaid (4.92 percentage points; 95% CI, 0.25-9.60 percentage points;In this cross-sectional study, ACA Medicaid expansion for working-age adults was associated with increased Medicaid enrollment and outpatient health care use among older adults with low income and chronic condition limitations who were dually eligible for Medicare and Medicaid.

Background: Given limited evidence on opioid prescribing among patients receiving treatment for cancer during the ongoing opioid epidemic, our objective was to assess predictors of and trends in opioid receipt during cancer treatment, including how patterns differ by type of cancer. Methods: Using cancer registry data, we identified patients with a first lifetime primary diagnosis of breast, colorectal, or lung cancer from 2013 to 2017 who underwent treatment within a large cancer center network. Cancer registry data were linked to electronic health record information on opioid prescriptions. We examined predictors of and trends in receipt of any opioid prescription within 12 months of cancer diagnosis. Results: The percentage of patients receiving opioids varied by cancer type: breast cancer, 35% (1,996/5,649); colorectal, 37% (776/2,083); lung, 47% (1,259/2,654). In multivariable analysis, opioid use in the year before cancer diagnosis was the factor most strongly associated with receipt of opioids after cancer diagnosis, with 4.90 (95% CI, 4.10–5.86), 5.09 (95% CI, 3.88–6.69), and 3.31 (95% CI, 2.68–4.10) higher odds for breast, colorectal, and lung cancers, respectively. We did not observe a consistent decline in opioid prescribing over time, and trends differed by cancer type. Conclusions: Our findings suggest that prescription of opioids to patients with cancer varies by cancer type and other factors. In particular, patients are more likely to receive opioids after cancer diagnosis if they were previously exposed before diagnosis, suggesting that pain among patients with cancer may commonly include non–cancer-related pain. Heterogeneity and complexity among patients with cancer must be accounted for in developing policies and guidelines aimed at addressing pain management while minimizing the risk of opioid misuse.

Key Points Question Are states that chose not to expand Medicaid under the Patient Protection and Affordable Care Act associated with reduced emergency access to acute care hospitals? Findings In this cross-sectional study of acute care hospital availability in all 50 US states and the District of Columbia, states that did not expand Medicaid experienced worsened emergency access to acute care hospitals compared with states that expanded Medicaid. Meaning This study found reduced emergency access to acute care hospitals in states that did not expand Medicare, which could negatively impact the quality of care for time-sensitive conditions such as acute myocardial infarction, stroke, sepsis, and trauma., This cross-sectional study uses hospital-level Medicaid and geospatial data to analyze the association of state expansion of Medicaid under the Patient Protection and Affordable Care Act with emergency access to acute care hospitals., Importance State decisions not to expand Medicaid under the Patient Protection and Affordable Care Act could reduce emergency access to acute care hospitals. Objective To determine the relationship between state Medicaid expansion and emergency access to acute care hospitals in the United States. Design, Setting, and Participants This cross-sectional study linked hospital-level data from the Centers for Medicare & Medicaid Services from 2007 to 2017 to US Census data for all 50 US states and the District of Columbia. Geospatial analyses and difference-in-differences regression models were used to compare temporal changes in the size of the population without 30-minute access to acute care hospitals between 32 states that expanded Medicaid with the population without access in 19 that did not, before and after expansion. Analyses focused on the total population and those with low incomes; secondary analyses examined emergency access to safety-net hospitals. Exposures State-level Medicaid expansion. Main Outcomes and Measures Population without emergency access to an acute care hospital, defined as living outside a 30-minute drive of any hospital. Results States that did not expand Medicaid experienced an increase in the population without access to hospitals overall (without expansion: 6.76% to 6.79% [0.03%]; vs with expansion: 5.65% to 5.35% [–0.30%]; difference-in-differences, 0.33%; 95% CI, 0.33%-0.34%; P

RESEARCH OBJECTIVE: Cost sharing is intended to mitigate the effects of moral hazard in health insurance but can have unintended consequences if patients underuse medically beneficial care that is subject to out‐of‐pocket costs. The Medicare program requires substantial cost sharing, including deductibles and coinsurance for outpatient care and prescription drugs. However, little is known about the consequences of this benefit design for low‐income Medicare beneficiaries who do not qualify for Medicaid or Part D Low‐Income Subsidies (LIS), which defray these costs. In this study, we harnessed quasi‐random variation in exposure to Medicare cost sharing, resulting from “cliffs” in cost sharing subsidies above vs. below income eligibility thresholds for Medicaid and the LIS, to assess the effects of cost sharing on low‐income beneficiaries’ out‐of‐pocket spending and use of care. STUDY DESIGN: We conducted regression discontinuity analyses using detailed household income data from the Health and Retirement Study (HRS) linked to Medicare claims. Our study design compared Medicare beneficiaries with incomes above vs. below eligibility thresholds for the Qualified Medicare Beneficiary (QMB) program, a Medicaid benefit that eliminates cost sharing in Medicare Parts A and B for beneficiaries $2,000) out‐of‐pocket medical costs, relative to beneficiaries whose income was below this threshold. Beneficiaries whose income exceeded the LIS threshold had 17% fewer prescription drug claims and were 16% more likely to have high out‐of‐pocket costs. We found no discernable differences in inpatient utilization above vs. below either threshold. CONCLUSIONS: Our findings show how cost sharing obligations in the Medicare program affect low‐income beneficiaries’ use of care: beneficiaries whose income just exceeds thresholds at which these cost sharing obligations are eliminated or appreciably reduced use substantially fewer prescription drugs and, in some cases, outpatient care. IMPLICATIONS FOR POLICY OR PRACTICE: Medicare beneficiaries with minimally different incomes can face substantially different out‐of‐pocket costs that affect their use of care. Extending Medicaid and LIS cost sharing subsidies to additional near‐poor beneficiaries, and gradually tapering assistance for individuals with modestly higher incomes, could alleviate the impacts of Medicare’s cost sharing obligations on near poor beneficiaries’ use of care. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.

Background In the context of COVID‐19, cancer survivors represent a particularly vulnerable population that may be “doubly hit” by both costs of cancer treatment and financial strain imposed by the pandemic. Methods We performed a review of the literature pertaining to cancer, financial toxicity, and economic challenges. Results Multiple societies have put forth recommendations to modify delivery of cancer care in order to minimize patient exposure to the virus. Cancer survivors, especially patients with head and neck cancer, have been disproportionately affected by rising unemployment levels and economic recessions in the past, both of which are linked to higher cancer mortality. Patients who rely on employer‐provided insurance and do not qualify for Medicaid may lose access to life‐saving treatments. Conclusions It is essential to implement interventions and policy changes in order to mitigate the effects of this pandemic but also to ensure this becomes a nonissue during the next one.

BackgroundThe Affordable Care Act led to improvements in reporting a usual source of care, but it is unclear whether patients are changing their usual source of care in response to coverage gains. We assess whether prior insurance instability is associated with changes in use of emergency and office-based care after the Marketplace and Medicaid expansion were introduced.MethodsOur study draws from the 2013-14 Medical Expenditure Panel Survey, identifying a cohort of non-elderly adults with full-year health insurance coverage in 2014. We use linear and multinomial logistic regression to assess the relationship between insurance instability prior to 2014 (uninsured for 1-11 months, ≥12 months) and person-level changes in use of health care after gaining coverage (change in ED and office visits from 2013 to 2014) with continuously insured individuals serving as a comparison group.ResultsBeing uninsured for at least one year prior to gaining full-year coverage in 2014 was associated with a 33% increase in ED visits (0.06 visits, pConclusionThe long-term uninsured may have substantial health needs and pent-up demand for health care, seeing more physicians across multiple settings in the year after gaining coverage as they seek to get unmanaged conditions under control. Closing the gap in primary care use between the previously uninsured and those with health insurance coverage may help improve long-term health outcomes.

INTRODUCTION AND OBJECTIVE:Over the last several years, the surgical care for bladder cancer has become increasingly centralized. We sought to examine trends in overall and bladder-cancer specific ...

INTRODUCTION AND OBJECTIVE:Rural and urban disparities exist in genitourinary cancer. This disparity may result from numerous health determinants and ultimately impacts stage at diagnosis and treat...