Medical Care

BRCA1/2 Testing in Massachusetts Among Women With Private Insurance or Medicaid, 2011–2015

Purpose: Testing for BRCA1/2 mutations has increased among privately insured women in the United States. However, little is known about testing rates or trends among women with Medicaid. We sought to determine whether BRCA1/2 testing rates differed between women with private insurance compared with women with Medicaid in a state where both insurance types cover the test, and to compare testing trends from 2011 to 2015. Methods: We conducted a retrospective cohort study of medical claims from January 2011 through June 2015. We included Massachusetts women aged 18–64 with private insurance or Medicaid and at least 12 months of continuous enrollment. We used multivariable linear regression to examine the association of insurance type, age, and time with testing rates. Results: Mean monthly BRCA1/2 testing rates were lower among women with Medicaid compared with those with private insurance. Among privately insured women, mean monthly rates rose from 9.3 per 100,000 in 2011 to 18.4 per 100,000 in 2015, while among Medicaid-insured women, rates increased from 3.7 to 14.7. There was no difference in the monthly rate of increase in both groups (P=0.07). In adjusted analyses, rates were lower among Medicaid-insured women (7 fewer tests per month than privately insured women, P<0.001), and differed by age, with women aged 44–54 most likely to receive testing and women 18–34 the least likely. Conclusion: BRCA1/2 testing rates were lower among women insured by Medicaid compared with those with private insurance, though rates increased from 2011 to 2015 among both groups of women at a similar rate.

Cancer Screening Among Adults With and Without Serious Mental Illness

Background: Persons with serious mental illness (SMI) die 10–20 years earlier than the general population; cancer is the second leading cause of death. Differences in cancer screening between SMI and the general population are not well understood. Objectives: To describe receipt of cancer screening among individuals with versus without SMI and to explore clinicians’ perceptions around cancer screening for people with SMI. Methods: Mixed-methods study using 2010–2017 MarketScan commercial insurance administrative claims data and semi-structured clinician interviews. In the quantitative analyses, we used multivariate logistic regression analyses to calculate the likelihood of receiving cervical, breast, colorectal, or prostate cancer screening among people with versus without SMI, defined as schizophrenia or bipolar disorder. We conducted semi-structured interviews with 17 primary care physicians and 15 psychiatrists. Interview transcripts were coded using a hybrid deductive/inductive approach. Results: Relative to those without SMI, individuals with SMI were less likely to receive screening for cervical cancer [adjusted odds ratio (aOR): 0.80; 95% confidence interval (CI): 0.80–0.81], breast cancer (aOR: 0.79; 95% CI: 0.78–0.80), colorectal cancer (aOR: 0.90; 95% CI: 0.89–0.91), and prostate cancer (aOR: 0.85; 95% CI: 0.84–0.87). Clinicians identified 5 themes that may help explain the lower rates of cancer screening in persons with SMI: access to care, available support, prioritization of other issues, communication, and patient concerns. Conclusions: People with SMI were less likely to receive 4 common types of cancer screening. Improving cancer screening rates in the SMI population will likely require a multidisciplinary approach to overcome barriers to screening.

Associations Between Disability and Breast or Cervical Cancers, Accounting for Screening Disparities

Introduction: Studies suggest that women with disability experience disparities in routine, high-value screening services, including mammograms and Papanicolaou (Pap) tests. However, few studies have explored whether women with disability have higher risks than other women of developing breast or cervical cancers. Methods: The authors analyzed 2010, 2013, 2015, and 2018 National Health Interview Surveys, which involved civilian, noninstitutionalized US residents, and included supplemental surveys on cancer screening. The authors used self-reported functional status limitations to identify women without disability and women with movement difficulties (MDs) or complex activity limitations (CAL) predating breast or cervical cancer diagnoses. Multivariable models evaluated associations of disability status to cancer diagnosis, adjusting for other variables. Analyses used sampling weights, producing national estimates. Results: The sample included 66,641 women; 24.4% reported MD and 14.5% reported CAL. Compared with women without disability, women with pre-existing MD or CAL had significantly higher rates of breast cancer (2.2% vs. 3.5% and 3.6%, respectively) and cervical cancer (0.6% vs. 0.8% and 1.0%, respectively). Women with disability had significantly lower recent mammography and Pap test rates than women without disability. After adjusting for all covariates, the values for odds ratio (95% confidence interval) of pre-existing CAL for cancer diagnoses were 1.21 (1.01–1.46; P=0.04) for breast cancer and 1.43 (1.04–1.99; P=0.03) for cervical cancer. Conclusions: Pre-existing disability is associated with a higher likelihood of breast and cervical cancer diagnoses, raising the urgency of eliminating disability disparities in mammography and Pap testing. Further research will need to explore the causes of these higher cancer rates.

Post–Affordable Care Act Improvements in Cancer Stage Among Ohio Medicaid Beneficiaries Resulted From an Increase in Stable Coverage

Background: The mechanisms underlying improvements in early-stage cancer at diagnosis following Medicaid expansion remain unknown. We hypothesized that Medicaid expansion allowed for low-income adults to enroll in Medicaid before cancer diagnosis, thus increasing the number of stably-enrolled relative to those who enroll in Medicaid only after diagnosis (emergently-enrolled). Methods: Using data from the 2011–2017 Ohio Cancer Incidence Surveillance System and Medicaid enrollment files, we identified individuals diagnosed with incident invasive breast (n=4850), cervical (n=1023), and colorectal (n=3363) cancer. We conducted causal mediation analysis to estimate the direct effect of pre- (vs. post-) expansion on being diagnosed with early-stage (-vs. regional-stage and distant-stage) disease, and indirect (mediation) effect through being in the stably- (vs. emergently-) enrolled group, controlling for individual-level and area-level characteristics. Results: The percentage of stably-enrolled patients increased from 63.3% to 73.9% post-expansion, while that of the emergently-enrolled decreased from 36.7% to 26.1%. The percentage of patients with early-stage diagnosis remained 1.3–2.9 times higher among the stably-than the emergently-enrolled group, both pre-expansion and post-expansion. Results from the causal mediation analysis showed that there was an indirect effect of Medicaid expansion through being in the stably- (vs. emergently-) enrolled group [risk ratios with 95% confidence interval: 1.018 (1.010–1.027) for breast cancer, 1.115 (1.064–1.167) for cervical cancer, and 1.090 (1.062–1.118) for colorectal cancer. Conclusion: We provide the first evidence that post-expansion improvements in cancer stage were caused by an increased reliance on Medicaid as a source of stable insurance coverage.

Claims-Based Measures of Care Coordination and Long-Term Health Among Older Women With Endometrial Cancer

Background: Coordination of care between providers may help ensure that cancer survivors receive the appropriate health care services to improve their long-term health. We examined associations between a claims-based measure of care coordination and several health outcomes among older endometrial cancer survivors. Methods: Using SEER-Medicare data, we identified women with endometrial cancer at ages 66+ during 2009–2015 (N=13,696). Medicare claims during years 1–3 postdiagnosis were used to calculate care density, a measure of care coordination, as the ratio of the number of patients shared among a woman’s outpatient providers to the number of provider pairs seen by that patient. We estimated associations between care density tertile and hospitalizations, emergency room (ER) visits, and all-cause mortality from 3 years postdiagnosis on, and adherence to guideline-recommended follow-up during years 3–5 postdiagnosis. Results: No clear trends were observed for risk of all-cause mortality, hospitalizations or ER visits according to care density category. However, for hospitalizations (HR=0.93; 95% CI: 0.87–0.99) and ER visits (HR=0.93; 95% CI: 0.88–0.98), there was a slightly lower risk in the highest care density tertile compared with the lowest. Women in the middle (OR=1.67; 95% CI: 1.40–2.00) and highest care density tertiles (OR=1.63; 95% CI: 1.36–1.96) were more likely to be adherent to follow-up recommendations than those in the lowest tertile. Conclusions: Greater care coordination during the early survivorship period may be associated with a slightly lower risk of hospitalization and ER visits and better adherence to surveillance recommendations after endometrial cancer.