Access to insurance and stage of cervical cancer in Massachusetts

Size: px

Start display at page:

Download "Access to insurance and stage of cervical cancer in Massachusetts"

Neil Whitehead
5 years ago
Views:

1 Access to insurance and stage of cervical cancer in Massachusetts Sarah Feldman MD, MPH Brigham and Women s Hospital Department of Gynecologic Oncology Boston, MA USA Co-Authors: Michelle Davis MD, Colleen Feltmate MD, Michael Muto MD, Neil Horowitz MD, Michael Worley MD, and Ross Berkowitz MD

2 Disclosures No financial relationships or conflict of interest to disclose

Background A healthcare reform act was passed in MA in 2006 with the aim of providing health insurance coverage to all state residents Reforms included: Expansion of public programs Creation of a

3 Background A healthcare reform act was passed in MA in 2006 with the aim of providing health insurance coverage to all state residents Reforms included: Expansion of public programs Creation of a health insurance exchange with subsidized coverage for income below 300% and 150% of the Federal Poverty Level (FPL) Individual Mandate- financial penalty up to 50% of the lowest cost premium In 2009 only 1% of taxpayers payed the penalty Increase in preventive care visits from 69.9% in 2006 to 75.8% in 2010 Massachusetts Health Insurance Survey showed that low income residents were more likely to be uninsured despite qualifying for subsidized coverage Cost remains an issue: 12% increase in patient volume with health spending 15% higher than the national average

Background In 2010 MA policies were amended to be consistent with the Affordable Care Act Overlap between state and federal policies including: Insurance market reforms State-based exchange Subsidies

4 Background In 2010 MA policies were amended to be consistent with the Affordable Care Act Overlap between state and federal policies including: Insurance market reforms State-based exchange Subsidies for private coverage Expansion of public coverage Individual coverage requirements Employer requirements In line with optimizing preventive care services In 2012 updated cervical cancer screening guidelines were released based on high quality evidence to maximize the benefits of screening while minimize harm of overtreatment However, in a study by Beavis, et al age standardized mortality rates are higher than previously estimated Corrected mortality 10.1 per 100,000 vs. 5.7 per 100,000 for black women Corrected mortality 4.7 per 100,000 vs. 3.2 per 100,000 for white women

5 Objective The aim of this study is to review cases of cervical cancer diagnosed and treated at a tertiary care center in Massachusetts over the past five years Review patterns of insurance Stage at presentation Race Treatment outcomes

6 Methods Retrospective review of the IRB approved Tumor Registry Database at Brigham and Women s Hospital (BWH) Cases selected between January 2011 and June 2016 Most recent 5 years following uptake of the ACA Clinical, demographic, and follow up data were extracted from the longitudinal medical record. Exclusion criteria: Histology other than squamous cell carcinoma or adenocarcinoma Incomplete treatment or follow up data

7 Results 105 cases of cervical cancer were identified between patients excluded: 1 lost to follow up prior to treatment 3 unusual histologies: mesonephric carcinoma, malignant melanoma, embryonal rhabdomyosarcoma The majority (74.3%) were diagnosed with stage I disease 14 (13.9%) presented with advanced stage disease. Cervical Cancer Stage 6% 8% 12% 74% Stage I Stage II Stage III Stage IV

8 Results Insurance coverage in all patients with cervical cancer 13% 35% 7% 45% Private Public/Government Issued None Documented International All cervical cancer cases n = 101 Age (mean) 46.1 BMI (mean) 26.2 Histology SCC Adenocarcinoma Race White Hispanic Black Asian/Arabic American Indian Referral BWH pre-invasive clinic Outside institution Residence MA New England USA (other) International 49 (48.5%) 52 (51.5%) 81.8% 8.1% 1.0% 8.1% 1.0% 24 (23.8%) 77 (76.2%) 78 (77.2%) 11 (10.9%) 5 (5.0%) 7 (6.9%)

9 Results Stage IA Stage IB Stage II Stage III Stage IV Number 18 (17.8%) 57 (56.4%) 12 (11.9%) 6 (5.9%) 8 (7.9%) Age (mean) Insurance Private Public/Government Issued None Documented International 14 (77.8%) 2 (11.1%) 2 (11.1%) 0 (0%) 27 (47.4%) 20 (35.1%) 6 (10.5%) 4 (7.0%) 3 (25%) 5 (41.7%) 1 (8.3%) 3 (25%) 1 (16.7%) 4 (66.7%) 1 (16.7%) 0 (0%) 1 (12.5%) 4 (50%) 3 (37.5%) 0 (0%) Referral Outside Institution 10 (55.6%) 46 (80.7%) 10 (83.3%) 5 (83.3%) 6 (75%) 78% of patients with Stage IA disease had private insurance 4 (28.6%) of 14 patients with advanced disease had no documented insurance

10 Results Total =17 Cervical Cancer Cases Per Year Total = 26 Total =20 Total =18 10 Total = 12 Total = Stage I Stage II Stage III/IV

11 Limitations Retrospective series, small numbers Relatively homogenous population Referral center, limitations in assessing screening failures

12 Conclusions Despite effective screening programs, 14% of patients still present with advanced cervical cancer even in a state with over 10 years of mandatory health insurance Despite accessibility to health care coverage, 20% of all patients and 37.5% of patients with Stage IV disease report not having insurance Excluding out of state and international patients, 8% of MA residents diagnosed with cervical cancer had no documented insurance These rates are higher than the reported uninsured rates in MA in 2010 (6.3%) While recent studies highlight increased cervical cancer mortality with racial disparities, the patient population at this tertiary care center in MA is fairly homogenous This series highlights an area of unmet need (uninsured and likely under or unscreened) in addressing cervical cancer prevention

13 Questions

ASCCP Guideline Changes and Management of the Abnormal Pap Test Accurately Targeting Intervention

ASCCP Guideline Changes and Management of the Abnormal Pap Test Accurately Targeting Intervention Beryl Manning-Geist MD a,c, Allison Vitonis Sc. M. a, Michelle Davis MD a,b, Sarah Feldman MD MPH a,b a