Disparities in Cancer Care: Another Inconvenient Truth
Pallavi Kumar, MD, and
Beverly Moy, MD, MPH
|Pallavi Kumar, MD
||Beverly Moy, MD, MPH
It is no secret that despite major advances in cancer research, screening, and treatment, not all Americans with cancer have benefited equally. Although there has been a 14% decrease in the rate of cancer-related death between the years 1991 and 2004, racial and ethnic minority patients continue to disproportionately die more from cancer compared with their white counterparts, even after adjusting for insurance status and income.1
The oncology community is well aware of the existence of cancer disparities; however, solutions to improve the equity of cancer care are sorely lacking. Why have we not done more? Where is the outrage?
With the passage of the Patient Protection and Affordable Care Act (ACA), we are now in a real position to eliminate disparities in cancer care.2 The ACA contains a number of provisions that have the potential to expand and improve access, as well as quality of care for the underserved. These provisions include Medicaid expansion to an additional 16 to 20 million individuals, creation of health insurance exchanges, elimination of coverage barriers, and closure of the Medicare "donut hole." Other core elements with important implications for cancer care include: mandating coverage of preventive services that have U.S. Preventative Services Task Force ratings of an "A" or a "B," ensuring coverage for children with cancer, requiring payment for routine costs of clinical trial participation, and establishing bundled payments in order to incentivize efficient delivery of quality cancer care.
The question before us now pertains to how we will use these tools to provide better care to the underserved.
Solutions to Cancer Disparities
Despite the numerous opportunities in the ACA to improve our current delivery of cancer care, change will only happen if we unite to achieve a few common goals: improving access to and quality of cancer care, pursuing rigorous research in interventions aimed at reducing cancer health disparities, and advocating for our patients by supporting health care reform. As simple as these may seem, they are essential to the progression of our field.
Improve access to care. Vulnerable patients will only receive quality cancer care if they have access to it. Although an additional 16 to 20 million individuals will have access to Medicaid under the ACA, this expanded coverage might not translate into better outcomes for indigent patients with cancer. Evidence has shown that patients with cancer who have Medicaid coverage fare as poorly as their uninsured counterparts.3-7 This is at least partially due to the fact that almost one-third of oncologists do not accept Medicaid, therefore, the burden of caring for these patients falls on an ever shrinking pool of providers.8
In 2008, Medicaid reimbursement rates averaged 72% of Medicare rates,9 which itself is below that of most private insurers. Is this the best that we can do for our most vulnerable patients? Oncologists should remain committed to accepting patients with Medicaid insurance, among others. We look to our legislators and to ASCO to lead efforts to ensure appropriate reimbursement so that providers can continue to care for patients regardless of their ability to pay. We must redouble our efforts to strengthen Medicaid, not abandon it.
Related Education Session
Overcoming Disparities in Clinical Trial Accrual among African Americans
Monday, June 4
1:15 PM-2:30 PM • S100bc
Sandra M. Swain, MD (Chair)
What Factors Influence African American Cancer Patients’ Decisions Regarding Participation in Clinical Trials?
Jean Ford, MD
Use of Culturally-Targeted Video for Changing Attitudes Towards Clinical Trials
Deliya Banda, PhD, MPH
A Critical Review of Clinical Trial Enrollment of African Americans in Clinical Trials
Worta J. McCaskill-Stevens, MD
Now is the time to shift away from research that merely documents disparities in cancer care and instead focus on real solutions to improve cancer equity. We must fund studies that implement interventions in vulnerable populations. Academic centers have a responsibility to encourage trainees to pursue research in cancer disparities solutions. We must also continue to support researchers conducting comparative effectiveness research, which applies the rigor of clinical research in a "real world" setting.
Lastly, we must strive to improve minority patient participation in clinical trials.
Improving quality of cancer care. There is a convincing body of evidence showing that patients with lower socioeconomic statuses are less likely to receive appropriate oncologic care following a diagnosis of cancer.10,11 We must devise solutions to ensure that these patients receive timely care and have concrete survivorship plans. Early recognition of vulnerable patients with social or cultural barriers to care and implementation of patient navigator programs to help guide patients through treatment are both potential solutions.
Also essential to the mission of increasing quality care for minority patients is the provision of adequate training in cultural competence for both physicians and providers, so as to better understand the social and cultural contexts in which patients experience cancer treatment and to empower patients to be active participants in their care.
Perhaps nowhere in medicine more than oncology will physicians face the challenge of providing novel treatments with a small or marginal benefit at a sometimes prohibitive cost. As cost considerations increasingly rise to the forefront, will our most vulnerable patients bear the brunt of these difficult decisions? We should want to provide all of our patients with excellent care irrespective of their ability to pay. As a community, one of the tasks that lies ahead in an era of increasing fi nancial considerations is to determine what defi nes a "benefit," and cost must be a part of that calculus. We look to leaders in the field to refine treatment guidelines, taking into account these cost–benefit analyses. This will facilitate a transition to care that is high quality, cost effective, and equitable.
Support health care reform. As oncologists, awareness of the implications of the ACA for our patients is especially important now, as the legislation faces serious challenges. The Supreme Court heard 6 hours of oral arguments from March 26-28, 2012, in the case of Florida v. HHS (brought by 26 states) examining the constitutionality of the ACA, including that of the individual mandate provision and the severability of the individual mandate from the ACA.
The Supreme Court’s decision on the constitutionality of the individual mandate as well as the inseparability of the mandate from the act as a whole is expected to be issued at the end of this month. If the mandate is deemed unconstitutional and also inseparable from the entire act, as its critics argue, the ACA in its entirety could be in jeopardy. We feel this would be a major setback in the mission of expanding health care coverage for millions of currently uninsured individuals.
Although the ACA is not perfect, the entire oncology community should embrace this attempt to improve equity in cancer outcomes and show unified voice in support of health care reform.
Editor’s Note: In their article regarding disparities in cancer care, Drs. Kumar and Moy clearly restate the problem of disparities and look to the Patient Protection and Affordable Care Act (ACA) as a step on the road to a solution to this problem. There is little doubt that the ACA provides a possible means to overcome some of the barriers to uniformity of cancer care. That said, many of these barriers are poorly understood and the assumption that leveling the playing field for access to care will solve the problem may be too simplistic. This is particularly true of accrual to clinical trials. In addition to the advocacy for the ACA emphasized by Drs. Kumar and Moy, funding of studies aimed at understanding the barriers to clinical trial recruitment among minority populations should be high on the list of priorities.
— ASCO Daily News Associate Editor John Sweetenham, MD
With the passage of the ACA, we are poised at the brink of finding and implementing real solutions to reduce disparities in cancer care.12
We urge cancer providers to care for our most vulnerable patients. We urge cancer researchers to focus on research that implements interventions in cancer disparities rather than merely documenting the disparities themselves. We urge stakeholders to support Medicaid and prioritize its solvency.
We urge leaders in the field to develop guidelines based on evidence, cost-effectiveness, and comparative-effectiveness data. Finally, we urge our colleagues to advocate for their patients and support health care reform. Although it is not perfect, this legislation represents the most expansive social legislation since the creation of Medicare in 1965, and it has the potential to reduce disparities in access to and delivery of cost-efficient cancer care. Now is the time to put our outrage into action.
About the Authors: Dr. Kumar is a fi rstyear fellow in hematology and oncology at the Dana-Farber Partners Cancer Center training program. Dr. Moy is the clinical director of the Breast Oncology Program and a medical oncologist at the Massachusetts General Hospital. Dr. Moy serves as the chairman of ASCO’s Advisory Group on Health Disparities and chair-elect of the Ethics Committee, and she is a frequent contributor to the Commentary section of ASCOconnection.org. She has been an ASCO member for 13 years.
- Mead H, Cartwright-Smith L,, Jones K, et al. Racial and Ethnic Disparities in U.S. Healthcare: A Chartbook. The Commonwealth Fund website. http://www.commonwealthfund.org/Publications/Chartbooks/2008/Mar/Racial-and-Ethnic-Disparities-in-U-S--Health-Care--A-Chartbook.aspx. Accessed March 12, 2012.
- Patient Protection and Affordable Care Act. Public Law 111-148. U.S. Government Printing Office: Federal Digital System website. http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf. Accessed March 12, 2012.
- Ayanian JZ, Kohler BA, Abe T, et al: The relation between health insurance coverage and clinical outcomes among women with breast cancer. N Engl J Med. 1993;329(5):326-331.
- Roetzheim RG, Gonzalez EC, Ferrante JM, et al. Effects of health insurance and race on breast carcinoma treatments and outcomes. Cancer. 2000;89(11):2202-2213.
- Roetzheim RG, Pal N, Gonzalez EC, et al. Effects of health insurance and race on colorectal cancer treatments and outcomes. Am J Public Health. 2000;90(11):1746-1754.
- Kelz RR, Gimotty PA, Polsky D, et al. Morbidity and mortality of colorectal carcinoma surgery differs by insurance status. Cancer. 2004;101(10):2187-2194.
- Ward E, Halpern M, Schrag N, et al. Association of insurance with cancer care utilization and outcomes. CA Cancer J Clin. 2008;58(1):9-31.
- Boukus E, Cassil A, O'Malley A. A Snapshot of U.S. Physicians: Key Findings from the 2008 Health Tracking Physician Survey. Data Bulletin No. 35. Center for Studying Health System Change website. http://www.hschange.com/CONTENT/1078/?words=au227. Accessed March 12, 2012.
- Medicaid-to-Medicare Fee Index, 2008. The Henry J. Kaiser Family Foundation website: http://statehealthfacts.org/comparetable.jsp?ind=196&cat=4.Accessed March 13, 2012.
- Bickell NA, Wang JJ, Oluwole S, et al. Missed opportunities: racial disparities in adjuvant breast cancer treatment. J Clin Oncol. 2006;24(9):1357-1362.
- Baldwin LM, Dobie SA, Billingsley K, et al. Explaining black-white differences in receipt of recommended colon cancer treatment. J Natl Cancer Inst. 2005;97(16):1211-1220.
- Moy B, Polite B, Halpern M, et al. American Society of Clinical Oncology Policy Statement: Opportunities in the Patient Protection and Affordable Care Act to Reduce Cancer Care Disparities. J Clin Oncol. 2011;29(28):3816-3824.