Ensuring Quality Cancer Care (1999) / Chapter Skim
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3 Ensuring Access to Cancer Care
3 Ensuring Access to Cancer Care
Pages 46-78
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From page 46... ...
Some of the connections are intuitive and obvious: women without health insurance have breast cancer detected at later stages and have poorer survival rates than women with insurance (Ayanian et al., 1993)
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cancer care are . Some of the factors that have been investigated as possibly affecting access to optimal health insurance coverage and type of coverage; cost, including health insurance and out-of-pocket costs; · attributes of the health care delivery system (e.g., geographic distribution of cancer care facilities, lack of service coordination)
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From page 48... ...
In this chapter, the role of financial barriers in the context of cancer care is reviewed, in particular, problems related to health insurance coverage and out-of-pocket costs. Then the literature exploring the sources of the mortality differentials among sociodemographic groups is summarized by the following phases of care (For a more indepth review of this literature and a conceptual framework regarding issues of access to cancer care, see the NCPB commissioned paper by Mandelblatt and colleagues [Mandelblatt et al., 1998, available on line at: www.nas.edu/cancerbd]
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From page 49... ...
The American Cancer Society has a volunteer-based program called Road to Recovery that provides transportation for cancer patients to and from medical appointments and treatments (Anne Marie Oria, Texas American Cancer Society, personal communication to Elizabeth Kidd, October 1998~. · Cancer Care, a nonprofit, voluntary agency serving primarily the New York City area provides, on a limited basis, financial assistance for treatment-related expenses (e.g., transportation, child care, home care, pain medication)
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, and copayments or coinsurance over the course of cancer treatment can be substantial (HIAA, 19981. Furthermore, many insurers, including Medicare, do not cover all of the drugs and treatments used by cancer patients (see discussion of prescription drug coverage below)
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· Women are more likely than men to have late-stage colorectal cancer at diagnosis (Mandelblatt et al., 19961. Financia/ Barriers to Cancer Screening Lack of health insurance is clearly linked to lower rates of cancer screening (Ayanian, 1993; Hedegaard et al., 1996; Katz and Hofer, 1994; Mickey et al., 1997)
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From page 52... ...
Cancer screening tests were a covered benefit for Medicare beneficiaries, but until 1998 a copayment was required for these tests. Health Care Delivery and Cancer Screening The way health care is delivered also affects the use of cancer screening tests.
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Concerns about inconvenience, discomfort, trouble, embarrassment, fear of radiation, and pain involved in screening are among the reasons people forgo cancer screening tests (Davis et al., 1996; Glanz et al., 1996; Myers et al., 1991; Stein et al., 19901. Other attitudes fatalism, a feeling that one's health cannot be affected by traditional medicine, and religious or cultural beliefs may also preclude cancer screening (Kagawa-Singer, 1997; Lannin et al., 1998; Mo, 1 992~.
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, and · African-American patients were less likely to report receiving advice about cancer screening or receiving screening tests than white patients seeing the same physicians (Gemson et al., 19881. The older people are, the less likely they are to be screened for breast and cervical cancers (Fox et al., 1994; Hedegaard et al., 1996; NCHS, 1997; NCI, ~ 9951.
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From page 55... ...
Obstetrician-gynecologists are more likely than family practitioners to order cancer screening tests for women. Internists generally recommend screening at lower rates than other primary care providers, and subspecialists providing primary care tend to screen at the same, or lower rates than primary care providers (Albanes et al., 1988; Bassett, 1985; Bergner et al., 1990; Mann et al., 1987; Schwartz et al., 1991; Weinberger et al., 1991; Weisman et al., 1989; Zapka et al., 1992)
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From page 56... ...
However, in one study, written feedback and financial incentives were ineffective in improving physician compliance to cancer screening guidelines in primary care sites serving women age 50 and older cared for in a Medicaid HMO (Hiliman et al., ~ 9981. Phase 2: Evaluation of Abnormal Screening Results Fo//ow-Up of Abnorma/ Results Screening tests alone do not provide a diagnosis of cancer; this can be made only with further testing.
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. · A review of the literature on strategies to increase adherence to breast and cervical cancer screening among underserved women determined that management systems directed to both patients and providers were consistently effective for most underserved women.
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The treatment that patients actually receive depends on a number of factors, however, including the availability of health care resources, insurance coverage, physicians' awareness of treatment options, and patients' treatment preferences. These variations often show up as differences in the geographic distribution of cancer treatments (BalIard-Barbash et al., 1996; Farrow et al., 1992, 1996; Harlan et al., 1995; Nattinger et al., 1992; Samet et al., ~ 990~.
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From page 59... ...
. Having health insurance and the type of coverage one has are also associated with differential treatment patterns: · Among individuals with non-small-cell lung cancer, patients without private insurance receive surgery less often than those with it (Greenberg et al., l9S8)
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data, 76 percent of women age 65-69, 68 percent age 70-74, 56 percent age 75-79, and 24 percent age 80 years or older received radiation therapy after breast conserving surgery for Stage ~ or 1:] cancer.
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Variations in Cancer Treatment by Race, Social Characteristics, and Gender Differences in treatment by race have been well documented: African-American patients are less likely than white patients to undergo surgical resection for colorectal cancer (Cooper et al., 1996) , to receive bone marrow transplantation for leukemia or Iymphoma (Mitchell et al., 1997)
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From page 62... ...
For patients with cancer, clinical trials can provide access to the best available and most promising new treatments. There are striking variations in age-specific rates of participation in cancer clinical trials: more than 70 percent of children with cancer participate, but fewer than two percent of individuals age 50 and older with cancer participate in cooperative group clinical trials sponsored by the National Cancer Institute (Tejeda et al., 1996)
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From page 63... ...
. Physicians underrefer patients to clinical trials because of concerns about patient age, frailty, inadequate health insurance coverage, ability to travel to the clinical trial center, and other aspects of participation that might be considered a burden to the patient (Foley and Moertel, 1991)
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Medicare will reimburse for pain management at an inpatient facility, but not for outpatient oral analgesics. This is a major barrier to adequate pain management for terminal cancer patients who choose to die at home.
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The National Cancer Policy Board sought additional information about barriers to effective end-of-life care for cancer patients by commissioning interviews with 19 expert physicians, nurses, social workers, and health services researchers. The findings are summarized in the paper, Issues in End of Life Care for People with Cancer: Interviews with Selected Providers and Researchers (Gelband et al., 19991.
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From page 66... ...
Limited access to primary care or cancer screening contributes to having cancer diagnosed at later stages when the prognosis is worse. Having health insurance coverage improves access, but does not guarantee that cancer screening tests are used.
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, and miscommunication between patients and health care providers.
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American Journal of Preventive Medicine 5~6~:353-359. Begg CB, Carbone PP.
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1990. A randomized study of cancer screening in a family practice setting using a recall model.
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1997. An examination of differential follow-up rates in cervical cancer screening.
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1998. Physician financial incentives and feedback: Failure to increase cancer screening in Medicaid managed care.
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Breast and cervical cancer screening in Ontario and the United States. Journal of the American Meciical Association 272~71:530-534.
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1995. Breast and cervical cancer screening in a low-income managed care sample: The efficacy of physician letters and phone calls.
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1993b. A nurse practitioner intervention to increase breast and cervical cancer screening for poor, elderly black women.
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1997. Continuity of care and the use of breast and cervical cancer screening services in a multiethnic community.
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1998. The association between health care coverage and the use of cancer screening tests.
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1996. Representation of African Americans, Hispanics, and whites in National Cancer Institute cancer treatment trials.
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1996. Delivering breast and cervical cancer screening services to underserved women: Part I
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