Quality Improvement
Kevin M. Sullivan, MD
Fellow
City of Hope
Pasadena, California, United States
Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
Over the last two decades, the popularity of Medicare Advantage (MA) plans has increased with more than a third of older (65 years and greater) Americans now enrolled in MA plans. In contrast to traditional Medicare (TM), MA plans mitigate costs by limiting utilization to certain contracted, in-network providers and by requiring prior authorization for specialist referrals. Our prior work identified significant gaps in MA plan coverage for high-volume cancer surgery. Here, we sought to compare the impact of MA plan enrollment (vs. TM) on access to high-volume complex cancer surgery and long-term overall survival (OS).
Methods:
We performed a retrospective analysis from 2000-2012 using the Office of Statewide Health Planning Inpatient Database (OSHPD) linked to the California Cancer Registry (CCR). Patients 65 years or older, undergoing elective inpatient curative-intent cancer surgery for stage 1-3 cancers of the lung, esophagus, stomach, pancreas, colon, and rectum were included. Multivariate Cox proportional hazard model was used to assess the impact of insurance status on OS.
Results:
A total of 67,580 Medicare beneficiaries met inclusion criteria comprising 14,545 lung resections, 1,833 esophagectomies, 3,567 gastrectomies, 2,132 pancreatectomies, 36,336 colectomies, and 9,167 proctectomies. Compared to TM, MA beneficiaries undergoing lung, esophagus, stomach, and pancreas resections were significantly less likely to have surgery at a high-volume center (Table 1). On multivariate analysis, after controlling for age, comorbidities and stage, MA beneficiaries had worse OS compared to TM when undergoing lung (hazard ratio [HR] 1.07; p=0.002), stomach (HR 1.12; p=0.035), and pancreas (HR 1.12; p=0.01) resections.
Conclusions:
Compared to TM, MA enrollment was associated with a lower probability of surgery at high volume center for lung, esophagus, stomach, or pancreas resection. Consequently, MA plan enrolment (vs. TM) was independently associated with worse overall survival for lung, stomach, or pancreas resections. Based on these findings, access to high volume complex cancer surgery should be prioritized in MA plans.