Insurance Expansion Improves Resection Rates Among Patients with Colorectal Cancer

The implementation of health care reform in Massachusetts increased surgical resection rates for colorectal cancer and decreased the likelihood of emergent resection, suggesting that insurance expansion may improve access to care in this patient population, according to research published in Journal of Clinical Oncology.

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“Colorectal cancer is exceedingly common and is currently the third leading cause of cancer death in the United States,” said Andrew P Loehrer, MD, alumni fellow at Massachusetts General Hospital’s Codman Center for Clinical Effectiveness in Surgery (Boston, MA). “Uninsured patients are more likely to present with advanced disease and less likely to receive optimal care, which often leads to worse outcomes. The question of whether better access to cancer care can be achieved through insurance expansion has been begged for some time now.”

In 2006, Massachusetts enacted health care reform policies, many of which are considered forerunners to the Affordable Care Act. The law expanded Medicaid coverage to residents living 150% below the federal poverty line; established a state-subsidized insurance program for Medicaid-ineligible residents with income less than 300% below the federal poverty line, called Commonwealth Care; and mandated that residents carry health insurance.

Dr Loehrer and colleagues hypothesized a rise in resection rates among patients with colorectal cancer directly affected by health care reform, with a corresponding decrease in insurance-related treatment disparities. Using the Hospital Cost and Utilization Project State Inpatient Databases, the researchers identified 17,499 patients with colorectal cancer admitted to a Massachusetts hospital between January 2001 and December 2011, as well as 144,253 patients from three control states (Florida, New Jersey, and New York). 

The State Inpatient Databases captured patients’ methods of payment. Patients who paid for treatment out-of-pocket, through Medicaid or Commonwealth Care, or were not charged were considered government-subsidized or self-paying, whereas patients with employer-sponsored or individually-purchased health care coverage were considered privately insured. Surgical resection served as the study’s primary outcomes measure, with the probability of emergent or elective resection a secondary outcome measure.

The researchers observed a 15% increase in admission rates among patients with government-subsidized or self-paying patients in Massachusetts following health care reform implementation compared with similar patients in control states (Incident rate ratio [IRR], 1.15; 95% CI, 1.14-1.16; P < .001). Further, resection rates among government-subsidized or self-paying patients in Massachusetts increased by 44% (IRR, 1.44; 95% CI, 1.23-1.68; P < .001). A subgroup analysis stratified by disease site found that Massachusetts patients with colon cancer experienced a 49% increase in resection following health care reform compared with patients in control states (IRR, 1.49; 95% CI, 1.26-1.77; P < .001), with a 34% increase shown among patients with rectal cancer (IRR, 1.34; 95% CI, 1.05-1.71; P = .021).

The probability of emergent resection decreased by 6.21 percentage points following Massachusetts health care reform implementation (95% CI, -11.88 to -0.54; P = .032), with the probability of elective admission for resection rising by 8.13 percentage points (95% CI, 1.34-14.91; P = .019). Although the researchers observed a decrease in disparities surrounding colorectal cancer resection following reform, government-subsidized or self-paying patients still remained significantly less likely to undergo resection that privately insured patients (odds ratio, 0.63; 95% CI, 0.55-0.72; P < .001).

Dr Loehrer and colleagues acknowledged study limitations, including the potential for coding errors in administrative data and their inability to determine disease stage at the time of diagnosis. Additionally, because State Inpatient Databases only capture hospital admissions, the researchers could not access data from patients treated in the outpatient setting.

“There is presently no cure for colorectal cancer without surgical resection,” Dr Loehrer said. “Following health care reform in Massachusetts, we saw increased resection rates, which increase the chance for patient survival, as well as a significant reduction of patients presenting in the emergent setting, who were thus less likely to have short-term complications. The implication of our research is that insurance expansion can lead to timelier diagnoses, a higher likelihood to receive a surgeon referral, and perhaps a greater willingness to undergo elective surgical resection.”