Well, duh: Insured cancer patients do better

Maybe it's unfair to proclaim this a "well, duh!" study, but its conclusions do seem rather obvious. On the other hand, it's information that we need in a cold, hard scientific form, and I'm glad that the investigators did it:

(AP) -- Uninsured cancer patients are nearly twice as likely to die within five years as those with private coverage, according to the first national study of its kind and one that sheds light on troubling health care obstacles.

People without health insurance are less likely to get recommended cancer screening tests, the study also found, confirming earlier research. And when these patients finally do get diagnosed, their cancer is likely to have spread.

The research by scientists with the American Cancer Society offers important context for the national discussion about health care reform, experts say - even though the uninsured are believed to account for just a fraction of U.S. cancer deaths. An Associated Press analysis suggests it is around 4 percent.

4% may seem like a small number, but it's not so small when you consider how many people die of cancer every year. Moreover, the reason why it's probably not larger is because cancer is a primarily a disease of the elderly, who for the most part are covered by Medicare. Here's more:

In the new study, researchers analyzed information from 1,500 U.S. hospitals that provide cancer care. They focused on nearly 600,000 adults under age 65 who first appeared in the database in 1999 and 2000 and who had either no insurance, private insurance or Medicaid.

Researchers then checked records for those patients for the five years following. They found those who were uninsured were 1.6 times more likely to die in five years than those with private insurance.

More specifically, 35 percent of uninsured patients had died at the end of five years, compared with 23 percent of privately insured patients.

Earlier studies have also shown differences in cancer survival rates of the uninsured and insured, but they were limited to specific cancers and certain geographic areas.

I haven't had a chance to look up the original paper yet to delve into the details of the methodology and findings. Perhaps when I do, I'll write more.

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Interestingly, this poster presented at this year's ASH annual meeting, suggests that Medicare patients actually do better than those with private insurance, suggesting that that evil socialized medicine doesn't do so bad either.

Orac, I could be wrong, but I don't think the first paragraph is supposed to be part of the block quote.

~David D.G.

By David D.G. (not verified) on 20 Dec 2007 #permalink

In a classic example of what psychoanalysts call a folie a blog-deux I just posted on the same study. Maybe someone should ask Orac and me to write "dueling-pianos" posts on some subject of interest, like how to blow a smoke ring.

Uninsured patients pay full price for everything. Insurance companies negotiate steep discounts for their patients and so pay very much less than the full price. And so, all other things being equal, the uninsured runs out of money before being cured, and then the hospital discharges him.

Since the uninsured are subsidizing the insurance companies, why shouldn't they get skinned? They don't have a lobby at all. Stupid people.

By Ken Shabby (not verified) on 20 Dec 2007 #permalink

Are the uninsured subsidizing the insured, or merely paying the price of providing discounts to insurance companies? ISTM that the price the insurance company pays, as it represents the bulk of patients, is closer to a true market price of the service than the artifically inflated number that the uninsured pay. Its like those bogus discount retailers that put inflated "typical retail" prices on their merchandise and then discount it 50% to make the real price look attractive by comparison.

Just getting an appontment with the appropriate oncologist is a major struggle if you are uninsured. When an uninsured friend had breast cancer I was horrified by the long waits for appointments, the lack of continuity of care, and the mountains of paperwork that constantly went astray.

By Sea creature (not verified) on 20 Dec 2007 #permalink

On May 5th my high school friend Kenny died. He was a real rascal, and I visit Union Square, NY whenever I am in the city to remember him. He spent many days protesting there during the '60's.

He had no private insurance and wound up having to go MediCAL. The hospitals and doctors took forever to schedule his surgery because of MediCAL regs, and the start of post-op care was also delayed. When he had the tumor return they wanted to do more surgery, but could he wait a few weeks, he was asked.

He had no choice, and wound up going home to die. Even then, MediCAL did not want to pay for the home hospice morphine infusion pump.

I'm not sure what we should make of this. Some seem to be jumping on the govermnent payment bandwagon.

Does it surprise anyone that insured people do better? Hell that's why I have insurance. One of the big reasons I stick with this job. Basically I work hard for my insurance, both the employer provided part, and the co-pay that I chose to come out of my wages.

It can be shown that modern late model cars are safer too. Does that suggest that people should be subsidized to purchase new cars?

"And so, all other things being equal, the uninsured runs out of money before being cured, and then the hospital discharges him."

No, John, that's not correct. Under federal law, once a hospital admits someone, ability to pay is irrelevant. The hospital has to keep the patient until he/she meets standards for discharge. This law was passed as a civil rights law to prevent hospitals from turning away minorities.

It has had two "collateral effects" in recent years. One, especially in response to the number of uninsured migrant workers who use ERs as primary care providers, is that many hospitals have closed their ERs. If you are treated at an Acute Care facility not associated with the hospital, the hospital doesn't have to admit you at all. Second is "dumping." The patient is ready for discharge, but there is no place to place the patient - who no longer needs hospital care but isn't ready to be sent home (and there isn't anyone who is ready, willing and able to provide hospice care). There is no requirement that a hospice or nursing service provider take a patient who cannot pay. So, the patient gets "dumped."

Three points not discussed in the press reports are: (1) Survival rates for Medicaid patients are little better than for the uninsured. http://www.msnbc.msn.com/id/22332573/ (see the graph); (2) Whenever a government program is involved, there is rationing of services, and, under some programs, a patient is barred from seeking other services, treatments or medications even at the patient's sole expense. See, e.g., www.timesonline.co.uk/tol/life_and_style/health/article3056691.ece "NHS threat to halt care for cancer patient", The Sunday Times, Dec. 16, 2007, "A WOMAN will be denied free National Health Service treatment for breast cancer if she seeks to improve her chances by paying privately for an additional drug. *** Ministers say it is unfair on patients who cannot afford such top-up drugs and that it will create a two-tier NHS. It is thought thousands of patients suffer as a result of the policy."). If you'll recall the scandal a few years ago at Walter Reed and other military facilities as to the Medical Holding facilities, this is another example. During times of tight budgets under the Clinton Administration, the military let these facilities go to pot. When there was a sudden jump in need, they were completely inadequate. Boom and bust in response to priorities and funding is common for government programs; and (3) The study does not discuss the stage at which insured, Medicaid and uninsured patients cancer was diagnosed. Survival odds change a lot with earlier diagnosis and treatment.

These types of restrictions on care are occurring in the US, for a variety of reasons. See, e.g., More ED Patients, Less ED Specialists (Nov. 21, 2007), http://whitecoatrants.wordpress.com/2007/11/21/more-ed-patients-less-ed… While this article seems to especially blame the lawyers (who are a factor, although I think the article over-states that particular factor's importance), the fact is, for a variety of reasons, probably that reinforce their individual effects, medical care availability is being increasingly restricted.

Insured patients typically have better access to primary care, and so screening, and so earlier diagnosis. The uninsured, who have to pay greater amounts than the rates negotiated by insurers, pay in advance for out-patient services, and have to pay the entire costs (rather than only co-pay amounts) tend to forego check-ups and screening tests. When they rely on Acute Care and ERs for primary care, they aren't going to have their cancers diagnosed nearly as early.

Another factor - one that is near and dear to Orac - is the effect of CAM providers. In 1989 or 1990 the Louisiana Dept. of Health and Hospitals published a study on Cancer Mortality in Louisiana. In Louisiana the Charity Hospital System provided free medical care to all persons. The System's ERs were over-run. Adding to the problem is that many patients moved, and would go to one ER, then another in another city, etc., so that very frequently the only medical history available was the one taken at that particular visit. Additionally, many of the patients used "non-traditional" care (now called CAM). The study found that except for lung cancer (wholly explained by a culture in which people began smoking younger and more than elsewhere in the US) cancer incident rates in Louisiana were at or below national averages, whereas cancer mortality rates were much higher. Simply put, by the time the cancer was diagnosed, the patient was terminal. Not noted in the study, but a factor, was that several of the senior members of the Louisiana Legislature were Plaintiffs' attorneys, Louisiana law recognizes a cause of action for "lost opportunity to survive", Louisiana had waived sovereign immunity so that the state can be sued on this basis, and these attorneys resisted, and largely thwarted, efforts to adequately fund or modernize the Charity System's record systems, or to fund out-reach/screening community programs.

In terms of the economics, the insured patients support the medical care system. Typically, even after accounting for the negotiated rates, required adjustments and write-offs, the insurer pays somewhere between 2/3's and ¾'s of the billed rate. Government programs like Medicare, Medicaid and SCHIP pay about 10% (which, admittedly doesn't reflect other monies paid to hospitals via other government programs). While the uninsured (many of whom could afford insurance, but were foolish or unlucky in deciding to risk not purchasing it) are billed the full amount - and, for catastrophic illness or injury, then can seek protection of the Bankruptcy Court.

These are also factors to consider when discussing national health care reform. The current system has many weaknesses. However, many proposed "reforms" carry real risk of being worse.

"Uninsured cancer patients are nearly twice as likely to die within five years as those with private coverage, according to the first national study of its kind and one that sheds light on troubling health care obstacles. "
Not to discount the study, but when there is a difference between screening rates, they should use population numbers for comparison and not 5-year survival rates. What about lead-time bias?