Insurance Status And Clinical Outcomes Following Cancer Therapy: Are We Being Penny Wise?

Several studies show that cancer patients without health insurance or Medicaid coverage have inferior access to care and outcomes. We report outcomes for cancer patients treated with radiotherapy at our urban academic medical center with an open-door policy and backend billing, where treatment is not refused or delayed because of insurance coverage. We searched an institutional database to identify all patients treated with radiotherapy with curative intent for cancers of the head and neck, breast, lung, cervix, uterus, or rectum between the years 2007 and 2012. Multivariable analyses were performed to examine associations between insurance status and clinical outcomes. 1,266 patients met eligibility criteria. 31% were Hispanic, and 37% were Black or African American. 30% of patients had private insurance, 51% had Medicaid, and 19% had Medicare. With a median follow-up duration of 41.8 months for surviving patients, 122 recurrences (9.6%) and 242 deaths (19.1%) have been observed. On multivariate analysis adjusted for age, diagnosis, stage, Charlson comorbidity index, socio-economic status (SES) and treatment noncompliance (defined as missing two or more scheduled radiotherapy treatments), having Medicaid was associated with inferior progression free survival (HR=1.34, 95% CI 1.05-1.72, p=0.020) and inferior overall survival (HR=1.38, 95% CI 1.06-1.79, p=0.017). However, competing risks analysis demonstrated no significant association between Medicaid and cancer recurrence (Fine and Gray’s SHR=1.17, 95% CI 0.81-1.70, p=0.403) on multivariable analysis. Effective cancer therapy can be delivered to a diverse and underserved patient population, regardless of insurance status. Inferior survival rates observed in patients with Medicaid demonstrate the urgent need to improve survivorship care for this patient population.