Disparity in telehealth and emergency department use among Medicaid and commercially insured patients receiving systemic therapy for cancer in Washington State following the COVID-19 Pandemic

Background: Washington was the first US state to experience the COVID-19 pandemic. Transmission risks and patient fears of visiting oncology practices during its onset resulted in rapid adoption of telehealth services. We hypothesized that the pandemic would widen disparities in oncology practice visits between Medicaid and commercially insured patients, resulting higher rates of emergency department (ED) visits during initial treatment. Methods: Linking Washington State SEER records with Medicaid and commercial insurance enrollment and claims records, we compared adults age <65 with new solid tumor malignancies who received systemic treatment at academic and community oncology practices. Persons starting therapy March - June 2020 (COVID) were compared with those starting therapy March-June 2017-2019 (Pre-COVID). Poisson regressions were used to evaluate differences in oncology practice office visits and telehealth visits. Logistic regressions were used to evaluate the likelihood of at least one ED admission among patients starting systemic therapy pre- and post-COVID. Results: Among patients who met inclusion criteria (652 Commercial, 349 Medicaid), Medicaid enrollees had more advanced disease and more comorbidity versus commercial enrollees. In unadjusted analysis of E&M and telehealth service visit codes, office-based visits fell for both insurance groups (Table) while telehealth service visits (negligible pre-COVID) were higher for commercial versus Medicaid enrollees postCOVID. The proportion of persons with ≥ 1 ED visit during therapy fell for both insurance groups. In Poisson models, Medicaid enrollees had significantly fewer total visits (P=0.001) and fewer telehealth visits (p<0.001) compared commercial enrollees during the COVID period. In the logit models, ED visits trended lower for both groups after COVID (OR 0.53 95% CI 0.279 to 1.008). Among Medicaid enrollees, persons ages 40-49 and breast cancer patients were more likely to visit the ED. Among the commercially insured, persons with 2 or more comorbidities were more likely to visit the ED. The pre-post COVID change in likelihood of an ED visit was not significantly different between insurance groups (p=0.355). Conclusions: In Washington State, the COVID-19 pandemic created a substantial disparity in access to office-based and telehealth care for low-income patients receiving systemic therapy for new cancers. Reduced oncology practice visits among Medicaid patients did not widen existing disparities in utilization of emergency care.

Medicaid patients more likely to die at home without hospice during the pandemic versus before, exacerbating disparities with commercially insured patients

Background: The COVID-19 pandemic dramatically reduced family access to hospitals and created new barriers to home hospice care, raising concerns about how the pandemic has impacted cancer patients' place of death and end of life home hospice support. Hypothesizing that Medicaid-enrolled cancer patients may be at greater risk of disruptions in end-of-life care compared to commercially insured patients, we examined changes in place of death and home hospice support for Medicaid and Commercial enrollees following the pandemic. Methods: We linked WA State cancer registry records with claims from Medicaid and approximately 75% of commercially insured cancer patients in the state. Patients ages 18-64 with solid-tumor malignancies who died March-June 2020 (COVID) were compared to those who died March-June 2017-2019 (Pre-COVID). Place of death was categorized as hospital, home with hospice, and home without hospice;nursing home deaths were excluded. Given our sample size, we examined differences in the likelihood of place of death with Fisher's exact tests and multinomial logistic regressions stratified by payer and by COVID period, controlling for age, gender, race, stage, cancer type, and census tract-level neighborhood deprivation. We report marginal effects. Results: In Fisher's exact analyses, Medicaid but not commercial patients were significantly less like to die in hospital and more likely to die at home without hospice during COVID (Table). In pre-post adjusted analysis of Medicaid patients, the probability of dying in the hospital was 12.3% (p=0.03) percentage points lower during the pandemic versus before, while the probability of dying at home without hospice was 11.1% (p=0.04) greater. Place of death did not change significantly pre-post for commercial patients. In addition, Pre-COVID, the probability of dying in the hospital was 10.7% (p=0.03) greater for Medicaid than commercial patients. During COVID, the probability of dying at home without hospice was 15.8% (p=0.04) greater for Medicaid versus commercial patients but lower for women (ME=20.2%;p=0.01) and colorectal versus breast cancer patients (ME=39.2%;p=0.01). Conclusions: Following COVID, Medicaid patients place of death shifted from hospital to homes, but without an increase in the use of home hospice services. In contrast, place of death and hospice use among commercial patients did not significantly change. This widening disparity in home deaths without hospice services raises concerns that the pandemic disproportionately worsened end of life experience for low income patients with cancer. (Table Presented).