Analyzing Hospital Choices of Colon Cancer Patients in Four States in Appalachia.

While geographic disparities in cancer treatment are documented, little research has investigated patients' willingness to travel longer distances for treatment at higher-quality hospitals. Even fewer studies have compared metropolitan and non-metropolitan patients on this dimension. Using population-based data from the Appalachian counties of four states, we identified all hospitals within a plausible driving distance of each newly diagnosed colon cancer patient and estimated conditional logit models of hospital choices for cancer surgery. Two sets of important findings emerged. First, both metropolitan and non-metropolitan patients chose higher-quality over lower-quality hospitals, and were willing to travel farther to use high-quality facilities. Second, non-metropolitan patients were not willing to travel farther than their metropolitan counterparts to hospitals that were more desirable along most dimensions, but non-metropolitan patients were willing to travel farther to high-volume hospitals. These findings show how travel distances to high-quality hospitals contribute to geographic disparities in colon cancer treatment.

Effects of Hospital Type and Distance on Lymph Node Assessment for Colon Cancer Among Metropolitan and Nonmetropolitan Patients in Appalachia.

We studied differences in access to large or accredited cancer programs as a possible explanation for geographic disparities in adherence to the national guideline on lymph node assessment for Stages I to III colon cancer. State cancer registries were linked with Medicare claims of patients diagnosed from 2006 to 2008 from Appalachian counties of four states. Metropolitan and nonmetropolitan patients differed on adherence, proximity to high-volume or accredited hospitals, and hospital type. We modeled effects of hospital type on adherence with ordinary least squares and instrumental variables (instrumenting for hospital type with relative distance). The evidence was strongest for improved adherence in high-volume hospitals for nonmetropolitan patients. We estimate that roughly 100 deaths might be prevented over 5 years among each year's incident cases if the nonmetropolitan disparity in hospital volume were eliminated nationally. We conclude that regionalization or targeting smaller hospitals would improve adherence in nonmetropolitan areas, but also argue for improving adherence generally.

Reducing Medicaid Churning: Extending Eligibility For Twelve Months Or To End Of Calendar Year Is Most Effective.

Medicaid churning--the constant exit and reentry of beneficiaries as their eligibility changes--has long been a problem for both Medicaid administrators and recipients. Churning will continue under the Affordable Care Act because, despite new federal rules, Medicaid eligibility will continue to be based on current monthly income. We developed a longitudinal simulation model to evaluate four policy options for modifying or extending Medicaid eligibility to reduce churning. The simulations suggest that two options--extending eligibility either to the end of a calendar year or for twelve months after enrollment--would be the most effective methods for reducing churning. The other options--a three-month extension or eligibility based on projected annual income--would reduce churning to a lesser extent. States should consider implementation of the option that best balances costs while improving access to coverage and, thereby, the health of Medicaid enrollees.

Does cancer reduce labor market entry? Evidence for prime-age females.

Existing studies of the labor market status of cancer survivors have focused on the extent to which cancer disrupts the employment of individuals who were working when diagnosed with cancer. We examine how surviving cancer affects labor market entry and usual hours of work among females aged 28 to 54 years who were not working when first diagnosed. We find that prime-age females have employment rates 2 to 6 years after diagnosis that are 12 percentage points lower than otherwise similar women who were initially out of the labor force, full-time employment rates that are 10 percentage points lower, and usual hours of work that are 5 hours per week lower. These estimates are somewhat larger than estimates for prime-age women employed at the time of diagnosis and highlight the importance of considering nonworking females when assessing the economic and psychosocial burden of cancer.

New estimates of gaps and transitions in health insurance.

Changes in individual or family circumstances cause many Americans to experience gaps and transitions in public and private health insurance. Using data from the 2004-2007 Survey of Income and Program Participation, this article updates earlier analyses of insurance gaps and transitions. Eighty-nine million people (one third of nonelderly Americans) were uninsured for at least 1 month during those 4 years. Approximately 23 million lost insurance more than once. The analyses call attention to the continuing instability and insecurity of health insurance, can inform implementation of national reforms, and establish a recent baseline that will be helpful in evaluating the reforms' effects on coverage stability.

Use of psychotropic medications by US cancer survivors.

OBJECTIVES: This study aimed to describe national utilization of psychotropic medications by adult cancer survivors in the USA and to estimate the extra use of psychotropic medications that is attributable to cancer survivorship. METHODS: Prescription data for 2001-2006 from the Medical Expenditure Panel Survey (MEPS) were linked to the data identifying cancer survivors from the National Health Interview Survey, the MEPS sampling frame. The sample was limited to adults 25 years of age and older. Propensity score matching was used to estimate the effects of cancer survivorship on utilization of psychotropic medications by comparing cancer survivors and other adults in MEPS. Utilization was measured as any use during a calendar year and the number of prescriptions purchased (including refills). Analyses were stratified by gender and age, distinguishing adults younger than 65 years from those 65 years and older. RESULTS: Nineteen percent of cancer survivors under age 65 years and 16% of survivors age 65 years and older used psychotropic medications. Sixteen percent of younger survivors used antidepressants, 7% used antianxiety medications. For older survivors, utilization rates for these two drug types were 11% and 7%, respectively. The increase in any use attributable to cancer amounted to 4-5 percentage points for younger survivors (p < 0.05) and 2-3 percentage points for older survivors (p < 0.05), depending on gender. CONCLUSION: Increased use of psychotropic medications by cancer survivors, compared with other adults, suggests that survivorship presents ongoing psychological challenges.

Maintaining coverage, affordability, and shared responsibility when income and employment change.

The Affordable Care Act builds on existing sources of public and private health insurance, while creating new health insurance exchanges and subsidies. A potential disadvantage of preserving many sources of health insurance is the likelihood of abrupt changes in coverage or financial responsibility when individual circumstances change. This brief describes four policy challenges related to such changes: adjusting premium and cost-sharing subsidies when incomes change; coordinating eligibility for premium credits, Medicaid, and the Children's Health Insurance Program; encouraging and facilitating continuous coverage; and minimizing transitions between individual and small-business exchanges. Policy recommendations to reduce uncertainty, simplify coverage decisions, and minimize insurance transitions include extending coverage to the open enrollment period at the end of the year, generous treatment of income gains in correcting premium tax credits, and unifying the small-business and individual exchanges.

Medical expenditures of adult cancer survivors aged <65 years in the United States.

BACKGROUND: To the authors' knowledge, this is the first study to provide national estimates of medical expenditures for all adult cancer survivors aged <65 years. Most studies of expenditures for cancer survivors in this age group have been based on the Medical Expenditure Panel Survey (MEPS) and were limited to "affected survivors." METHODS: MEPS expenditure data for 2001 to 2007 were linked to data identifying all survivors from the National Health Interview Survey (NHIS), which is the MEPS sampling frame. The sample was comprised of adults ages 25 to 64 years. Propensity-score matching was used to estimate the effects of cancer on average total and out-of-pocket expenditures for all services and separately for prescriptions. Probit models were used to estimate effects on the probability of exceeding different expenditure thresholds. RESULTS: Mean annual expenditures on all services in 2007 were $16,910 ± $3911 for survivors who were newly diagnosed with cancer, $7992 ± $972 for survivors who had been diagnosed in previous years, and $3303 ± $103 for other adults. Fifty-three percent of survivors were not identified in MEPS but only by linking to NHIS. Expenditures for all survivors averaged approximately $9300 compared with $13,600 for "affected survivors." For previously diagnosed survivors, the increase in mean expenditures attributable to cancer was approximately $4000 to $5000 annually. On average, relatively little of the increase was paid out of pocket, but cancer nearly doubled the risk of high out-of-pocket expenditures. CONCLUSIONS: Previous MEPS analyses overstated average expenditures for all survivors. Nevertheless, the current results indicated that the increase in expenditures attributable to cancer is substantial, even for longer term survivors, and that cancer increases the relative risk of high out-of-pocket expenditures.

The implications of cancer survivorship for spousal employment.

BACKGROUND: The purpose of this research was to estimate employment effects for spouses of cancer survivors who were working at the time of the cancer diagnosis. METHODS: Spouses of cancer survivors were drawn from the Penn State Cancer Survivor Survey. Comparable spouses of individuals without cancer were drawn from the Panel Survey of Income Dynamics. The final sample included 827 spouses of cancer survivors (542 husbands, 285 wives) and 2,766 spouses of individuals without cancer (1,459 husbands, 1,307 wives). Three employment outcomes were studied 2-6 years after diagnosis: whether working, whether working full time (35+ hours per week), and usual hours per week. We used propensity scores to match cases to controls 3:1. RESULTS: Wives of cancer survivors had a lower probability (-7.5 percentage points) of being employed 2-6 years after diagnosis (p = 0.036). They were slightly more likely to be working full time, while averaging 1.1 fewer hours per week overall, but these effects were not statistically significant. Cancer's effect on husbands was not significant for any of the employment outcomes. However, if survivor wives and husbands were working at follow-up, they had more than twice the odds of working full-time (wives OR = 2.18, p = 0.0004; husbands OR = 2.65, p = 0.012) and worked more hours per week than other spouses (wives 1.9, p = 0.041; husbands 1.5, p = 0.04). CONCLUSIONS: The implications to cancer survivors and their spouses of these results is that the employment of survivor spouses, especially of wives, is somewhat reshaped by cancer in the medium to long run. However, there is little or no effect on aggregate hours worked by spouses who were employed at diagnosis.

Long-term employment effects of surviving cancer.

We compare employment and usual hours of work for prime-age cancer survivors from the Penn State Cancer Survivor Survey to a comparison group drawn from the Panel Study of Income Dynamics using cross-sectional and difference-in-differences regression and matching estimators. Because earlier research has emphasized workers diagnosed at older ages, we focus on employment effects for younger workers. We find that as long as two to six years after diagnosis, cancer survivors have lower employment rates and work fewer hours than other similarly aged adults.

Cancer survivorship, health insurance, and employment transitions among older workers.

This study examined the effect of job-related health insurance on employment transitions (labor force exits, reductions in hours, and job changes) of older working cancer survivors. Using multivariate models, we compared longitudinal data for the period 1997-2002 from the Penn State Cancer Survivor Study to similar data for workers with no cancer history in the Health and Retirement Study, who were also ages 55 to 64 at follow-up. The interaction of cancer survivorship with health insurance at diagnosis was negative and significant in predicting labor force exits, job changes, and transitions to part-time employment for both genders. The differential effect of job-related health insurance on the labor market dynamics of cancer survivors represents an additional component of the economic and psychosocial burden of cancer on survivors.

Transitioning to Medicare before age sixty-five.

Disabled workers who start receiving Social Security Disability Income (SSDI) must wait twenty-four months to qualify for Medicare. Legislation introduced in Congress would eliminate this waiting period, to guarantee that people with disabilities severe enough to qualify for SSDI will not be uninsured. We provide a longitudinal view of Medicare enrollment before age sixty-five by following a national sample of people ages 55-64. One person in six was covered by Medicare before turning sixty-five. A quarter of new enrollees were uninsured during the waiting period. There were great disparities in reliance on Medicare and coverage in the waiting period.

Meeting the need for personal care among the elderly: does Medicaid home care spending matter?

OBJECTIVE: To determine whether Medicaid home care spending reduces the proportion of the disabled elderly population who do not get help with personal care. DATA SOURCES: Data on Medicaid home care spending per poor elderly person in each state is merged with data from the Medicare Current Beneficiary Survey for 1992, 1996, and 2000. The sample (n=6,067) includes elderly persons living in the community who have at least one limitation in activities of daily living (ADLs). STUDY DESIGN: Using a repeated cross-section analysis, the probability of not getting help with an ADL is estimated as a function of Medicaid home care spending, individual income, interactions between income and spending, and a set of individual characteristics. Because Medicaid home care spending is targeted at the low-income population, it is not expected to affect the population with higher incomes. We exploit this difference by using higher-income groups as comparison groups to assess whether unobserved state characteristics bias the estimates. PRINCIPAL FINDINGS: Among the low-income disabled elderly, the probability of not receiving help with an ADL limitation is about 10 percentage points lower in states in the top quartile of per capita Medicaid home care spending than in other states. No such association is observed in higher-income groups. These results are robust to a set of sensitivity analyses of the methods. CONCLUSION: These findings should reassure state and federal policymakers considering expanding Medicaid home care programs that they do deliver services to low-income people with long-term care needs and reduce the percent of those who are not getting help.

Work disability associated with cancer survivorship and other chronic conditions.

The long-term effects of cancer and its treatment on employment and productivity are a major concern for the 40% of cancer survivors in the U.S. who are working age. This study's objectives were (1) to quantify the increase in work disability attributable to cancer in a cohort of adult survivors who were an average of 46 months post-diagnosis and (2) to compare disability rates in cancer survivors to individuals with other chronic conditions. Data from the Penn State Cancer Survivor Study (PSCSS) and the Health and Retirement Study (HRS) were compared. The PSCSS sample included 647 survivors age 55-65, diagnosed at four medical centers in Pennsylvania and Maryland. There were 5988 similarly aged subjects without cancer in the HRS. Adjusted odds ratios for work disability were estimated for cancer survivorship, heart disease, stroke, diabetes, lung disease, and arthritis/rheumatism with multivariate logistic regression. Even for cancer-free survivors, the adjusted disability rate was significantly higher in comparison to adults with no chronic conditions (female OR = 1.94; male OR = 1.89). There were few significant differences between disability rates for cancer and other conditions. The elevated disability rate is another argument for viewing cancer survivorship as a chronic condition potentially requiring a broad range of psychosocial services.

Responding to employment concerns of cancer survivors.

The report on cancer survivorship recently released by the Institute of Medicine called on providers to become familiar with the employment rights of survivors, to offer them information about employment rights and programs, and to help minimize the adverse effects of cancer on employment. This review is designed to help providers respond to the Institute of Medicine's recommendations by describing relevant employment and health insurance protections, nationally accessible services and information sources for survivors, functional limitations that may affect survivors' work, and a variety of rehabilitation services that may be helpful for survivors with disabling residual effects of cancer and its treatment. It also suggests directions for further efforts on the part of public and private cancer organizations, researchers, and clinicians to address the employment concerns of survivors.

Income disparities in the quality of life of cancer survivors.

BACKGROUND: Studies of cancer survivors usually report positive correlations between income and health-related quality of life (QoL). These correlations cannot necessarily be interpreted as income disparities because earnings and income are affected by health, as well as the reverse. OBJECTIVES: The goal of this study was to quantify income disparities in QoL among cancer survivors by using instrumental variables (IV) to assess and, if necessary, correct for reverse causality. METHODS: We constructed an instrumental variable for income from home ownership, sources of unearned income, marital status at diagnosis, and spousal characteristics. Then, we examined income's effect on QoL in regressions controlling for other clinical and demographic predictors of QoL. The data were from interviews in 2002 with a cohort of cancer survivors who were 25 to 62 years of age when diagnosed during 1997 to 1999. MEASURES: The Functional Assessment of Cancer Therapy-General (FACT-G) and the SF-12 measured QoL in multiple domains. Questions adapted from the Health and Retirement Study ascertained the ratio of annual family income to the poverty threshold in 2001. RESULTS: Endogeneity tests were sensitive to assumptions of linearity for the income-QoL relationship and the choice of QoL measure. Consistently estimated income disparities were significant in all QoL models. The income elasticity of QoL ranged from 2% to 10%. CONCLUSIONS: There are income-related disparities in the QoL of cancer survivors that cannot be explained away by the effect of health on earnings. High-income patients are not only more likely to survive cancer, but they enjoy better QoL as survivors.

Employment pathways in a large cohort of adult cancer survivors.

BACKGROUND: Employment and work-related disability were investigated in a cohort of adult cancer survivors who were working when they were diagnosed from 1997 to 1999 with a variety of cancers. Employment from the time of diagnosis through the early years of survivorship was studied, self-reported effects of cancer survival on disability and employment were quantified, and risk factors associated with cancer-related disability and withdrawal from employment were identified. METHODS: One thousand four hundred thirty-three cancer survivors were interviewed by telephone from 1 year to nearly 5 years after diagnosis. They were asked retrospectively about employment from the time of diagnosis to follow-up and about work-related disability at follow-up. They also were asked whether disabilities or reasons for quitting work were cancer-related. Return to work and quitting work were projected over time in a life-table analysis. Risk factors were identified from logit analyses. RESULTS: One of five survivors reported cancer-related disabilities at follow-up. Half of those with disabilities were working. A projected 13% of all survivors had quit working for cancer-related reasons within 4 years of diagnosis. More than half of survivors quit working after the first year, when three-quarters of those who stopped for treatment returned to work. Survivors of central nervous system, head and neck, and Stage IV blood and lymph malignancies had the highest adjusted risk of disability or quitting work. CONCLUSIONS: Cancer survival sometimes has long-term effects on employment and the ability to work. Employment outcomes can be improved with innovations in treatment and with clinical and supportive services aimed at better management of symptoms, rehabilitation, and accommodation of disabilities.

Low-income children's preventive services use: implications of parents' Medicaid status.

This article examines the effect of parents' Medicaid status on the use of preventive health services by young children. Using data from the 1996 Medical Expenditure Panel Survey (MEPS), we analyzed a logit model for receipt of any well-child visits (WCVs) that compared three groups of low-income children. The three groups, defined by the joint insurance status of children and their parents, involved Medicaid pairs (both the child and the parent had Medicaid throughout the year), mixed pairs (the child had Medicaid and the parent was uninsured), and uninsured pairs (both child and parent were uninsured). Medicaid coverage for children was positively associated with receipt of any WCVs. However, the utilization effect of Medicaid coverage for children was significantly larger when the parent was also on Medicaid instead of being uninsured. Considering uninsured children with uninsured parents in 1996, enrolling only the children in Medicaid would have increased the percentage with WCVs from 29 to 43 percent according to simulations with the logit model. If the parents were enrolled in Medicaid as well, the percentage of children with any WCVs would have increased to 67 percent.

Battery-powered health insurance? Stability in coverage of the uninsured.

This study assesses the stability of Americans' health insurance status over a four-year period. Relatively few Americans were continuously uninsured for the four years 1996 to 1999, but a sizable number of the uninsured lacked a stable source of coverage. At least as many people were repeatedly uninsured as experienced a single gap in otherwise stable coverage. Given these dynamics, policymakers should think of "uninsured" as referring not to people, but rather to gaps in coverage over time. Reforms that stop short of universal coverage should be evaluated in terms of their likely effects on the continuity and stability of coverage.