Plenary Coverage: ASCO Chief Medical Officer Dr. Richard L. Schilsky Discusses LBA1 with Dr. Amy Davidoff.

Welcome to the ASCO Daily News podcast. I'm Dr. Richard Schilsky, Senior Vice President and Chief Medical Officer of ASCO. I'm pleased to be joined by Dr. Amy Davidoff, Senior Research Scientist in the Department of Health Policy and Management at the Yale School of Public Health and a member of the Yale Cancer Center to discuss racial disparities in cancer care. Dr. Davidoff presented abstract LBA1 entitled "Affordable Care Act-- Medicaid Expansion Impact on Racial Disparities in Time to Cancer Treatment" during today's plenary session. Dr. Davidoff, welcome to the podcast.

Thank you for inviting me.

So, obviously, the Affordable Care Act has changed the landscape for patients with cancer in many ways, including by expanding insurance coverage and improving access to care. Why did your team decide to examine the impact of the ACA through the lens of racial disparities?

Prior to the ACA, low income, non-elderly adults had high rates of insurance and poor access to care, whether overall or for adults diagnosed with cancer. The population of uninsured adults was disproportionately African-American and numerous studies on the effects of the Affordable Care have demonstrated increases insurance and reduced race disparities in coverage. So we decided that we really wanted to understand whether this reduction in race disparities in coverage translated into improvements in care processes.

With respect to cancer, studies by policy researchers, including myself, have demonstrated increases in insurance coverage for newly diagnosed cancer patients and some evidence of earlier stage at diagnosis for newly diagnosed cancer patients but very little research related to the Affordable Care Act in cancer patients has focused on the real processes of care. The flatiron data set allows a really rich examination of that dimension. And so we decided to examine whether there were disparities in timely treatments and whether the ACA was associated with reductions in those disparities.

Makes good sense. Obviously, racial disparities in cancer care pose a serious issue and, in fact, a crisis for many patients who are at risk for either a delay in diagnosis or a delay in initiation of treatment as you point out. So tell us about your findings. How has the Medicaid expansion under the ACA improved access to care for African-American patients? Why do those patients seem to have benefited more from the Medicaid expansion than the white patients in your study population?

As we all know, insurance is a really important factor in improving access to health care, generally-- specifically specialty care, such as oncology care-- and particularly for very low income adults who lack the financial needs to pay for care out of pocket. So to the extent that the ACA Medicaid expansions increased insurance coverage for African-Americans, we would expect reduced delays in diagnostic, workup, treatment initiation, continuation, and improvements in other outcome dimensions. We think that African-Americans likely benefited more than others because they had the most to gain in terms of insurance coverage.

So what was the actual magnitude of benefit that you observed on your time point of time to treatment initiation?

Prior to the Medicaid expansion, we measured that 43.5% of African-American patients were treated within 30 days of diagnosis and that was almost 5 percentage points less than for white patients after accounting for patient age, sex, and other factors that may have affected that timing. Patients diagnosed after their state had expanded Medicaid, among those almost 50% of African-American patients were treated within 30 days, which is now less than 1 percentage point less than for white patients. So the gap between African-American and white patients that we observed prior to Medicaid expansion had almost nearly disappeared for patients who were diagnosed in states with Medicaid expansions. So as you point out your study focused primarily on time to treatment initiation and we presume that will eventually lead to better outcomes for cancer patients. Will you be continuing to study this cohort determine if better outcomes actually were observed? We certainly can do that, particularly over time as we have longer periods in which to observe patients. We have not yet looked at that. And we certainly could for patients diagnosed in states with earlier expansions.

Do you attribute the findings of your research to be due entirely to Medicaid expansion and the presumed greater access to care? Or are there other potential covariates that, perhaps, you haven't accounted for that might explain the earlier time to treatment initiation? This is something I've actually been wondering about myself is, is this strictly a result of Medicaid expansion? Or could there have been other things going on in those states at the same time or with those populations at the same time that contributed to the earlier time to treatment initiation?

[? We ?] think there are a lot of things that are happening during this time period, including the introduction of many of the novel immunotherapies at end of life often that require some type of genetic testing prior to deciding about treatment. And those are happening concurrent with this sort of expanding Medicaid period that we're looking at. I think, though, that we account for those changes that are occurring over time by including control variables for quarter times, the calendar quarter.

We also take into account state effects which control for sort of any unchanging underlying characteristics of each state in the analysis. So in terms of covariates, I think I'm less worried about that and more interested in other ways that the Affordable Care might have influenced timely treatment. Improving access to primary care which may have somehow assisted patients to be more informed, educated about their cancer treatment options if they had a primary care provider who is assisting them in managing those transitions. If patients were being enrolled in a clinical trial, the Affordable Care Act improves access to insurance coverage for routine care for patients in a clinical trial. So there are other aspects of the Affordable Care Act that could have facilitated these changes in timely treatment.

Your point about access to primary care I find really interesting. Because in a sense, it's generally the primary care physician who makes the diagnosis of cancer. It's not the oncologist. And so when you're looking at a data set of oncologists medical records, you're looking at a population of patients who have already found their way to the oncologist.

But in order to get to the oncologist, they presumably enter the health care system with a primary care provider who establishes the cancer diagnosis, gets them to the oncologist who can then initiate the treatment, which was your primary outcome measure. So there is an interesting progression here from how and when the patient can actually enter the health care system when some potential cancer related symptom initially surfaces. So it's really interesting point.

I try to think holistically. In terms of this policy, I think-- not to get into politics here, but I think people who see the Affordable Care Act as just insurance coverage need to sort of step back and think about the just wide range of ways that it affects health care providers, payments, health care delivery innovation, et cetera. It's really very broad.

Yes, so I was going to sort of wrap up with that question. Not to get into politics, but, obviously, the Affordable Care Act has been under threat really from the moment it was passed, maybe even before that of course from those who opposed its passage. But it is at least for the moment the law of the land. I suppose it's possible that if significant changes are made over time that states will find it more difficult to sustain this Medicaid expansion. Now, just curious as to what you're thinking about over the longer term in terms of how these benefits that are accruing to these patient populations can be sustained or what the consequences could be if the Medicaid expansion can't be continued?

I think it's always hard to know how people [AUDIO OUT] when you take away something new that you've given them. So it is possible that even if some of the Medicaid expansions are rescinded that people may be motivated to obtain insurance through other mechanisms, certainly people who were eligible for Medicaid under sort of the pre-Affordable Care Act mechanisms who sort of came out of the woodwork to enroll once the Affordable Care Act was publicized and promoted. Those people probably will stay enrolled in Medicaid. But for certain populations, they were never eligible previously. And so they would probably lose their coverage. And we would go back to probably newly enhanced disparities in treatment associated with insurance, which is disproportionately affecting vulnerable populations such as African-Americans.

So it's certainly something that we'll have to be alert to. And, obviously, I think your research findings in a sense illustrate the potential favorable impact of Medicaid expansion, but also expose the risks of potentially retrenching from that position. So thanks a lot for discussing your research with me. It's been really a great conversation. Again, today, my guest has been Dr. Amy Davidoff of the Yale Cancer Center. Thanks for being on our podcast. You're very welcome.

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