In an interview with Targeted Oncology, Cary Gross, MD, discussed retrospective research that revealed testing and treatment disparities among Medicaid beneficiaries with advanced non–small cell lung cancer, and the steps needed to improve outcomes for the patient population.
Across community practices and hospitals in the United States, patients with advanced non–small cell lung cancer (NSCLC) who are Medicaid beneficiaries are less likely to undergo the recommended biomarker testing and receive biomarker-driven therapy compared with private insurance holders.
The results come from electronic medical records of patients with advanced NSCLC who were between the ages of 18 and 64, with either Medicaid or commercial insurance at diagnosis. The recommended biomarker tests for advanced NSCLC include ALK, EGFR, ROS, and BRAF gene alterations, as well as PD-L1 expression. Moreover, the recommended biomarker-driven therapies for advanced NSCLC include immunotherapy or tyrosine kinase inhibitor treatment.
“There is a difference here. Medicaid is substantially less than private insurance,” said Cary Gross, MD, professor of medicine and of epidemiology, and founder and director, the Cancer Outcomes, Public Policy and Effectiveness Research Center, Yale School of Medicine; director, Adult Primary Care Center, Quality Improvement; chair, National Clinician Scholars Program; and director, National Clinician Scholars Program, in an interview with Targeted Oncology™.
“But also, even with private insurance, only 45% of patients were getting the recommended testing in 2018. So, I think we're in a situation where it's important to look at the inequity. But also, it's important to look at the overall focus of about what we're doing and how we could intervene to improve access to biomarker testing for all patients,” he added.
In the interview with Targeted Oncology, Gross discussed his retrospective research, which revealed testing and treatment disparities among Medicaid beneficiaries with advanced NSCLC. He also explained the steps needed to improve outcomes for the patient population.
TARGETED ONCOLOGY: Can you provide background of Medicaid patients and how testing and treatment may differ for them?
Gross: The reason my authors and I set out to study the relation between Medicaid and the quality of lung cancer care is that Medicaid is a vitally important payer in the American health care system. It's our nation's largest public health insurance program and covers approximately 1 in 5 Americans. For our study, that comparator was patients with private insurance. But what I wanted to be clear about is that Medicaid is far better than having no insurance. Many studies have shown that patients with Medicaid have better access to care than the uninsured. Patients with Medicaid are more likely to get high quality care and have higher satisfaction than patients who are uninsured. So, I wouldn't want anyone to look at our study and say, “I guess Medicaid is not that good,” or “Let's get rid of Medicaid.” That's not what we're talking about. This is a study of Medicaid versus private insurance. And the reason why we set out to explore Medicaid is because prior studies have suggested that patients with cancer and Medicaid experience lower quality of care than patients who are privately insured.
Recently, a colleague here at Yale, Dr. Michael Liebman, did a study where they surveyed 300 large cancer hospitals. There was a secret shopper survey. They had the secret shoppers call, pretending there are patients with 4 different cancer types, and sometimes they said they had Medicaid and sometimes they said they had private insurance. What they found was when patients called saying that they had Medicaid, one-third of hospitals across the country would not see patients with all 4 cancer types who had Medicaid. And that speaks to the issue of how it can be challenging for Medicaid beneficiaries to get access to high quality cancer care. So that's why we wanted to look more closely at this issue of Medicaid in the setting of biomarker testing and targeted cancer therapy in lung cancer.
What biomarker testing is recommended in the National Comprehensive Cancer Network [NCCN] guidelines for patients with advanced NSCLC?
So, the progress against lung cancer is so rapid that these biomarkers are cropping up every year or 2. It began as recommendations to test for EGFR or ALK mutations, and BRAF. In the more recent years, RET, MET, and KRAS have cropped up. There are several biomarkers, and it's increasing over time. Our study period ended in 2019, so we looked at about 4 or 5 biomarkers. But that's an important concept, that A) it is complex and evolving, and B) for our study, we only looked at biomarkers that were deemed to be recommended up through 2019.
Can you discuss your key goals for the retrospective analysis?
We looked at a large cohort of community-based practices. These were patients with lung cancer who were treated in the community setting across the country. We looked at their de-identified electronic medical record data to answer the following questions: How is Medicaid insurance compared to private insurance? Is Medicaid insurance associated with the quality-of-care for advanced non–small cell lung cancer with respect to both biomarker testing, and biomarker-driven treatment? We also looked at survival in Medicaid patients vs [those with] the private insurance.
What methods were used to conduct this analysis?
We partnered with a data science company, which is called a Flatiron, to use their de-identified data. And we pulled together a sample of about 7,000 patients with advanced non–small cell lung cancer from across the country. Then, we did a head-to-head comparison of the patients who had Medicaid, which comprised about 10% of the sample to the remainder of the privately insured patients, which is roughly 6,000 patients.
We used a multivariable model to adjust for clinical factors such as the cancer type and stage of diagnosis, and we looked at different years to adjust for time. We also adjusted for race and ethnicity, because it's important to emphasize that in this country. We have legacy and ongoing systemic racism. We wanted to know after you balanced out the race and ethnicity between the Medicaid and the commercial groups, are there persistent differences in quality of care. It's just an important caveat to our study is that we recognize that because Medicare is often the first option for many [minority] patients who need insurance. But it's vital when we're thinking about levers for change, levers to address racism and promote equity, that we need to think about how can we better understand the Medicaid program and, if needed, improve the quality of care for Medicaid beneficiaries?
What is notable about the study findings?
With regard to testing, we found that patients with Medicaid were substantially less likely to get biomarker testing. For instance, for EGFR testing, privately insured patients, about 65%, received EGFR testing versus 41% of Medicaid [patients], and ALK testing [occurred in] 63% of private[-insure patients vs] 48% of Medicaid [patients]. This was a consistent finding across all the different biomarkers that we looked at. If you put it all together, [we] ask the question, which patients received all the tests they're supposed to be getting at any given time, [what] we found was that in the final study year of 2018, 45% of patients with private insurance had received all the recommended testing. Only 34% of patients who have Medicaid received all the recommended tests. So, those are the 2 main findings here.
…The second main finding was related to treatment. The natural question was if the Medicaid patients are less likely to get biomarker testing, are they also less likely to get biomarker-driven therapy? And, as one would expect, that's exactly what we found. Medicaid beneficiaries were 30% less likely to receive biomarker-driven therapy, then commercially insured patients. Unfortunately, we also found that patients with Medicaid had a 23% higher risk of death than patients with private insurance. Then, what we did is we then adjusted in our model for whether each individual patient had received biomarker testing and biomarker treatment. We looked at the difference in mortality without adjusting for who got [testing]. And as I mentioned, the Medicaid patients were 23% more likely to die, then we accounted for who got testing and treatment. And we found that the relative risk decreased somewhat so the higher risk was down to 15% associated with Medicaid. What that means is [with] unadjusted Medicaid, 23% had higher risk of death. After we accounted for biomarker testing and treatment, Medicaid patients [had a] 15% higher risk of death. That means that a fair proportion of this disparity in survival in Medicaid patients can be attributed to this lack of access to testing and treatment. These findings strongly suggest that treatment is 1 of the main culprits in why Medicaid patients with lung cancer are having worse outcomes.
What should providers take away from this research?
Often, we tend to think of policy, just as something that happens maybe in Washington, DC. And, clearly, we need to advocate for improvements and change to our Medicaid program. I mentioned earlier that this other study found that many hospitals don't accept Medicaid patients. And one reason behind that maybe because Medicaid reimburses much less than private insurance. So, at the big picture of policy level, we need to advocate for improvements to the Medicaid program. That may be focused around increasing reimbursement rates to ensure that these patients are able to get into any clinic and hospital they need to. Also, though, I think this is an opportunity for the medical establishment to think where are they? Where are we as individuals? Where are we as individual practices for hospitals? Where do we stand regarding health equity, and are we seeing Medicaid patients as promptly as our commercial patients? Are we ensuring that our patients with Medicaid have access to appropriate testing and treatment? I would just argue that sometimes advocacy, I think all physicians know that the vast majority of physicians do this on a daily basis. But advocacy also happens at the individual patient by patient level, so it's not only about politics, it's about advocating for our patients who are trying to get into our doors and in the hospitals.
I think these findings are they're really a call to action both for policymakers, but also just for food for thought for what we can do to advocate at our local level.
What are your recommendations on how to improve care for patients with advanced NSCLC who are treated in the community setting?
One of our more surprising findings was that back in 2018, there was still a relatively low uptake of biomarker testing. So, I think for all patients, it's critical that we identify mechanisms to ensure that our patients are getting an evidence-based testing and evidence-based treatment. And then, we need to address the vital health equity questions.
Gross CP, Meyer CS, Ogale S, et al. Associations Between Medicaid Insurance, Biomarker Testing, and Outcomes in Patients With Advanced NSCLC. J Natl Compr Canc Netw. 2022 May;20(5):479-487.e2. doi: 10.6004/jnccn.2021.7083.