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Outcomes of Patients With NSCLC Participating in Medicaid vs Commercial Insurance
Research has indicated that Medicaid patients with cancer receive lower-quality care than those with commercial insurance. For example, an analysis of ALK biomarker testing in patients with non–small cell lung cancer (NSCLC) found that Medicaid patients were 40% less likely to be tested than commercially insured patients. Moreover, a study that examined cancer survival found that, compared with patients with private insurance, patients with public insurance had an increased risk of mortality ranging from 11% to 25%, depending on the type of cancer. However, whether access to biomarker testing and personalized medicine accounts for differences in outcomes is unknown.
To examine the associations between type of insurance and use of biomarker testing, targeted therapy, and overall survival, Cary Gross, MD, Cancer Outcomes, Public Policy and Effectiveness Research Center, Yale Cancer Center, New Haven, CT, and colleagues conducted a retrospective study of patients diagnosed with advanced NSCLC from January 2011 to September 2019 (JNCCN. 2022;20(5):479-487. doi:10.6004/jnccn.2021.7083).
Findings showed that, compared with commercially insured patients, Medicaid patients with advanced NSCLC were less likely to receive biomarker testing and biomarker-driven therapies, “which may in part contribute to [their] higher observed risk of mortality compared with commercially insured patients,” wrote Dr Gross and colleagues.
Eligible study patients were selected from a nationwide US healthcare database and had to be between 18 and 64 years old and have Medicaid or commercial insurance at diagnosis. Using these criteria, the researchers enrolled 6145 commercially insured patients and 865 Medicaid patients. They then assessed whether patients received biomarker testing for ALK, EGFR, ROS1, BRAF, and programmed death-ligand 1. In addition, they used adjusted Cox regression to compare the likelihood of being tested, receiving biomarker-driven therapy such as cancer immunotherapy or tyrosine kinase inhibitors, and mortality by insurance type.
The researchers found that Medicaid patients were more likely to be black or African American (20% vs. 9.3%, P<0.001) and less likely to receive biomarker testing (57% vs. 71%, P<0.001) than commercially insured patients.
Results of the adjusted analysis revealed that Medicaid patients were less likely to have evidence of testing (hazard ratio [HR], 0.81; P<0.001), any first-line treatment (HR, 0.72; P<0.001), and first-line biomarker-driven therapy (HR, 0.70; P<0.001) than commercially insured patients.
The greater risk of death found among Medicaid patients compared with commercially insured patients (HR, 1.23; P<0.001) remained unchanged after adjusting for biomarker testing but was somewhat improved after adjusting for testing and treatment types (HR, 1.12; P=0.01). However, Medicaid patients with evidence of biomarker testing had a lower risk of death than those without evidence of such testing (HR, 1.27; 95% confidence interval, 1.06 to 1.52; P=0.01).
“Medicaid beneficiaries with [advanced] NSCLC had a 19% and 30% higher risk of not receiving biomarker testing and biomarker-driven therapy, respectively,” Dr Gross and team noted, adding, “Furthermore, Medicaid beneficiaries had an observed 23% higher risk of mortality than commercially insured patients, which may be partially mediated by disparities in receipt of treatment in general and targeted therapies in particular.”
“Improved access to evidence-based molecular testing and targeted therapies may improve outcomes for Medicaid beneficiaries with lung cancer,” they concluded.
