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Medicaid patients experience longest delays in melanoma surgery

Patients with melanoma were more likely to experience delays in surgery if they were insured by Medicaid compared with Medicare or private insurance, according to results published in JAMA Dermatology.

The aim of the retrospective cohort study was to investigate the time between diagnosis and surgery for patients with Medicare, Medicaid or private insurance in North Carolina between 2004 and 2011.

The analysis included 7,629 patients with a diagnosis of stage 0 to III melanoma who were continuously enrolled in insurance from at least 1 month before the month of diagnosis through 12 months after diagnosis, according to study background.

Surgical delay, defined as definitive surgical excision more than 6 weeks after diagnosis of melanoma, served as the primary endpoint.

The cohort was comprised of 3,631 (48%) patients on Medicare, 3,667 (48%) patients with private insurance, and 331 (4%) patients with Medicaid.

Fourteen percent of patients with private insurance experienced delays to surgery compared with 17% covered by Medicare and 24% covered by Medicaid (P < .001).

In an analysis that adjusted for demographics, the trend of increased surgical delays for Medicaid compared with private insurance persisted (RR = 1.36; 95% CI, 1.09-1.70).

Nonwhite patients also carried an increased risk for delay (RR = 1.38; 95% CI, 1.02-1.87).

Delays occurred less frequently when a dermatologist was performing the surgery (RR = 0.82; 95% CI, 0.72-0.93) or making the diagnosis (RR = 0.81; 95% CI, 0.71-0.93) compared with a nondermatologist.

“A reduction in delays in melanoma surgery could be achieved through better access to specialty care and cross-disciplinary coordination,” the researchers concluded.

In an accompanying editorial, Jason P. Lott, MD, MHS, MSHP, of the Cornell Scott-Hill Health Center, New Haven, Conn., wrote that the data set by Adamson is a welcome addition to the body of knowledge in the specialty.

“The authors’ primary question — does patient insurance type (commercial, Medicare or Medicaid) influence time to surgery for primary incident melanoma? — addresses a fundamental issue regarding the most commonly used therapy for this serious disease,” he wrote, and added that a number of conclusions can be drawn from their results.

“First, it is sufficiently clear that Medicaid patients in North Carolina experience unequal temporal patterns of surgical care for primary melanoma compared with patients covered by other payers,” he wrote. “As the authors note, whether these results are generalizable to other regions of the United States is unknown, but it is possible (if not probable) that similar surgical delays occur among Medicaid patients elsewhere.”

Adamson also highlighted the finding that nonwhite patients and those in rural vs. nonrural areas also experienced delays.

“Third, surgical delay for melanoma is not merely restricted to Medicaid patients but in fact occurs for a substantial fraction of all patients, regardless of payer status,” he wrote, adding that patients treated by a dermatologist experienced shorter delays.

“What this study does not (nor was intended to) answer, however, is ‘why?’ — why are differences in time to surgery for patients with melanoma associated with payer status and select patient characteristics?” he wrote. “This is obviously a complex question, but several hypotheses might be considered.”

One is that physicians may not have financial incentives to treat patients covered by Medicaid compared with other insurance, according to Adamson. He added that another is that patients covered by Medicaid face stigma, structural barriers and nonmedical challenges related to transportation, language and environment.

“To some extent, all may be true,” he wrote. “An equally important question is whether the surgical delays for melanoma described in this study are, in fact, meaningful. The authors themselves are cognizant of this point — the existence of disparity in time to surgery per se is no cause for despair if the metric itself is flawed, such that either presence or absence of delay results in indistinguishable outcomes (irrespective of insurance status or other patient-, clinician- or payer-level characteristics).”

Adamson suggested that the 6-week period defining delay has not been firmly established as the most appropriate cutoff point.

“What is certain, however, is that we have much left to learn,” he wrote. “Hopefully, this research will be one of many steps toward ultimately elucidating sources and causes of variation in time to surgery, as well as other aspects of melanoma care utilization, as we continue to strive to deliver the best dermatologic care for our patients.” – by Rob Volansky

Disclosures: Lott reports being an employee of Bayer Healthcare LLC, but that the company had no involvement in the manuscript. The other authors’ report no relevant financial disclosures.