Need Surgery for Melanoma? Which Insurance Causes Delays?

Roxanne Nelson, BSN, RN

October 04, 2017

The type of insurance coverage can influence how quickly a patient with melanoma is able to undergo surgical treatment.

Compared with patients covered by Medicare and private insurance, Medicaid patients were significantly more likely to experience delays in surgery, according to new findings.

In contrast, those with private insurance had the least frequent number of surgical delays.

Led by Adewole S. Adamson, MD, MPP, from the University of North Carolina at Chapel Hill, the authors found that 24% of patients on Medicaid underwent surgery 6 weeks or later from time of diagnosis, as compared with 17% of Medicare patients and 14% of patients with commercial insurance.

Physician specialty also played a role in surgical timing. Delays were less likely if the surgery was being performed by a dermatologist than by a nondermatololgist.

"Delays in melanoma care could be reduced through better access to specialty care and cross-disciplinary partnerships to ensure that patients can safely navigate the treatment episode," the authors write. "Understanding why Medicaid patients receive less timely care for melanoma should be given further scrutiny," they add.

The study results were published October 4 in JAMA Dermatology.

In this study, Dr Adamson and his colleagues aimed to find out whether insurance payer, patient-level, clinician-level, or tumor-level factors were associated with delays in surgery for patients diagnosed with melanoma.

Their retrospective cohort study included 7629 patients who were diagnosed with melanoma between 2004 and 2011 in North Carolina. Data were acquired from the North Carolina Cancer Registry, which is linked to administrative claims from Medicare, Medicaid, and private insurance.

Most patients were covered by Medicare (n = 3631 [48%]) or a private carrier (n = 3667 [48%]), with a small proportion covered by Medicaid (n = 331 [4%]). The most common anatomic site for tumors was the head and neck (29%), followed by the trunk (28%), upper extremities (26%), and lower extremities (16%).

Most of the tumors were early stage, with almost half (44%) diagnosed at stage 0 (melanoma in situ) and 38% at stage I.

Overall, 16% (n = 1207) of patients experienced a delay in surgery of longer than 6 weeks. When broken down by insurance type, those with private insurance had the fewest delays vs Medicare and Medicaid patients (519 [14%], 609 [17%], and 79 [24%], respectively).

Other factors associated with surgical delay included older age (P = .03) and nonwhite race (33 [24%] vs 1174 [16%]; P = .02) and having a rural ZIP code (471 [17%] vs 736 [15%]; P = .004).

Tumor location (P < .001) and higher disease stage (P < .001) were also associated with delays in surgery beyond 6 weeks.

The likelihood of a delay was reduced if the physician performing the surgery (risk ratio [RR], 0.82; 95% confidence interval [CI], 0.72 - 0.93) or the clinician who made the diagnosis (RR, 0.81; 95% CI, 0.71 - 0.93) was a dermatologist vs a clinician from another specialty.

One of Many Steps

In an accompanying editorial, Jason P. Lott, MD, MHS, MSHP, from the Cornell Scott-Hill Health Center, New Haven, Connecticut, points out that the study doesn't answer the "why" question.

The design was not intended to delve into the reasons for surgical delays, and it is "obviously a complex question," says Dr Lott. He offers several hypotheses as to why Medicaid patients have increased surgical delays.

One is that physicians may be financially disincentived to treat Medicaid vs non-Medicaid patients, and also that Medicaid patients "may face more stigma and other structural barriers to effectively access care."

"Medicaid patients may experience greater contextual challenges outside clinic walls that impede care delivery (eg, transportation, language, built environment) that extend beyond the untoward effects of low income or poverty," writes Dr Lott.

The findings of the study also reinforces the importance of physician specialty in the provision of surgical care for melanoma, and this is consistent with previous research, he notes.

"[D]elay is minimized when dermatologists are the primary caretakers from biopsy to excision," notes Dr Lott. "Albeit unproven, several factors may account for this observation."

One factor is that coordinating care may be more easily accomplished among and across dermatologists as compared with other specialties "because the former have deep expertise in the diagnosis and management of this condition, as well as solidified professional relationships that provide networks for referral and surgical treatment when necessary," he says.

There is still much to learn, Dr Lott concludes, and he is hopeful that 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."

This study was supported in part by the University of North Carolina at Chapel Hill Department of Dermatology and the University of North Carolina Integrated Cancer Information and Surveillance System. The study authors have disclosed no relevant financial relationships. Dr Lott is an employee of Bayer Healthcare LLC

JAMA Dermatol. Published online October 4, 2017. Abstract, Editorial

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