Insurance Type Linked With Disparities in the Treatment of Gynecologic Cancer

Whether a patient with gynecologic cancer has insurance or is underinsured, there are major barriers which currently exist in accessing and affording quality care for the treatment of their cancer.

While new therapies, such as dostarlimab (Jemperli), have been approved for the treatment of patients with endometrial cancer by the FDA, the costs of obtaining these agents may be beyond what one can afford, leaving patients with more medical expenses than originally bargained for.

In gynecologic oncology, the majority of patients are 65 and older and have some form of Medicare. However, costs, access to quality care, and services can vary based on which Medicare plan one is able to afford. Those who lack insurance often face lower rates of screening and surveillance for their cancer, delayed follow-up after abnormal results, later stage diagnosis, and delays obtaining the proper type of care.

These disparities are a major problem as they contribute to one-third of women with gynecologic cancer never visiting a gynecologic oncologist, even though this is the standard of care recommended by both the Society of Gynecologic Oncology (SGO) and American Society of Clinical Oncology (ASCO).

“There needs to be a gynecologic oncologist in every insurance network and patients should have a choice of where they can go, so they can access the provider that they feel is right for them. They should be able to get guideline recommended care while minimizing the hoops, such as prior authorization, delays, or preauthorization, and they should be able to get it at a cost that isn't going to make them go bankrupt,” stated Anna Jo Bodurtha Smith, MD, in an interview with Targeted Oncology^TM.

In the interview, Smith, a third year Gynecologic Oncology fellow at the University of Pennsylvania, fellow at the Penn Center for Cancer Care Innovation and Leonard Davis Institute of Health Economics, discusses the effects various insurance types have on the quality of care of patients with gynecologic cancers.

Targeted Oncology: Can you discuss your research on insurance mediated disparities in gynecologic oncology?

Smith: One of my long-term interests has been on how insurance affects availability, access and affordability of care in the United States. We traditionally think about insurance alone being the biggest thing about access to care, but we know that there are specific barriers to care. There are issues with affordability, availability, and accessibility of care for insured patients.

This was a review article looking at every step of the gynecologic oncology process from screening or symptom presentation to diagnosis. From diagnosis to treatment, to surveillance, to insurance and whether patients have public insurance such as Medicare and Medicaid or private insurance where there are potential barriers based on their insurance type.

What sparked your interest in looking at insurance-mediated disparities in this space?

It's both based on my prior research, as well as my own personal family experience. Starting with the family experience, my grandfather got diagnosed with cancer when he was around my current age. This was prior to us having a lot of the health programs we have now, prior to Medicaid, prior to Medicare, etc., and he and my mom lost everything. They lost their insurance; they ended up paying for everything out of pocket and it is sort of the formative family story we have about what happens when you get cancer and don't have insurance.

That spurred my early interest in insurance and starting in college, I've worked since then on how insurance impacts health care outcomes. More recently as an OBGYN resident, I finished my medical training around the time of the Affordable Care Act and was very interested on how the Affordable Care Act could impact patients with gynecologic cancer. Much of my research that preceded this article was around the fact that the insurance gain under the Affordable Care Act did lead to earlier stage diagnosis, earlier access to care, and we were publishing data that improves survival. Insurance really does matter for patients with gynecologic cancer.

In what ways does having insurance or not impact health care outcomes in patients with gynecologic cancer?

What we talk about a lot is whether having insurance or not matters. We know that patients who are uninsured are less likely to get screening, which for cervical cancer, breast cancer, or colorectal cancer, is so important. They're more likely to delay presentation to care and ultimately diagnosed with late stage less likely to be cured.

What I was interested in in this article, which sort of had been spurred by my research on the Affordable Care Act, is what happens when patients are insured, but their insurance isn't enough? Or there's something we call underinsured meaning they either struggle to afford care with their insurance, they aren't able to access it with their insurance, or it's not available with their insurance. We specifically looked at each of those stages for Medicaid, Medicare, and private insurance and looked at where the barriers were.

Can you further discuss some of the barriers seen with each type of insurance?

It varies a bit by your insurance as to what the barriers are. Starting with private insurance, because I think that's what we traditionally think about when getting people the care we need in the United States model of employer sponsored insurance, we know there can be issues from your symptoms throughout treatment. One of the big issues at the start is that the Affordable Care Act covers cervical cancer screening, but private insurance is not required to cover the cost of any follow-up. We know that the follow-up for abnormal cervical cancer screening can be quite costly for a lot of privately insured patients.

Similarly, gynecologic visits are not not always consistently covered and the care you may need for gynecologic symptoms, such as vaginal bleeding or bloating, which are symptoms of gynecologic cancer, those visits may have a high copay, limiting women's patient's ability to get in for those early symptoms. Then once you're diagnosed with gynecologic cancer with private insurance, we're seeing more and more plans that have narrower health care networks. So it may be that there is a gynecologic oncologist in your network but it's not the one closest to you. Your insurance wants to go see somebody far away or they may not be the provider that's local. There is some research that there have been insurance plans that have no gynecologic oncologist in the network. One has to navigate how to get care for their cancer when insurance is saying there is nobody who can care for it.

Then we know that private insurance plans have, understandably, tried to figure out how we can lower the cost of care. Unfortunately, a lot of the costs fall back on patients. During one's cancer treatment with private insurance, one may experience high cost of visits for follow-up and medications can be quite expensive. We know that patients with private insurance on average spend $5,000 in their first year of gynecologic cancer treatment, which is a lot of money. Then, we know that there are more things like prior authorization that can cause delays and put up administrative barriers to getting patients the gynecologic cancer care they need with private insurance.

One of the other things we found in our research, and I find in my clinical practice is, there have been specific barriers for patients with Medicare. Particularly with the fact that about a third to half of patients with Medicare have Medicare Advantage, which is a sort of private form of Medicare, we need to make sure, since Medicare is a national program that is supposed to get patients access to cancer care, that we're also thinking about the elderly who are the most vulnerable population and that they have similar access to affordable cancer drugs. Regardless of if they choose to be on traditional Medicare, or if they choose to be in a Medicare Advantage, or Medicaid private insurance, that they have the same access to care. We did see that there were some differences between traditional Medicare and Medicare Advantage in terms of patients being able to see and afford gynecologic oncology services.

How can we best address these insurance-mediated disparities?

For patients with private insurance, 1 of the things that national networks, such as SGO and ASCO, are working on is that we should have insurance to cover the standard of care. We should have insurance to cover these treatments in ways that are affordable and accessible to patients. There needs to be a gynecologic oncologist in every insurance network and patients should have a choice of where they can go, so they can access the provider that they feel is right for them. They should be able to get guideline recommended care while minimizing the hoops, such as prior authorization, delays, or preauthorization, and they should be able to get it at a cost that isn't going to make them go bankrupt.

Your research stated that 1/3 of women with gynecologic cancer never see a gynecologic oncologist? Why is that number so high and what can we do to change it?

It is staggeringly high. Every guideline for the last 20-25 years has recommended that if you have gynecologic cancer, you see a gynecologic oncologist. For other cancers, we would not say you can just see anybody. You should see a specialist. So why do women's gynecologic cancers end up in that situation? Some of it is insurance issues. There's nobody nearby, there's nobody in your insurance plan, and then we know that because gynecologic oncologists are subspecialists, and there are only around 1000 in the country, patients may struggle to travel to one. I think insurers have a lot they could do to improve care and 1 of the things is saying that the standard of care is seeing a gynecologic oncologist and they will help you get there. They should figure out how to have a telemedicine visit with somebody if there's not somebody local, or if the nearest oncologist is far away, figure out how we can physically get you there.

What are the key recommendations you hope people take away from this research?

A couple takeaways for clinicians is to ask patients about what their barriers are once they get in the door. Are they going to struggle to see you because it's far away? Are they going to struggle with the co-pay? Are there ways you can work with them or their insurance to make their care go the best possible without breaking the bank? For health systems, are there ways you can work with insurers to make sure that all their patients are getting incentivized to see a gynecologic oncologist? Are there ways to work with insurers to encourage them to help their patients get the standard of care? Then for policy makers, we should have good national guidelines for what cancer treatments should be. Making sure that every patient, regardless of where they live, type of insurance, etc., has access to those cancer therapies at an affordable cost.

After reading this research, what should oncologists keep in mind when treating these types of patients?

I think getting people into a gynecologic oncologist is probably the biggest thing and making sure that patients do see us at some point in their treatment. It can be that we work closely with their local providers to then get them the chemotherapy they need. We don't need to do everything ourselves. Making sure they see us once and then making sure that others just make sure that disparities aren't perpetuated throughout treatment because of cost accessibility or affordability issues is important. If a patient says no and they don't want standard of care therapy, we must probe and make sure it's not a cost or insurance issue that's holding them back for getting their care they need.