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The Effect of Medicare Health Care Systems on Women With Breast and Cervical Cancer

Robert S. Kirsner, MD, PhD^*, Fangchao Ma, MD, PhD^*, Lora Fleming, MD, PhD, Edward Trapido, ScD^*, Robert Duncan, PhD, Daniel G. Federman, MD^¶ and James D. Wilkinson, MD, MPH

From the *Department of Dermatology and Cutaneous Surgery, Department of Epidemiology and Public Health, and Sylvester Comprehensive Cancer Center, University of Miami School of Medicine, Miami, Florida; Department of Dermatology, Veterans Administration Medical Center, Miami, Florida; and ¶Division of General Medicine, Veterans Administration Medical Center, Department of Internal Medicine, Yale University School of Medicine, West Haven, Connecticut.

OBJECTIVE: Two common health care delivery systems in the United States are fee-for-service and managed care systems, including health maintenance organizations (HMOs). Differences may exist in patient outcomes depending upon the health care delivery system in which they are enrolled. We evaluated possible differences in the stage at diagnosis for breast and cervical cancer between 2 Medicare health care delivery systems (ie, fee for service and HMO) over the period 1985–2001.

METHODS: We used a linkage of 2 national databases: the Medicare database from the Centers for Medicare and Medicaid Services and the National Cancer Institute's Surveillance, Epidemiology, and End Results program database to evaluate differences in stage at diagnosis between HMO and fee for service for breast and cervical cancer.

RESULTS: We studied 130,336 Medicare-aged women with breast cancer (83% Medicare fee for service) and 6,758 women with cervical cancer (87% Medicare fee for service). We found an earlier stage of diagnosis for HMO patients, which remained significant after adjusting for potential confounding variables. Women enrolled in HMOs with breast cancer were 17% more likely and those with cervical cancer 35% more likely to be diagnosed at an in situ stage of diagnosis than fee-for-service patients. It is of note that when women had other cancer diagnoses, no statistically significant differences were seen in stage at diagnosis for either cancer between fee-for-service and HMO patients.

CONCLUSION: Differences exist in stage at diagnosis between Medicare patients enrolled in HMOs compared with fee for service. This is likely due in part to use of or access to care.

LEVEL OF EVIDENCE: II-2

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