ACA Heralds Modest Increase in Healthcare Utilization for Testicular Seminoma

Alice Goodman

March 2014, Vol 5, No 2 - Economics of Cancer Care

San Francisco, CA—Concerns that healthcare utilization will increase dramatically once more patients are insured under the Affordable Care Act (ACA) may be overblown, based on results of a large study of Medicaid and underinsured patients with seminoma, the most common type of tes­ticular cancer.

The study, which was reported at the 2014 Genitourinary Cancers Symposium, suggests that there will only be a moderate increase in adjuvant therapy for patients with stage IA/B seminoma, an approach that is considered discretionary, and no increase in the use of the National Comprehensive Cancer Network (NCCN)-recommended adjuvant therapy for patients with stage II disease. These results, the investigators suggest, may have implications for other patients under the ACA.

“Once the ACA is in use, the question is whether cancer treatment utilization will skyrocket or will stay the same and follow NCCN guidelines. Our study sought to provide some insight into this question,” said lead investigator Jonathan J. Paly, MD, Department of Radiation Oncology, Massachusetts General Hospital, Boston.

“Under the ACA, insurance coverage will expand for the uninsured category, and they will become more like the Medicaid population. We found evidence to suggest that when these people become insured, there will only be a modest increase in treatment considered discretionary” (ie, adjuvant therapy for stage IA/B seminoma).

The NCCN’s guidelines recommend active surveillance for stage IA/B seminoma. “The older approach was chemotherapy-lite or radiation and orchiectomy for 1 testicle. With that approach, patients may feel more reassured than with active surveillance, and once insurance is available, they could opt for that,” Dr Paly explained.

The National Cancer Data Base was used to identify Medicaid or underinsured patients diagnosed with seminoma between 1998 and 2010. Of 41,745 patients with seminoma, 5895 (14%) fell into these categories. Compared with Medicaid patients, uninsured patients were more likely to be younger (aged <29 years), Hispanic, live in the South, treated in community hospitals, reside in areas with higher education levels, and present with stage IA/B disease (66.5% vs 59.4%, respectively; P <.01).

A multivariate analysis adjusted for sociodemographic and clinical characteristics showed that underinsured patients with stage IA/B disease were 14% less likely than Medicaid patients to receive adjuvant therapy or chemotherapy. “People who are uninsured are more in line with the NCCN recommendations than those insured by Medicaid,” Dr Paly said.

In addition, patients with stage IA/B seminoma who were Hispanic, aged ?50 years, diagnosed between 2006 and 2010, treated in low-volume facilities, or had tumors <4 cm were less likely than their counterparts to receive adjuvant therapy. No treatment differences by insurance were observed in patients with stage IIA/B disease.

“These findings suggest that it will be extremely important to counsel patients with stage IA/B seminoma about the benefits for postorchiectomy surveillance for early-stage disease, so that they will follow national recommendations,” Dr Paly stated.