BREAST CANCER: Detection, Treatment Better in HMOs?
Although breast cancer detection and treatment patterns vary tremendously among health plans, older women enrolled in Medicare HMOs are more likely to be diagnosed at an early stage and receive radiation therapy than their counterparts in traditional fee-for-service settings. In a study published today in the Journal of the American Medical Association, researchers from HCFA and the National Cancer Institute examined breast cancer cases using Medicare enrollment data for women diagnosed between 1988 to 1993 in 11 regions nationwide (Rubin, USA Today, 2/24). The researchers found that among nearly 22,000 women with detected breast cancer, only 7.6% of HMO enrollees were diagnosed at late stage -- beyond the operable point -- compared with 10.8% of fee-for-service patients. Among women diagnosed with breast cancer in its earliest stage, the rates of breast-conserving surgery were similar, with 38.4% of HMO enrollees and 36.8% of fee-for-service patients undergoing the procedure. Following surgery, however, women enrolled in HMOs were overall "significantly more likely to receive radiation therapy" -- 69% compared with 63.7% in fee-for-service plans. But the authors found that surgery and radiation treatment patterns "varied markedly" among HMOs; rates of radiation after lumpectomy for women in HMOs ranged from a low of 49.2% in one region to a high of 82.5% in another region. By contrast, the radiation rates among fee-for-service members in the same two regions were more consistent, ranging from 61.1% to 69%.
The authors conclude that while there is concern that "financial considerations may inappropriately influence treatment patterns under capitation arrangements," they found "reassuring" evidence that "most elderly HMO enrolles are not experiencing problems with access to radiation therapy compared with women in the FFS setting" (Riley et al., JAMA, 2/24 issue). Writing in an accompanying editorial, Dr. Sheldon Retchin, a professor of internal medicine at Virginia Commonwealth University, warns that "the financial motivation of the HMO may influence the intent of the prevention incentives," pointing to the "substantial performance variations" the study found among treatment patterns (JAMA, 2/24). Noting the "important quality measures" taken by the HMOs highlighted in the study, American Association of Health Plans President Karen Ignagni warned against "discouraging the use of the tools that allow HMOs to achieve results like the ones when in this and other studies" (AAHP release, 2/23).