Associations Between Medicaid Insurance, Facility Medicaid Share, and Guideline-Concordant Prostate Cancer Care

Although prostate cancer (PCa) care for individuals with Medicaid insurance is unevenly distributed across facilities, the effects on care quality remain incompletely understood. Thus, in this study, we sought to investigate the dynamics between both patient-level Medicaid status and facility-level Medicaid share and receipt of guideline-concordant care for patients with localized PCa. We used the National Cancer Database to select patients aged 21-64 diagnosed with localized PCa from 2014 to 2021. We stratified the cohort by clinical risk according to the National Comprehensive Cancer Network’s risk guidelines (very low/low, unfavorable intermediate, and high/very high-risk disease due to clearer guidelines in these groups, as there is no clear preferred management for patients with favorable intermediate disease.¹ Our primary outcome was receipt of guideline-concordant management (‘low risk’: active surveillance; ‘unfavorable intermediate’ and ‘high risk’: either radical prostatectomy or androgen deprivation therapy and radiation therapy). We implemented a mixed-effects logistic regression model to determine the relationship between Medicaid insurance status and receiving guideline-concordant care. This model included facility share of Medicaid as a fixed effect to evaluate the association between the proportion of Medicaid patients in each facility on the likelihood of receiving guideline-concordant care. We also included patient Medicaid status and facility Medicaid share quartile to examine the role of patient-level and facility-level factors.

We identified 231,071 patients with localized prostate cancer. 74.2% and 71.9% of patients with private insurance and Medicaid, respectively, had guideline-concordant care. In our patient-level analysis, having Medicaid insurance was associated with higher odds of guideline-concordant care among the subset with low-risk PCa (OR 1.25, 95% CI 1.12-1.40, p<0.01) but lower odds in the high-risk subsets (OR 0.67, IQR 0.62-0.73, p<0.01). Our mixed effects regression model demonstrated that individual Medicaid status, uninsured status, and facility Medicaid share quartile were associated with lower odds of receiving guideline-concordant care (Medicaid: OR 0.95, 95% CI 0.90-0.99, p=0.03; uninsured: OR 0.91, 95% CI 0.84-1.00, p=0.04; Medicaid share: OR 0.96, 95% CI 0.93-1.00, p=0.03). When stratified by clinical risk, Medicaid status was associated with higher odds of guideline-concordant care among low-risk disease (OR 1.25, 95% CI 1.12-1.40, p<0.01), and with lower odds of receiving guideline-concordant care among intermediate unfavorable risk disease (OR 0.61, 95% CI 0.55-0.68, p<0.01) and high-risk disease (OR 0.67, IQR 0.62-0.73, p<0.01).

This finding was supported by Figure 1, which showed that the probability of receiving guideline-concordant care decreased with higher facility Medicaid share among patients in the overall cohort, as well as those with intermediate unfavorable and high-risk disease. In contrast, among patients with low-risk disease, the probability of receiving guideline-concordant care actually decreased with higher facility Medicaid share.

Altogether, our study found that facilities with a higher proportion of Medicaid patients tended towards providing less or no treatment regardless of risk stratification. While this conservative management approach was appropriate in patients with low-risk disease, it was misaligned in those with higher-risk disease. From these findings, we proposed specific policy efforts to bolster the quality of care for patients with Medicaid and address the uneven distribution of care quality demonstrated in this study. For example, we suggested increasing Medicaid reimbursement rates to provide evidence-based treatment, such as definitive therapy in higher-risk patients, as well as increasing oversight of Medicaid exclusion or selective contracting practices to ensure hospitals with nonprofit status equitably serve patients with public insurance.

Figure 1. Predicted Probability of Guideline-Concordant Care based on Facility Medicaid Share for a. overall cohort, b. patients with low-risk disease, c. patients with intermediate unfavorable disease, and d. patients with high-risk disease.

Written by: Isaac E. Kim Jr,¹ Benjamin I. Chung,¹ Dhruv Puri,² Simon J. C. Soerensen,¹ James Nie,³ Walter R. Hsiang,³ Samuel Washington III,³ Michael S. Leapman⁴

Department of Urology, Stanford School of Medicine, Palo Alto, RI, USA.
Department of Urology, UC San Diego School of Medicine, La Jolla, CA, USA.
Department of Urology, UC San Francisco, San Francisco, CA, USA.
Department of Urology, Yale School of Medicine, New Haven, CT, USA.

Reference:

Diven MA, Tshering L, Ma X, Hu JC, Barbieri C, McClure T, et al. Trends in Active Surveillance for Men With Intermediate-Risk Prostate Cancer. JAMA Netw Open. 2024 Aug 22;7(8):e2429760.

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