Assessing California's Prostate Cancer Treatment Resources for the Working Poor in Urban and Rural California
by Sarah E. Connor, MPH, CHES and Mark S. Litwin, MD, MPH
EXECUTIVE SUMMARY
Health insurance coverage facilitates access to the health care system and services required by individuals throughout life. In lieu of access through privately-purchased or employment-based health insurance, uninsured individuals must turn to the county and state safety nets to meet their healthcare needs. These safety nets are fragmented at best and designed to meet the needs of low-income women and children, the disabled, and seniors 65 or older.
For those who are caught, the safety net can make an enormous difference. But those who fall through the safety net are faced with tremendous barriers to obtaining needed health care. Uninsured adults are less likely to receive preventive and screening services and to receive them in a timely manner. Numerous population-based studies have shown that the uninsured are less likely than those with insurance to receive services for major health conditions including cancer. Uninsured cancer patients are generally in poorer health and more likely to die prematurely because of delayed diagnosis. Individuals without health insurance are 25% more likely to die prematurely than those with insurance. The United States spends nearly $100 billion per year to provide uninsured residents with medical services, often for preventable diseases or diseases that physicians could treat more efficiently with earlier diagnosis. However, it is estimated that 18,000 Americans still die prematurely each year due to a lack of health insurance.
With approximately 46 million Americans uninsured, holes exist in the healthcare safety net due to an overwhelming demand for limited resources. These holes are economically impacting the individual, the family, the community, the state, and the nation. The direct economic costs of cancer for the United States have increased dramatically from $10.6 billion for 1963 to $41.2 billion for 1999. The economic impact of cancer is also being felt at a state level. A recent study by Max et al. showed that in 1998 prostate cancer alone cost California $360 million in direct and indirect costs. With men comprising 50 percent of the uninsured in California, it is clear that they are faced with a patchy healthcare safety net unable to meet their basic health care needs, let alone provide the highly specialized care required to treat prostate cancer.
Prostate cancer is the most common cancer diagnosis, and third leading cause of cancer death, among men in the United States. Every year in California, an estimated 1,200 low-income, uninsured men are newly diagnosed with prostate cancer. On average, these men are younger than most U.S. men diagnosed with prostate cancer, present with moderate to highly aggressive tumors, and present at a later stage of disease than patients in the general population. Without treatment, these patients are at high risk of cancer progression and excess mortality from prostate cancer.
In an effort to fill the gap in California's safety net, the California legislature adopted California Health and Safety Code Section 104320 in 2000, which created the IMPACT Program (Improving Access, Counseling and Treatment for Californians with Prostate Cancer). This Program provides treatment for uninsured or underinsured, low-income men (200% or below of Federal Poverty Level) with a biopsy-confirmed diagnosis of prostate cancer who are not eligible for state or federal health insurance programs (e.g., Medi-Cal and Medicare). IMPACT has the ability to reduce the substantial barriers faced by low-income, uninsured men in accessing the highly specialized and relatively scarce group of subspecialty physicians that provide prostate cancer treatment in their local communities. The contract for this program has been administered by UCLA since April 2001.
Despite IMPACT's goals being consistent with other disease-specific programs created by State to address gaps in the safety net, debate continues as to the need for such a program. A belief persists that men have access to the care they need through county and state-level safety net programs such as the Medically Indigent Services Programs (MISP) and Medi-Cal. The objective of this study was twofold: to provide an overview of California's healthcare safety net on a county and state level, and to describe the IMPACT Program and the population utilizing IMPACT's services.
Methodology
Identification of county safety net resources
This assessment is designed to provide a picture of the healthcare safety net resources available to men in need of prostate cancer treatment residing in an urban (San Diego) or rural (Tulare) county in California. An exhaustive search was conducted utilizing data from the American Medical Association, Office of Statewide Health Planning and Development, interviews with local health department officials, Family Health Centers, Council of Community Clinics, and Internet search for health care resources in San Diego and Tulare counties to identify clinics and urologists serving these counties. These data were then used to create maps of county prostate cancer healthcare resources in San Diego and Tulare counties.
IMPACT Program and Subjects
Improving Access, Counseling, and Treatment for Californians with Prostate Cancer (IMPACT) is funded by the California Department of Health Services. Its goal is to provide uninsured men, who are not eligible for Medicaid, with timely access to high-quality treatment. Upon enrollment in the IMPACT Program, men are invited to participate simultaneously in an observational cohort study of patient-reported outcomes. Data collection includes telephone interviews administered in English and Spanish by trained language-matched interviewers, self-administered questionnaires in English and Spanish, and medical record abstraction. Participants received a $10 honorarium for each completed interview and questionnaire. We abstracted medical records (patient progress notes, imaging studies and pathology reports) to determine clinical stage. Descriptive statistics for demographics and medical characteristics of men enrolled in the IMPACT Program were calculated.
All procedures were approved by the University of California, Los Angeles (UCLA) Human Subjects Protection Committee and are compliant with the Health Insurance Portability and Accountability Act (HIPAA). All participants provided informed consent. The analyses, interpretations and conclusions in this brief are those of the authors and not the State of California.
Key Findings
Despite evidence to the contrary, there is a persistent belief in the myth that the uninsured can obtain health care when they need it. However, the healthcare safety net is not sufficient to meet the needs of the uninsured, particularly those with cancer who need specialized treatment, long-term care or follow-up. The low-income, uninsured Californians with prostate cancer are younger and present with more advanced and aggressive tumors than the average man diagnosed with prostate cancer in the United States. Other than prostate cancer, these men are generally healthy. This makes them excellent candidates for timely treatment to reduce their risk of cancer progression and death. The county and state safety net programs in California are not intended to provide this service. They are designed for the short-term health care needs of county residents. While the safety net can improve the health outcomes of those who benefit from its services - children, women, the disabled, and the elderly (65 or older) - these programs, as currently operated, cannot meet the ongoing needs of low-income, uninsured men undergoing prostate cancer treatment and follow-up.
The inability of county and state level healthcare safety nets to meet the prostate cancer treatment needs of low-income, uninsured men suggests that until the advent of a wider-reaching and more comprehensive solution to insuring the uninsured, the IMPACT Program is needed. The passage of SB 650 (Ortiz-D, Sacramento) made IMPACT a permanent program within the Department of Health Services (DHS), but it is unclear how the limited funding and extensive programmatic changes required by DHS will affect the Program's ability to reach the men in need of its treatment services. Budget reductions have eliminated key outreach and education components of the Program. Changes in provider reimbursement rates from Medicare to Medi-Cal based may result in initial savings but have resulted in increased costs in other areas such as patient transportation due to provider refusal to treat patients at these reimbursement rates.
Policy Implications
These findings highlight the importance of the need for the IMPACT Program in light of inadequacy of the county and state safety net programs. Despite the greater economic and social power held by men in the United States, women and children have greater access to health care through the county and state safety nets. Until this gap is closed and a systemwide change is implemented to ensure that resources are distributed equitably among both genders and all age groups, the state should ensure stable, consistent, and adequate funding for the IMPACT Program. Safety net programs exist at the whim of politics and are often the first to find their funding cut or eliminated when a budget crisis hits. Without access to care, low-come, uninsured men with prostate cancer go without treatment until their need is great and their outcomes extremely poor. The loss of IMPACT endangers not only the men diagnosed with the disease but elements of stable society as well. Men who are uninsured are more likely to die prematurely. This results in a greater burden on the state as the loss of the primary breadwinner leads to increased reliance on state social services. Families of the uninsured men seeking prostate cancer treatment are faced with the uncertainty and anxiety of the medical and financial consequences of their loved one's illness. Communities are faced with reductions in their health care capacity as the uninsured place a growing burden on health care resources leading to reduction in hospital services, loss of health care providers, and cuts in public health programs. And finally, the economic vitality of the state is endangered as a result of poorer health and premature death or disability of uninsured workers. IMPACT is needed until a long-term, comprehensive solution to the problem of health care access for California's low-income, uninsured population can be found. The consequences of lack of coverage on the individual and society are immense.
Funding for the research in this article was provided by the California Program on Access to Care, an applied policy research program administered by the California Policy Research Center in the University of California, Office of the President. The authors'/author's views and recommendations do not necessarily represent those of CPAC or the Regents of the University of California.