The effect of Medicare health care delivery systems on cancer outcomes

Date of Award




Degree Name

Doctor of Philosophy (Ph.D.)


Epidemiology and Public Health

First Committee Member

James Wilkinson - Committee Chair


Cancer is a leading cause of morbidity and mortality in the United States. Cancer prevention and control research includes improved delivery of health care messages (10 prevention), improving screening techniques (20 prevention), and improved therapy (30 prevention). Healthcare delivery systems are participants in all 3 of these efforts.The health care delivery system patients participate in may affect access to, and utilization of, health care resources that may determine health outcomes. This proposal focused on the effect of health care delivery and access to care (in terms of insurance) on cancer outcomes.Specifically, our aims were to determine the stage of colorectal, breast and cervical cancer at diagnosis for a 15 year period (a 10 year period for Melanoma) in fee-for-service and managed care systems, to determine if differences in mortality exist for melanoma, colorectal and breast cancer between these systems of health care delivery and if established involvement in a health care delivery system may, in part, be responsible for any differences seen in stage of diagnosis. This study represents an analysis of the linkage of two national databases: Medicare data from the Centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration or HCFA) database and the National Cancer Institute's (NCI) Surveillance, Epidemiology, and End Results (SEER) program database. We found that across several cancer sites, Medicare aged patients enrolled in MC compared to FFS had better cancer related outcomes including stage at diagnosis and survival. Specifically, we found Medicare patients enrolled in HMO health care delivery systems were significantly more likely to be diagnosed at an earlier stage for both melanoma (over a 10 year period) and breast, cervical and colorectal cancer (over a 15 year period) compared with patients enrolled in a FFS systems. These differences remained after controlling for potential confounders such as age, race, socioeconomic status, and marital status. We also found that for both breast and colorectal cancer, an overall survival advantage existed for patients enrolled in Medicare-HMO compared with FFS. These differences remained after controlling for potential confounders (such as stage at diagnosis, age, race, socioeconomic status, and marital status).


Health Sciences, Public Health; Sociology, Public and Social Welfare

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