Disparities in Access to Quality Care for the Underinsured Patients in the USA - Quoc-Dien Trinh

January 7, 2021

Underinsured patients face significant barriers in accessing high‐quality care.  “Access Denied: The Relationship Between Patient Insurance Status and Access to High‐volume Hospitals” studies the evidence of whether access to high‐volume surgical care is mediated by disparities in health insurance coverage. Quoc-Dien Trinh, an author of the study, joins Alicia Morgans to discuss his involvement in the study, how the data impacts his own practice, and what his thoughts are for future work in the area.


Quoc-Dien Trinh, MD, Assistant Professor of Surgery, Harvard Medical School, Urologic Oncologist at Brigham and Women’s Hospital, Dana-Farber Cancer Institute

Alicia Morgans, MD, MPH Associate Professor of Medicine in the Division of Hematology/Oncology at the Northwestern University Feinberg School of Medicine in Chicago, Illinois.

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Alicia Morgans: Hi, my name is Alicia Morgans and I'm a GU medical oncologist and Associate Professor of Medicine at Northwestern University in Chicago in the US. I am so excited to have here with me, today, Dr. Quoc Trinh, who is a urologist at the Brigham and Women's Hospital, as well as an Associate Professor of Urology at Harvard Medical School in Boston. Thank you so much for being here with us today, Quoc.

Quoc-Dien Trinh: Yeah, thanks for having me, Alicia.

Alicia Morgans: Wonderful. So, I wanted to talk with you about a really exciting and provocative paper called "Access Denied" really thinking about healthcare utilization patterns, and how access can actually make a difference in that. Can you tell us a little bit about why you did this study, and then what you did?

Quoc-Dien Trinh: Yeah. I think that, as you know, there's a lot of literature on the importance of volume, as a proxy for expertise, and surgical expertise. And there's a lot of data, some of it actually just came out recently, about how important it is to be treated by somebody who has high surgical volume and/or high surgical expertise. And you sometimes will see benefits in terms of survival that are matching, potentially, some of the most expensive and exciting drugs that are out there, where you can have a 60%, 70% benefit on survival if you are treated by a high volume surgeon or a surgeon that has a lot of expertise by other metrics or whatsoever.

So, again, really on the focus of equity, which is something that I think is important and a lot of the focus on my research, if patients that don't have the same insurance, or may have public insurance, or are uninsured are not getting treated by the so-called highest volume surgeons, then their potential will have problems downstream because if they're not treated by high-volume surgeons, then potentially their outcomes are not as good. And then, when you talk about things like racial disparities, or insurance disparities, maybe the problem is that they're not getting treated at the places or the surgeons that have potentially the greatest expertise. So, that was the gist of why we did this project. And, obviously, we were interested in seeing if Obamacare, the Affordable Care Act, potentially, had an impact over the study years to see if things have changed and improved for the better. So, I guess that's why we did that.

Alicia Morgans: Great. So, can you tell us a little bit about how you did this study? Because not everyone is familiar with outcomes research, database analyses. You used the National Cancer Database, I think, right?

Quoc-Dien Trinh: Yeah. So, the National Cancer Database is technically not population-based, it's hospital-based. So, to be part of that database, you have to be a commission on cancer center, accredited center, and you're actually pooling your data into that dataset. So, we used patients from that conveniently and extremely well-designed National Cancer Database, and we looked at this question of access to high-volume hospitals across a number of procedures, or conditions. And that included breast cancer, prostate cancer, lung cancer, and colon cancer.

And, again, the point of what we're trying to see here is to see if there was a relationship between where patients were seeking their care and the insurance that they carried or did not have. And what we found in our study, which in a way is unsurprising but really confirming to findings in a large national database, is to find that under-insured patients, which we usually define as Medicaid insurance or uninsured, were less likely to get their care at these so-called high-volume institutions.

I guess the secondary finding, I think, that's also interesting as like looking at the whole question of Obamacare, the Affordable Care Act is we did find that in later study years, there have been clear improvements for colorectal cancer, but not necessarily for other cancers.

Alicia Morgans: So, that's really, really interesting. And I wonder if it has to do with the age of diagnosis? And sometimes colorectal cancer patients are younger than some of our prostate cancer patients, who may actually be insured for a large part by Medicare. How do you explain some of these differences between disease types? Is that one way? Or what else are you thinking about?

Quoc-Dien Trinh: So, I think what you mentioned is definitely an important aspect of it. There's also the aspect of how access to these screening tests are currently made. Like colon cancer is usually quite straightforward. There's a direct access way to get that kind of screening. So, I'm not sure how much that may have impacted patients who have gotten their insurance and then were referred for a direct access colonoscopy, were diagnosed, and then subsequently managed at that kind of center. Whereas, others, some cancers that are screened, like prostate and breast, may have a different way of functioning. It's a little bit more complicated. So, there are potentially different downstream points of care where the patient may not end up seeing that kind of facility that's higher volume.

Alicia Morgans: That makes a lot of sense. And it's interesting and important that you've done this work. I know you're working, as you mentioned, in access and in trying to equalize and remove disparities whenever possible. How do you take these data to impact your own practice? And what are your thoughts in terms of future work? Because I'm sure you're going to continue on in this area.

Quoc-Dien Trinh: Yeah. I think that, as you know, I'm a urologist, and the focus of my work clinically is prostate cancer. I think that this kind of broad bird's eye view type paper will give us some ideas of how to do things but, in the end, it's really community engagement and coming down to the details that will make a difference. It's less glamorous but, ultimately, probably more important. I think in my little world of prostate cancer, I've been working with the Massachusetts Department of Public Health, we've been doing some pretty exciting work in trying to understand these kinds of insurance-based disparities at the state level, and even more refined at the county level. And we have found some pretty interesting differences where, in certain counties, you're not going to see necessarily the same kind of racial differences, or insurance-based differences that you would expect to see. But there are, certainly, some areas of the state that are a little concerning in terms of that kind of gap.

We've done some qualitative work and trying to understand a little bit more about how providers think. This is the kind of thing that is hard to voice. I don't want to say something too critical, but we know that we don't get paid the same, hospitals don't get paid the same depending on the insurance of the patient. And trying to understand, at the provider level, how much that impacts the decision-making. And, ultimately, try and understand hospitals, how these patients were referred. And, ultimately, I think we can do a lot of work at the provider level, educating our patients. We can do a lot of work with providers in trying to ensure equitable care. But I think the policy level work needs to be done that is at the highest level because, if you don't incentivize hospitals to treat people equally, and we know that some patients with their insurance pay differently, then there may be the wrong incentives to treat certain people and not others.

Alicia Morgans: I think that's such an important point. That we, as individuals, can work on things at a county level, at a hospital level, within our own practices and our referral patterns. But I certainly look to you and your team to continue to help give us this kind of data, so we can think about how to influence on a larger level, on a policy level, because if the incentives are just twisted, or shifted a little bit, maybe we'd all be incentivized to treat everybody, which is ultimately, I think, what we want to do. But sometimes these incentives get turned around a little bit backward and upside down. So, I think this is phenomenal work published in the Journal of Cancer. Was there funding for this work from one of those agencies? From ACS, or from someone else?

Quoc-Dien Trinh: So, not specifically for this work. We do have funding from the Brigham Research Institute, actually, to do one part of it, the prostate cancer part of the project. And, actually, we have a grant that is currently under review that uses this as a platform for future work.

Alicia Morgans: That is fantastic. So, Quoc, congratulations on your work. And congratulations on what you continue to do to move the needle in this area. And I really do look forward to seeing where everything goes. Thank you for your time.

Quoc-Dien Trinh: Thank you. Thanks for having me.