Symposium on Cancer - September 2010
Tex Med . 2010;106(9):27-34.
By Ron J. Anderson, MD, and Sue Pickens, MEd
According to the National Cancer Policy Board (NCPB), "there is no national cancer care program or system of care in the United States. Like other chronic illnesses, efforts to diagnose and treat cancer are centered on individual physicians, health plans, and cancer care centers. The ad hoc and fragmented cancer care system does not ensure access to care, lacks coordination, and is inefficient in its use of resources.1
NCPB has concluded that for many Americans with cancer, there is a wide gulf between what could be construed as the ideal and the reality of their experience with cancer care . According to the Institute of Medicine (IOM), the link between poor access to care and poor health outcomes is well established.2,3
In Texas, the lack of access is related directly to insurance status (24 percent of Texans are without health insurance at any one time), which is related to poverty (59 percent of those without insurance are below 200 percent of the federal poverty limit). According to Texas Cancer Facts & Figures 2008, poverty is the most critical factor affecting health. More than one-fourth of Texas households have an annual income less than $25,000. High poverty levels are associated with a lower proportion of cancers diagnosed as early-stage disease when prognosis for survival is most favorable.4 Even with safety net hospitals, the IOM studies show higher mortality for cancers in the uninsured largely due to delayed diagnosis.5
Not only is insurance an issue in Texas, but also the geographic distribution of the population and hospitals creates access issues. Many rural counties cannot support critical tertiary services such as trauma care (level 1 or 2 capability), burn care, neonatal care, pediatric intensive care, comprehensive cancer services, and other complex medical or surgical interventions.6
In addition to the organizational issues of care, Texas has a rapidly growing population, which has an increasing incidence of obesity, hypertension, diabetes, heart disease, and cancer.7 Texas has the highest rate of uninsured of any state in the nation. This represents more than 6 million people, which adds to the lack of access to care.
Major urban counties in Texas fare worse than the state as a whole when it comes to the number of uninsured. For example, in Dallas County, nearly 31 percent of residents, or more than 700,000 people, lack health insurance. In Harris County, 27 percent of the residents lack health insurance.8
However, given that funding for indigent health care in Texas is based at the county level and that major urban areas have created hospital districts, urban residents have better access than their counterparts in communities without hospital districts.
According to a study conducted by Amarasingham, Pickens, and Anderson, safety net hospitals in the the five major hospital districts in Texas - Harris County Hospital District (Houston), Parkland Hospital (Dallas County), John Peter Smith Hospital (Tarrant County), R.E Thomason Hospital (El Paso), and University Hospital (Bexar County) - saw out-of-county patients 4.2 times the full capacity of the five hospitals.9 For these hospitals, out-of-county patients incur substantial costs, but for the patients living outside these communities, access and eventual survival are at risk. In addition, of the more than 138 hospital districts in Texas, many are poorly funded and lack the ability to provide specialty care at the level needed to adequately address cancer care.
The Texas Legislature created M.D. Anderson Cancer Center in 1941 as part of The University of Texas. This institution is dedicated to "eliminating cancer in the nation and the world through outstanding programs that integrate patient care, research, and prevention, and through education for undergraduate and graduate students, trainees, professionals, employees and the public."10 This institution takes cancer patients from all over Texas, the United States, and the world, and has ranked No. 1 in cancer care in six of the past eight years by U.S. News and World Report . In 2009, it provided $266.9 million in uncompensated care to Texans. Although it has financial assistance options for those without insurance, it does not serve as a safety net facility for cancer care and cannot possibly care for all those needing cancer services in a centralized manner.
Parkland and Dallas County
Dallas County is a very diverse community. According to Neilson Claritas, 2009, Dallas County is primarily a minority majority county, with 39.3 percent of the population being Hispanic; 20.1 percent, African-American; 34.3 percent, white; 4.3 percent, Asian; and 2.0 percent, other. Additionally, 41.9 percent of the population, or 994,000 people, live at 200 percent below the federal poverty limit, according to the American Community Survey for 2008.
In response to these demographics, Parkland is the largest provider of primary and preventive health care for uninsured and underinsured persons in Dallas County. The hospital's mandate, as established by the Texas Constitution, is "to furnish medical aid and hospital care to indigent and needy persons residing in the hospital district." Parkland is the public hospital system that has served as the primary tertiary health care provider for the poor and indigent residents of Dallas County for more than 100 years. It is the primary safety net hospital for the residents of Dallas County. Parkland's population reflects the diversity within the county, serving a large part of the minority community. Parkland's patient population is 52 percent Hispanic, 27.5 percent African-American, 16 percent white, and 3 percent Asian. Additionally, 54 percent of Parkland patients are self-pay or charity patients, and 31 percent are Medicaid patients.11
An indication of the difficulties of this population receiving timely care was reported in a study conducted by Leitch and Garvey in the mid-1990s (Figure 1).12 A review of the Tumor Registry data from Parkland in the early 1980s indicated that approximately half of new breast cancer patients were diagnosed with stage III and IV disease, with 15 percent presenting with distant metastases. This contrasted with the findings of an American College of Surgeons study, which showed less than 15 percent of breast cancers diagnosed as stages III and IV. A screening project supported by the Susan G. Komen Foundation demonstrated the significant difference possible in the stage of diagnosis of breast cancer with routine annual screening. A significant education campaign was required to change behavior for this population to obtain annual screening examinations. The institution of mobile mammography and low- or no-cost mammograms at the hospital improved the compliance and lowered the percentage of women presenting with late-stage disease.
Between 2002 and 2006, African-American women in Dallas County suffered a disproportionate number of deaths due to breast cancer with a rate of 35.0 deaths per 100,000, compared with 26.1 deaths per 100,000 for the entire population.13 The Texas Department of State Health Services predicts 1,304 new cases of breast cancer in Dallas county and 248 deaths. These statistics, as well as increasing volumes, have moved Parkland to look to making major improvements in breast cancer services.14
Today, Parkland's Cancer Prevention and Intervention Program (CPIP) screens approximately 6,500 women annually through a mobile mammography van. The screening performed on the mobile mammography unit helps prevent new cases of breast cancer from going unrecognized and untreated.
The Breast Clinic at Parkland Health and Hospital System provides care to medically underserved breast cancer patients in Dallas. Parkland currently screens more than 21,600 women in both the mobile van and on campus settings. Parkland's cancer registry results indicate that increased access continues to find earlier stage cancers (Figure 2). This is particularly important in an indigent population where access and disparities are a constant concern. This compares the 1992 study results seen in Figure 1, in which the majority of nonscreened patients were diagnosed with stage III and IV cancers, with data from today when the majority of cancers are detected at stage I and II.15
Navigating the system from presentation to diagnosis to treatment can be physically, psychologically, and emotionally overwhelming, as well. Parkland and The University of Texas Southwestern Medical Center have designated a patient navigator - a specially trained member of the breast cancer treatment team who can help guide patients through the maze of necessary procedures, while simultaneously providing emotional support. Patient navigators are available to answer questions and provide continuity of care to patients with breast cancer. Additionally, they can help identify patients who qualify for clinical trials integral to the advancement of our knowledge of the disease. The importance of this service has recently been established from recent research funded by the National Breast and Cervical Cancer Early Detection Program for low-income women in Massachusetts. The study results indicate that case management to help women overcome logistic and psychosocial barriers to care may improve the time to diagnosis among low-income women who receive free breast cancer screening and diagnostic services, showing that programs that provide coordination and case management improve population health.16
With increasing patient volumes, Parkland's patients experienced delays in the ability to get screening and diagnostic tests and long waits for the initiation of chemotherapy. Parkland's board has made significant investments to provide state-of-the-art cancer care and improved access. Parkland's newly constructed oncology clinic is one of the fastest growing services now with 200 new patient referrals a month. Between fiscal years 2004 and 2008, patient visits increased more than 50 percent to more than 22,000 a year.
Along with services offered by the Parkland Health & Hospital System, the hospital collaborates with various community partners such as school districts, homeless shelters, churches, other hospitals, and the American Cancer Society to enhance the medical care delivery model. Through formalized relationships, a referral process has been adopted that allows patients referred to Parkland an expedited entry into the system. This has resulted in improved access for patients who, in the past, may have fallen through the cracks because of a lack of coordinated care.
Parkland recognizes that a healthy community does not begin with the health care system, but rather, "It is essential to build partnerships to address social determinants of health because no one group, be it health care providers, public health practitioners, or community members can accomplish the many tasks required for changing social, economic, and environmental conditions that impact health."17 These networks, while important for disease prevention and health promotion, can be used productively for early detection, prompt treatment, and chronic follow-up.
An increased number of all types of cancer cases has been noted since 2006. This increase is a result of the recession, improved access, and early identification of patients through the several access points to Parkland. This was a significant performance improvement project that identified several access points to Parkland Health & Hospital System to help improve the burden of cancer care to the safety net population. Along with increased access, Parkland moved from paper format to electronic automated disease index reports to better document the impact of the increased access. Electronic reports are matched against the cancer registry database and are reviewed. These new procedures have given the registry a more accurate look at the cancer burden seen at Parkland Hospital.
As a result of new access points and expanded capacity, Parkland has seen significant improvements in outcomes. For example, the change in stage I and II presentation of breast cancer cases has increased 20.4 percent with a corresponding decrease in stage III and IV cases (down 29 percent) from 2004 to 2008. Other improvements, though not as dramatic, include increased numbers of diagnosed early-stage cancers of the lung and prostate.15
Parkland is also the primary provider of family planning and prenatal care to indigent women in Dallas County, including routine cervical cancer screening. Parkland family planning and prenatal care programs record more than 150,000 visits a year. As such, Parkland provides early diagnosis for cervical dysplasia, the treatment for which virtually prevents progression to cervical cancer. Despite the high-risk nature of Parkland's population, new cases of cervical cancer arising within its screened population have become exceedingly rare even before the introduction of the human papillomavirus vaccine.18
An important aspect of cancer care, regardless of ability to pay, is follow-up. Children's Medical Center of Dallas, one of Parkland's partners, has one of the highest cancer treatment starts in the state for affected children. Many childhood cancers are cured, but treatment with chemotherapy leaves these children vulnerable to the potential for additional cancers later in life. The University of Texas Southwestern Medical Center (UTSW) has developed a registry to help follow these patients through adulthood. Cancer registries and regional referral networks are needed to monitor these patients.
Although logistically more difficult, regarding screening, Parkland and UTSW are exploring ways to attack the problem of colon cancer with screening colonoscopies and newer stool guaiac tests (for occult blood) and immunological studies (fecal immunochemical tests). This is a resource-intensive process; a barrier clearly exists because of a lack of diagnostic manpower available to provide enough colonoscopy studies to meet the current screening recommendations.
Similarly, the guidelines to screen for prostate cancer are controversial and need better definition. We need to be invested in research to find the appropriate solution to such screening for our populations. Texas has established the Cancer Prevention and Research Institute of Texas (CPRIT) established by the Texas legislature to fund cancer research and prevention programs over the next 10 years. (See "CPRIT Becomes a Reality.") This is a great advantage to the state to have passed the legislation and supportive funding, not only to do basic research but also to recruit dedicated physicians and scientists to improve cancer care and to fund population-based studies and delivery models. Parkland and several other safety net facilities have been able to tap into these funds to implement population-based studies that not only improve care but also improve access.
Hospital Districts and Policy Implications
Parkland began as a city hospital but evolved into a city-county effort with population growth. Parkland became a hospital district in 1954, moving to one tax base instead of two for tax equity. For example, Dallas residents paid both city and county taxes, where other cities in Dallas County paid only the county taxes. Parkland and other Dallas County tertiary care providers are now seeing increasing patient volumes from surrounding counties as well as from all parts of the state. Although 95 percent of Parkland's patients reside in Dallas County, 88 percent of the in-migration patients come from surrounding counties, and 77 percent of out-of-county patients are charity, self-pay, or Medicaid patients. Within the Dallas-Fort Worth area of more than 6 million people, there are limited facilities that can manage or are willing to manage cancer patients with limited funding.
Data from a study conducted on the financial condition of Texas hospitals using a novel definition for the safety net indicated that between 2001 and 2005, a sizable increase occurred in the volume of uncompensated care provided by both safety net and non-safety net hospitals. The already lower margins of the safety net hospitals leave them with less operational resources to compensate for future spikes in demand.19 The current system is not sustainable due to demographic pressures, population growth patterns, and a changing tax base. In 2010, the Dallas County ad valorem tax base decreased 3.3 percent and is predicted to drop 5 percent to 9 percent in 2011. State or adjacent county participation is needed to help hospital districts provide tertiary care such as cancer services on a regional basis.
It is important for Texas to address the artificial boundaries that affect our ability to improve public health: geographical, political, and economic. The case for regionalized care includes four components: preserve comprehensive tertiary services for all Texans, provide coverage or care for the medically indigent, improve health services for rural and suburban patients, and provide tax equity for all Texans.
Tertiary services are hard to support through market-based initiatives.20 Careful health planning using market techniques and public health measures should help develop better regional models. Geographic isolation and maldistribution of specialists make it difficult to provide tertiary services in rural areas. 21 As described earlier, Texas leads the nation in the number of uninsured residents. Both urban and rural residents turn to safety net hospitals for care, particularly for specialty services. However, many counties do not have a dedicated public hospital to care for indigent patients, nor do they have the capacity to support tertiary or quaternary services for all of their residents whether or not they are insured. Without such a safety net facility, uninsured patients have to navigate a labyrinth of county clinics, themselves limited by inadequate specialty and referral capabilities.22 One hundred and thirty-eight Texas counties are supported, in whole or in part, by such a county system, also known as county indigent health care programs.23 Historically, the level of spending exerted by counties on this program has been minimal and coverage is limited generally to less than 21 percent of the federal poverty level.24 Many Texas counties do not have a public hospital or hospital district (see "Texas Counties With Public Hospitals or Hospital Districts"). For those who are living in urban areas with large safety net hospitals, accessing cancer care is possible. However, for those living outside these areas, access to care is limited, and long-term survival may be at risk.
Amarasingham, Pickens, and Anderson recommend the development of regional authorities or boards that work closely with hospitals to design plans that meet the needs of a region. These plans should be based on the appropriate levels of care, from primary, secondary, to tertiary care, that will disperse the burden of the indigent but assure appropriate care at all levels.9 Urbanization of these needy populations may be the only way they can access care.
Texas now needs to consider taxpayer equity on a regional basis, including state assistance for complicated tertiary referrals such as trauma care, burn care, neonatal medicine, cancer care, radiation therapy, chemotherapy, bone marrow transplants, and others.
Texas is divided into public health regions for the administration of public health and health and human services. Many of these regions have one or more medical schools and affiliated teaching hospitals. Existing medical schools and their teaching hospitals could serve as important resources in regional care for tertiary and quaternary services, not only for the indigent but also for those with limited access because of location. Medical schools and their teaching hospitals, with assistance from state and federal funding mechanisms, could develop facilities and dedicated programmatic resources to regionalized care. The regional approach could allow these medical schools and their teaching hospitals to play key roles in comparative effectiveness research, finding better ways to reach the community and ensuring that safety net facilities are not overutilized for primary care.
With the costs of cancer care soaring, where chemotherapy could cost more than $100,000 a year, and the promise of new technologies and drug treatments taking care to higher levels every year, medical schools and their affiliated teaching hospitals could create a statewide cancer network that increases access to care that is managed to potentially lower costs on a case-by-case basis. With their locations throughout the state, access to care would be enhanced, care would be improved, and costs would potentially be lowered on a case-by-case basis.25
A regional plan that centralizes tertiary care but widely disperses primary and secondary care represents the soundest approach to delivering the most effective treatment. Current artificial geographies and political and economic boundaries have to be addressed collaboratively by both state and local governments.
Though Parkland is the safety net provider for tertiary cancer care in the North Texas area, it collaborates with churches, the public school system, community organizations, public health groups, and many other organizations to provide preventive care and health promotion, moving from a "sick" care system to a health model. However, where prevention interventions fail in the individual case, we are left with a need for appropriate care. It requires specialized skills and knowledge, access to sophisticated diagnostic and treatment facilities, and often long-term management of symptoms and recurrences.
Integration of all levels of care through case management in a medical home model is critical to the successful management of patients.26
The chronic disease model of care requires integration with specialty and subspecialty resources. Support for cancer patients requires many elements of the health care system and the community working together to ensure successful care. The complexity of cancer treatment bridges all the way from prevention to early diagnosis, treatment, follow-up, and even palliative care. Regional networks of cancer care, where current artificial geographies and political and economic boundaries are addressed collaboratively by state and local governments, and existing resources (medical schools and their existing teaching hospitals) are a natural outgrowth from the current singular county system to meet the needs of patients and communities. Statewide designation and financial support for regional cancer care and other tertiary services should be considered as a prudent policy for addressing the needs of all Texans, whether urban or rural.
Ron J. Anderson, MD, is the president and chief executive officer of the Parkland Health & Hospital System in Dallas. Sue Pickens, MEd, is the director of strategic planning at Parkland.
- Hewitt M, Simone JV, eds. Ensuring Quality Cancer Care . National Cancer Policy Board. Institute of Medicine and Commission on Life Sciences, National Research Council. Washington, DC: National Academy Press; 1999. http://www.nap.edu/openbook.php?record_id=6467&page=R.
- Institute of Medicine. Access to Health Care in America . Washington, D.C.: National Academy Press; 1994.
- Hoffman C. Uninsured in America: A Chart Book . Washington, DC: The Kaiser Commission on Medicaid and the Uninsured; 1998.
- Texas Cancer Facts & Figures 2008. page 17. http://www.texascancer.info/pdfs/factsandfigs2008.pdf .
- Committee on the Consequences of Uninsurance, Board on Health Care Services, Institute of Medicine. Care Without Coverage: Too Little, Too Late. Washington, DC: National Academy Press; 2002:8.
- Rickets TC, ed. Rural Health in the United States. New York, NY: Oxford University Press; 1999:41, 141.
- Code Red: the Critical Condition of Health in Texas . A Report of the Access to Health Care Task Force. 2008. http://www.coderedtexas.org/files/Report.pdf .
- US Census Bureau. American Community Survey, 2008. http://www.census.gov/acs/www/Products/index.html .
- Amarasingham R, Pickens S, Anderson RJ. County hospital and regional medical care in Texas: an analysis of out-of-county costs. Tex Med . 2004;100(6):56-59.
- The University of Texas M.D. Anderson Cancer Center Mission Statement. http://www.mdanderson.org/about-us/index.html .
- Parkland Decision Support Services, TII database, proprietary data.
- Leitch AM, Garvey RF. Breast cancer in a county hospital population: impact of breast screening on stage of presentation. Ann Surg Oncol . 1994;1(6):516-520.
- Texas Dept of State Health Services query system. http://soupfin.tdh.state.tx.us/cgi-bin/death10 .
- Texas Dept of State Health Services. Texas Cancer Registry. http://www.dshs.state.tx.us/tcr/ .
- 2009 Parkland Cancer Registry Annual Report and Cancer Data Review (2008 incidence), Parkland Health & Hospital System (internal report, 2009).
- Lob R, Allen J, Emmons K, Azanian J. Timely care after an abnormal mammogram among low-income women in a public breast cancer screening program. Arch Intern Med. 2010;170(6):521-528.
- Brennan Ramirez LK, Baker EA, Metzler M. Promoting Health Equity: A Resource to Help Communities Address Social Determinants of Health. Atlanta, GA: US Dept of Health and Human Services, Centers for Disease Control and Prevention; 2008. http://www.cdc.gov/nccdphp/dach/chaps/pdf/SDOHworkbook.pdf .
- Internal records, Dysplasia Clinic, Claudia Werner, MD. 2010.
- Stauffer BD, Amarasingham R, Pickens S, Anderson RJ. Comparing the financial condition of Texas hospitals using a novel definition of the safety net. Tex Med . 2008;104(8):56-62.
- Ormond BA, Wallin S, Goldenson SM. Supporting the Rural Safety Net. Washington, DC: Urban Institute; 2000. Paper No. 36. http://www.urban.org/UploadedPDF/occa36.pdf . Accessed April 1, 2003.
- Rickets TC, ed. Rural Health in the United States. New York, NY: Oxford University Press; 1999:41,141.
- Gaskin DJ. Safety Net Hospitals: Essential Providers of Public Health and Specialty Services. New York, NY: Commonwealth Fund; 1999:5-9. http://www.commonwealthfund.org/usr_doc/Gaskin_safety_net_hospitals_309.pdf?section=4039 . Accessed April 1, 2003.
- National Association of Public Hospitals and Health Systems. America's Safety Net Hospitals and Health Systems. 2000:4-9. http://www.naph.org/Template.cfm?Section=Publications&template=/ContentManagement/ContentDisplay.cfm&ContentID=2511 . Accessed April 1, 2003.
- Texas Dept of State Health Services, County Indigent Health Care Program. http://www.dshs.state.tx.us/CIHCP/eligibility.shtm .
- Geyman J. Cancer and comparative effectiveness research. The Hastings Center Health Care Cost Monitor. August 25, 2009. http://healthcarecostmonitor.thehastingscenter.org/johngeyman/cancer-and-comparative-effectiveness-research . Accessed March 10, 2010.
- Weller DP, Harris MF. Cancer care: what role for the general practitioner. Med J Aust. 2008:189(20):59-60. http://www.mja.com.au/public/issues/189_02_210708/wel10550_fm.html . Accessed March 16, 2010.
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