Center on Health Equity & Access: February 2023

Advancing Equity Requires Better Data Collection, Reporting, Says CMMI’s Dora Hughes, MD, MPH

As the Center for Medicare and Medicaid Innovation (CMMI) makes more moves to advance health equity, there is a greater focus on collecting better data and using it to take action, explained Dora Hughes, MD, MPH, chief medical officer, CMS, during the keynote speech at the National Comprehensive Cancer Network’s Patient Advocacy Summit, held December 2, 2022.

The Accountable Health Communities model was CMS’ first foray into screening beneficiaries with the purpose of helping them navigate the social services sector to get their needs met.

When this was first contemplated in 2016/2015, it was considered revolutionary that clinical providers—particularly for CMS, the nation’s premier health institution—would take this on,” Hughes said. “And now, with the kind of the cultural shift and the transformation, we’re able to see this is almost expected.”

CMMI was founded as part of the Affordable Care Act, and in 2021, the center decided to take a look back at its first 10 years to understand the lessons learned. Among them were ones that have implications for equity:

• Not enough focus on health disparities or Medicaid
• Too many providers reluctant or unable to accept downside risk
• Success of models too narrowly defined
• Models have a lack of patient or beneficiary perspective

Candidly, Hughes admitted equity has not always been a focus for CMMI. “We didn’t think about what impact our models are having on the range of beneficiary populations that we’re serving, particularly those that are facing health inequities,” she said.

With these lessons in mind, CMMI has launched its 2030 vision statement to guide the center through the next decade. The ultimate goal is creating a health system that achieves equitable outcomes through high-quality, affordable, person-centered care, which will be supported through 5 pillars:

• Driving accountable care for 100% of Medicare beneficiaries and the vast majority of Medicaid beneficiaries
• Advancing health equity
• Supporting innovation with new technology to create learning systems that allow participants to be successful in value-based care models
• Addressing affordability for not only the health system broadly but patients
• Partnering outside the traditional sphere of focus to achieve system transformation

Going forward with new models, and for models with at least 3 years left in the life span, CMMI will be considering how to ensure that equity is embedded throughout, increase the number of beneficiaries from underserved communities, evaluate models for their impact on health equity, and strengthen data collection and intersectional analyses.

“When we took a look back, we found that most of the beneficiary served in our models were White and affluent,” Hughes said. “And so how do we make sure we’re serving the full diversity of our beneficiary populations?

Particularly populations of color, lower-income populations, [and] those in rural areas,” we think key to that strategy.

Race and ethnicity is probably what CMMI has the best data on, but even that is flawed. Data on populations defined by sexual orientation, gender identity, and people with disabilities “is just sorely lacking.”

One of the new models coming up from CMMI is the Enhancing Oncology Model (EOM), which has a number of health equity components, including that participants will need to collect and report sociodemographic data. The model also includes additional payments for providers who need additional resources because they are taking care of a disproportionate number of underserved populations.

In addition to being required to screen for health-related social needs, participants must submit to CMMI a Health Equity Plan. “We want them to make sure that they know all of the needs [of] the beneficiaries [and] the populations they are serving,” Hughes explained. “Are there any disparities for any groups? How do you intend to close any gaps in care outcomes?”

EOM was announced in late June 20221 and will be launching in July 2023.

Reference
1. Caffrey M. CMS announces OCM successor, but gap year remains for oncology practices. The American Journal of Managed Care®. June 27, 2022. Accessed January 9, 2023. https://bit.ly/3IMAuv0

Spotlighting Health Disparities and Potential Solutions for Black Americans With MM

Multiple myeloma (MM) is the most common hematologic malignancy among Black Americans, who experience higher prevalence of disease. According to 2022 American Cancer Society data, an estimated 34,000 new cases of MM were diagnosed last year, and more than 12,400 individuals died from MM in the United States.¹

Amid growing incidence of MM, Black individuals are particularly at risk. Research has shown they have a 2-fold higher incidence (15.9 vs 7.5 cases per 100,000) and mortality rate (5.6 vs 2.4 cases per 100,000) than those of White individuals in the US, respectively.²
Researchers of an analysis published in the Journal of the National Medical Association sought to further investigate the source and impact of disparities in MM for Black individuals and potential solutions for improvement.³

“An estimated 6910 new cases and 2360 deaths from MM are expected among [Black Americans] annually, comprising 20% of all new cases and 18% of total deaths per year from MM in the United States. This is an enormous burden considering 1 in every 5 patients diagnosed with MM in the US is [Black],” they wrote. “Understanding and targeting the causes of disparities is critical to achieve more equitable treatment delivery and outcomes for all patients with MM.”

Outcomes of MM vary greatly in Black Americans, the study authors wrote. Data from Surveillance, Epidemiology, and End Results (SEER) registries from 1973 to 2005 have confirmed superior relative MM survival for Black patients compared with White patients, and SEER data from 2007 to 2013 showed superior MM specific survival, but not overall survival (OS).^4,5

However, these data were based on defined populations with a high access to health care and well-developed registration systems. Black Americans are more likely to live in low-income areas that are exposed to higher levels of environmental pollution and psychosocial stressors, which affect the access and utilization of health care services.⁶

Incremental use of autologous stem cell transplant (ASCT) and novel agent–based therapies over the past 2 decades has significantly improved survival rates for White patients with MM. But survival rates for Black patients have lagged, researchers noted, and the observed disparity is increasing.^7,8

“If evidence-based treatments were to be equally utilized, we would expect [Black Americans] to have universal improvement in survival….The sources of racial disparities in MM are multilayered and emanate from interplay of biological drivers, differential influence of genetic ancestry, and how these factors interact with and are shaped by other socioeconomic determinants of health care delivery and utilization,” said the study authors.³

For Black individuals, the difference in MM outcomes compared with White individuals may be explained by failure by the health care system to provide suitable cancer care. Underutilization of evidence-based treatment, receipt of suboptimal therapy, or limited access to treatment have all been cited to affect Black patients with MM, who also face a notable delay in the start of treatment.^9,10

A 2019 analysis of SEER data found that the average length of time between MM diagnosis and start of treatment with a novel therapy was 5.2 months for Black patients compared with 2.7 months for White patients.⁵ “Similarly, compared with [White Americans], Black Americans are 37% less likely to undergo ASCT and 21% less likely to be treated with bortezomib [Velcade], with underuse of these treatments associated with a 12% increased risk of death among Black patients,” researchers noted.

Poor enrollment of Black patients in clinical trials is also of major concern. Of the 2896 patients enrolled in 9 national cooperative group clinical trials on newly diagnosed MM, only 18% were non-White. And for pivotal trials leading to US regulatory approval of MM drugs, Black Americans constituted just 4.5% of all patients.⁹

“The inadequate representation of [Black] patients on clinical trials could perpetuate outcome disparity because their unique biology of the host and tumors is not accounted for while building patient treatment pathways,” said researchers.³

Beyond access to care, one factor that has been shown to disproportionately affect Black Americans is obesity, which is associated with incidence and mortality of MM. Data from National Health and Nutrition Examination Survey suggest that approximately 48% of non-Hispanic Black individuals have a body mass index (BMI) in the obese range, compared with 34.5% of non-Hispanic White individuals.¹¹

Black Americans are also disproportionately affected by related disorders such as metabolic syndrome, diabetes mellitus, and cardiovascular diseases.¹²

“Although causal inferences cannot be made from observational studies, the findings support strategies to increase awareness of MM risk among [Black Americans] with obesity, as well as show the need for prospective studies to determine whether weight reduction can reduce MM risk,” researchers said.³

Addressing these disparities calls for multidisciplinary efforts that fully engage all stakeholders, noted the study authors.³ The International Myeloma Foundation (IMF) was mentioned as an organization uniquely poised to address disparities due to its international reach.

Guided by an IMF council composed of key stakeholders in the MM field, including patients, advocates, physicians, and other health care providers, the organization’s Diversity Initiative aims to improve short- and long-term outcomes of Black patients by engaging the community, educating health care providers, and supporting patients.

“Developing protocols to improve access to quality care for individuals from diverse populations will be critical to improve the quality of MM care for all patients. Disparities will not be eliminated without the implementation of system changes that promote health equities, universal health insurance coverage, and access to high-quality care for all,” researchers concluded.³

References
1. American Cancer Society. Key statistics about multiple myeloma. Updated January 12, 2023. Accessed January 13, 2023. https://bit.ly/3Xi54AI
2. DeSantis CE, Miller KD, Sauer AG, Jemal A, Siegel RL. Cancer statistics for African Americans, 2019. CA Cancer J Clin. 2019;69(3):211-233. doi:10.3322/caac.21555
3. Bhutani M, Lonial S, Mikhael J. Disparities in multiple myeloma among African Americans. J Natl Med Assoc. Published online December 22, 2022. doi:10.1016/j.jnma.2022.10.001
4. Waxman AJ, Mink PJ, Devesa SS, et al. Racial disparities in incidence and outcome in multiple myeloma: a population-based study. Blood Adv. Published online December 14, 2020. doi:10.1182/blood-2010-07-298760
5. Ailawadhi S, Parikh K, Abouzaid S, et al. Racial disparities in treatment patterns and outcomes among patients with multiple myeloma: A SEER-Medicare analysis. Blood Adv. 2019;3(20):2986-2994. doi:10.1182/bloodadvances.2019000308
6. Willliams DR. Stress and the mental health of populations of color: Advancing our understanding of race-related stressors. J Health Soc Behav. 2018;59(4):466-485. doi:10.1177/0022146518814251
7. DeSantis CE, Miller KD, Sauer AG, Jemal A, Siegel RL. Cancer statistics for African Americans, 2019. CA Cancer J Clin. 2019;69(3):211-233. doi:10.3322/caac.21555
8. Ailawadhi S, Jagannath S, Lee HC, et al. Association between race and treatment patterns and survival outcomes in multiple myeloma: a Connect MM Registry analysis. Cancer. 2020;126(19):4332-4340. doi:10.1002/cncr.33089
9. Ailawadhi S, Jacobus S, Sexton R, et al. Disease and outcome disparities in multiple myeloma: Exploring the role of race/ethnicity in the Cooperative Group clinical trials. Blood Cancer J. 2018;8(7):67. doi:10.1038/s41408-018-0102-7
10. Ailawadhi S, Frank RD, Advani P, et al. Racial disparity in utilization of therapeutic modalities among multiple myeloma patients: a SEER-medicare analysis. Cancer Med. 2017;6(12):2876-2885. doi:10.1002/cam4.1246
11. Hales CM, Carroll MD, Fryar CD, Ogden CL. Prevalence of obesity and severe obesity among adults: United States, 2017–2018. NCHS Data Brief No. 360, February 2020. Accessed on January 13, 2023. https://bit.ly/3CGU4oT
12. Osei K, Gaillard T. Disparities in cardiovascular disease and type 2 diabetes risk factors in Blacks and Whites: dissecting racial paradox of metabolic syndrome. Front Endocrinol (Lausanne). 2017;8:204. doi:10.3389/fendo.2017.00204

Latest ACS Cancer Statistics Report Highlights Alarming Trends, Disparities in Prostate Cancer Care

Following the release of its 2023 report on cancer statistics, the American Cancer Society announced a new initiative to improve prostate cancer outcomes and reduce disparities.

On January 12, ACS released its annual report on cancer statistics. The report showed an overall reduction in cancer mortality and a substantial drop in cervical cancer incidence.¹ However, a concerning uptick in prostate cancer incidence and significant disparities prompted the launch of a new ACS initiative to improve prostate cancer outcomes.

News of the rise in prostate cancer follows a May 2022 report in JAMA Network Open, which found a possible connection between an increase in prostate cancer mortality and the controversial decision in 2012 by the US Preventive Services Task Force to recommend against prostate-specific antigen screening, which was roundly criticized by many urologists at the time.²
The ACS annual report, which was published in CA: A Cancer Journal for Clinicians, is based on population-level cancer incidence and outcomes data from the National Center for Health Statistics. Overall cancer mortality showed improvement, dropping by 33% since 1991. Based on the most recent available incidence and mortality data, the report projects 1,958,310 new cancer cases and 609,820 cancer deaths in the United States in 2023.

Lung, prostate, and colorectum cancers are attributed to the greatest number of deaths in men, whereas lung, breast, and colorectum cancers account for the highest number of deaths in women.¹

The overall trends in mortality were largely due to declines in lung cancer in both men and women in the wake of treatment advances and earlier detection, according to the report. In men, the lung cancer death rate dropped by 58% from 1990 to 2020. In women, it dropped by 36% from 2002 to 2020.

In addition the ACS annual report found that rates of cervical cancer dropped 65% in women aged 20 to 24 years from 2012 through 2019. This finding is particularly exciting, as this population was the first to receive the human papillomavirus (HPV) vaccine. This suggests that HPV vaccination may have a profound effect on the incidence of cervical cancer and other HPV-associated cancers.³
These findings also have implications for other infection-related cancers in general. “Increased investment in strategies to harness the immune system in cancer prevention is warranted,” Ahmedin Jemal, DVM, PhD, study author and senior vice president of surveillance and health equity science at ACS, said in a statement.³

Despite the improvement in overall cancer rates and mortality, certain cancer types had negative trends. Most notably, the incidence rate of prostate cancer, the most diagnosed and second-most deadly cancer among men in the US, rose 3% per year from 2014 to 2019. This alarming trend follows a 2-decade decline in prostate cancer incidence and was spurred by increases in advanced-stage diagnoses, according to the ACS report. For localized prostate cancer, the 5-year survival rate is 99% due to the efficacy of surgical intervention and radiation therapy. For metastatic prostate cancer, 5-year survival is just 32%.

“The increasing percentage of men presenting with advanced prostate cancer, which is much more difficult to treat and often incurable, is highly discouraging,” Karen E. Knudsen, PhD, MBA, CEO of the ACS, said. “[To] end cancer as we know it, for everyone, it is imperative for us to focus on cancers where trends for incidence and mortality are going in the wrong direction.”

Substantial disparities were also identified: The incidence rate of prostate cancer was 70% higher among Black men than White men, and mortality was 2 to 4 times higher in Black men than other ethnic groups.

In light of the uptick in prostate cancer incidence as well as the disparities seen in the report, the ACS announced the launch of Improving Mortality from Prostate Cancer Together (IMPACT), an initiative that will include advocacy, patient support, and research strategies to improve outcomes. The goal of the program is to reduce mortality for all men with prostate cancer, placing an emphasis on those disproportionately affected.

“IMPACT will fund bold new cancer research programs that connect the laboratory, the clinic, and the community,” said William Dahut, MD, chief scientific officer for the ACS. “These studies will help discern who is most at risk for prostate cancer, and how to prevent it.”

To facilitate earlier diagnosis, the ACS is also revising its own screening guidelines for prostate cancer using the best possible evidence, Knudsen said during a news conference. The organization aims to guide men, their primary care physicians, and urologists toward the most appropriate screening strategies based not just on age, but also family history, clinical history, and any known genetic risk.

The 2023 report does not account for known delays in screening and treatment throughout the COVID-19 pandemic, but next year’s report will have early insights into the impact of the pandemic on cancer incidence and mortality, Knudsen noted during the news conference.

References
1. Siegel RL, Miller KD, Wagle NS, Jemal A. Cancer statistics, 2023. CA
Cancer J Clin. Published online January 12, 2023. doi:10.3322/caac.21763
2. Burgess L, Aldrighetti CM, Ghosh A, et al. Association of the USPSTF Grade D recommendation against prostate-specific antigen screening with prostate cancer–specific mortality. JAMA Netw Open. 2022;5(5):e2211860. doi:10.1001/jamanetworkopen.2022.11869.
3. American Cancer Society releases latest cancer statistics, launches initiative to address prostate cancer resurgence and disparities. News release. PRNewswire. January 12, 2023. Accessed January 16, 2023. http://bit.ly/3QKey5J

Disparities in Treatment, Mortality Risk Are Observed Among Hispanic Americans With Multiple Myeloma

Hispanic Americans with multiple myeloma (MM) face disparities in treatment, clinical trial enrollment, and mortality risk, among other factors, which may be exacerbated by lower socioeconomic status (SES). Results were published in a systematic review published in Clinical Hematology International.¹

Characterized as the largest and fastest-growing minority group in the United States, individuals of Hispanic/Latino ethnicity make up approximately 19% of the US population.2 Health disparities in MM have been indicated to disproportionately affect minorities, particularly Hispanic Americans. However, there remain limited data on health disparities experienced by Hispanic Americans.

“Disparities in MM care for Hispanics in the United States continue to persist despite recent advancements in MM therapy. This can be related to limited access to care and lower utilization of effective MM therapies,” the study authors wrote. “Characterization of health disparities encountered by Hispanic Americans with MM is necessary to identify gaps and inform future strategies to eliminate them.”

The authors searched Embase, MEDLINE/PubMed, CINAHL, Scopus, and Web of Science databases for studies that reported on health disparities in Hispanic American patients with MM. Relevant studies that ​​compared incidence, treatment, and/or outcomes for Hispanic Americans with other ethnic groups through December 2021 were eligible for inclusion.

A total of 868 articles were identified, of which 22 original study articles were included in the systematic review. Articles were categorized based on topic, year of publication, and author. The number of publications was indicated to vary over time, with the highest number of studies (32%) published in 2021.

A majority of the included studies (59%) reported worse outcomes for Hispanic Americans with MM compared with other ethnic groups. Several key findings from the systematic review included:

• The incidence of MM in Hispanics was shown to be higher, with a median age at presentation 5 years younger than non-Hispanic Whites (65 years vs 70 years).³
• A higher proportion of Hispanic Americans with MM resided in zip codes with lower SES and zip codes with low education levels.4-6
• Hispanic Americans were found to receive less MM maintenance therapy and less supportive therapies, such as bisphosphonates.^7-8
• A longer time from MM diagnosis to novel therapy initiation was more prevalent in Hispanic Americans when compared with non-Hispanic Whites.⁹
• Enrollment in MM clinical trials was lower for Hispanic Americans.¹⁰

Furthermore, autologous stem cell transplantation (ASCT) use in Hispanic Americans was shown to be lower than in non-Hispanic Whites. Despite the incremental use of ASCT from 2008 to 2014, Hispanic Americans had the lowest rates of ASCT when compared with all other ethnic groups.⁹

Regarding mortality risk, the rate of in-hospital mortality was higher in Hispanic Americans when compared with other ethnic groups.¹¹ Although Hispanic Americans reported earlier age of diagnosis, these populations were found to be at higher risk of death, which researchers said may be related to lower SES.

“Improvement in MM survival, in this treatment landscape era of improved therapy options, was least pronounced in Hispanic Americans,” the authors wrote. “There is an urgent need to implement systemic and structural solutions to current barriers precluding equitable access to care for Hispanic patients.”

In discussing potential solutions to address the health disparities observed among Hispanic patients with MM, researchers cited the need to diversify the medical workforce because there remains a lack of physicians of Hispanic ethnicity within hematology/oncology.

References
1. AnampaGuzmán A, Alam ST, Abuali I, Al Hadidi S. Health disparities experienced by Hispanic Americans with multiple myeloma: A systematic review. Clin Hematol Int. Published online December 31, 2022. doi:10.1007/s44228-022-00026-2
2. Funk C, Lopez MH. A brief statistical portrait of US Hispanics. Pew Research Center. June 14, 2022. Accessed February 2, 2023. https://pewrsr.ch/3DQUI3t
3. Kaur G, Saldarriaga MM, Shah N, et al. Multiple myeloma in Hispanics: incidence, characteristics, survival, results of discovery, and validation using real-world and Connect MM Registry data. Clin Lymphoma Myeloma Leuk. 2021;21(4):e384-e397. doi:10.1016/j.clml.2020.11.013
4. Castañeda-Avila MA, Jesdale BM, Beccia A, Bey GS, Epstein MM. Differences in survival among multiple myeloma patients in the United States SEER population by neighborhood socioeconomic status and race/ethnicity. Cancer Causes Control. 2021;32(9):1021–1028. doi:10.1007/s10552-021-01454-w
5. Evans LA, Go R, Warsame R, Nandakumar B, et al. The impact of socioeconomic risk factors on the survival outcomes of patients with newly diagnosed multiple myeloma: a cross-analysis of a population-based registry and a tertiary care center. Clin Lymphoma Myeloma Leuk. 2021;21(7):451-460. doi:10.1016/j.clml.2021.02.001
6. Kamath GR, Renteria AS, Jagannath S, Gallagher EJ, Parekh S, Bickell NA. Where you live can impact your cancer risk: a look at multiple myeloma in New York City. Ann Epidemiol. 2020;48:43-50. doi:10.1016/j.annepidem.2020.05.005
7. Joshi H, Lin S, Fei K, et al. Multiple myeloma, race, insurance and treatment. Cancer Epidemiol. 2021;73:101974.15. doi:10.1016/j.canep.2021.101974
8. Zhou J, Sweiss K, Nutescu EA, Han J, Patel PR, Ko NY, et al. Racial disparities in intravenous bisphosphonate use among older patients with multiple myeloma enrolled in medicare. JCO Oncol Practice. 2021;17(3):e294-312. doi:10.1200/OP.20.00479
9. Ailawadhi S, Parikh K, Abouzaid S, et al. Racial disparities in treatment patterns and outcomes among patients with multiple myeloma: a SEER-Medicare analysis. Blood Adv. 2019;3(20):2986–2994. doi:10.1182/bloodadvances.2019000308
10. Duma N, Azam T, Riaz IB, Gonzalez-Velez M, Ailawadhi S, Go R. Representation of minorities and elderly patients in multiple myeloma clinical trials. Oncologist. 2018;23(9):1076–1078. doi:10.1634/theoncologist.2017-0592
11. Al Hadidi S, Dongarwar D, Salihu HM, et al. Health disparities experienced by Black and Hispanic Americans with multiple myeloma in the United States: a population-based study. Leuk Lymphoma. 2021;62:3256–3263. doi:10.1080/10428194.2021.1953013