title: The association of Medicare health care delivery systems with stage at diagnosis and survival for patients with melanoma.
abstract: OBJECTIVE
  To evaluate differences in the stage at diagnosis and survival for melanoma between the 2 most common types of Medicare health care delivery systems, fee-for-service (FFS) and managed care (health maintenance organizations [HMOs]), in the United States during the period from January 1, 1985, through December 31, 1994.
  
  
  METHODS
  We used a linkage of 2 national databases, ie, the Medicare database from the Centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration) and the National Cancer Institute Surveillance, Epidemiology, and End Results program database, to evaluate differences in demographic data, stage at diagnosis, and survival for melanoma between the HMO and FFS groups. Patients A population of 4608 patients (62% men; 92% white).
  
  
  RESULTS
  We found an earlier stage of diagnosis for the HMO group compared with the FFS group for melanoma as the first cancer diagnosis, but this did not persist when melanoma was the second or a later cancer diagnosis. For patients with melanoma as the first cancer diagnosis, improved survival was related to earlier stage at diagnosis.
  
  
  CONCLUSIONS
  Differences exist in stage at diagnosis between patients in HMOs compared with those in FFS health care plans. This is likely due in part to utilization of services or access to care for patients in HMOs, and may be similar to that of patients in FFS plans with a previous cancer diagnosis before their diagnosis of melanoma. We did not find an increased risk of diagnosis with a late-stage cancer among patients with vs those without a previous cancer diagnosis. Improved survival appears to be related to earlier stage at diagnosis.
authors.affiliation: Department of Epidemiology and Public Health, University of Miami School of Medicine, Miami, FL, USA. Rkirsner@med.miami.edu
authors.forename: Robert S
authors.initials: RS
authors.lastname: Kirsner
authors.forename: James D
authors.initials: JD
authors.lastname: Wilkinson
authors.forename: Fangchao
authors.initials: F
authors.lastname: Ma
authors.forename: Heather
authors.initials: H
authors.lastname: Pacheco
authors.forename: Daniel G
authors.initials: DG
authors.lastname: Federman
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003695:Delivery of Health Care / Q000458:organization & administration*; D042241:Early Diagnosis; D018588:Fee-for-Service Plans / Q000706:statistics & numerical data*; D005260:Female; D019538:Health Care Surveys; D006279:Health Maintenance Organizations / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D006278:Medicare / Q000458:organization & administration*; D008545:Melanoma / Q000175:diagnosis* / Q000401:mortality* / Q000628:therapy; D009367:Neoplasm Staging; D016017:Odds Ratio; D011379:Prognosis; D012042:Registries; D018570:Risk Assessment; D012878:Skin Neoplasms / Q000175:diagnosis* / Q000401:mortality* / Q000628:therapy; D012959:Socioeconomic Factors; D018709:Statistics, Nonparametric; D016019:Survival Analysis; D016896:Treatment Outcome; D014481:United States