Exploring Institutional and Insurance-Linked Disparities in Melanoma Outcomes: Insights from a VA and Tertiary Care Cohort Study

Highlight

This cohort study compares melanoma outcomes between a regional Veterans Affairs (VA) center and a nearby tertiary care center with shared physician staffing, uncovering significant variations in survival by melanoma stage and insurance type. The findings highlight improved melanoma-specific survival (MSS) in early-stage melanoma for VA patients, but worse outcomes for regional and distant melanoma stages compared to tertiary care. Insurance status strongly correlates with mortality differences within and across institutions, underscoring systemic care disparities.

Study Background

Melanoma, a malignant tumor of melanocytes, remains a significant clinical challenge globally due to its heterogeneous behavior and varying prognosis depending on stage at diagnosis. Survival outcomes are influenced not only by tumor biology but also by healthcare access, institutional resources, and systemic factors such as insurance coverage. Veterans represent a unique demographic with distinct healthcare delivery models under the Veterans Health Administration (VHA), while tertiary care centers typically serve more diverse patient populations with varying insurance statuses. Understanding how institutional and systemic factors contribute to melanoma outcomes is critical for optimizing management strategies and mitigating disparities.

Study Design

This retrospective cohort study analyzed melanoma patients seen over a 36-year period (January 1987 to May 2023) at two institutions in close geographic proximity: a regional VA center and a tertiary care center. Notably, the two sites shared physician staffing, controlling for provider factors. The study included 638 VA patients (612 males) and 9,682 tertiary care patients (5,564 males). Key endpoints were melanoma-specific survival (MSS) and melanoma-specific mortality (MSM) across localized, regional, and distant disease stages. Patient demographics, melanoma stage distribution, and insurance types were examined as key variables.

Key Findings

Patient demographics revealed that VA patients tended to be older and had a higher proportion of melanoma in situ compared to the tertiary center population (p<0.0001), suggesting differences in early detection or referral patterns.

MSS outcomes for male patients demonstrated a stage-dependent divergence: VA patients showed significantly improved MSS in localized melanoma (p=0.003) compared to males treated at the tertiary center. However, MSS was reduced for regional (p=0.0002) and distant-stage melanoma (p=0.02) in the VA cohort. When comparing VA males specifically to tertiary males insured through VA or other public insurance, the survival advantage for localized melanoma at the VA persisted (p<0.0001), but differences in advanced-stage survival (regional or distant) were no longer statistically significant, implicating insurance type as a confounding factor.

Within the tertiary care center, insurance status correlated strongly with melanoma-specific mortality: publicly insured patients exhibited significantly higher hazard ratios for MSM compared to privately insured patients. Specifically, Medicare was associated with a 46% increased hazard (HR 1.46, 95% CI 1.22–1.75), Medicaid with a 67% increase (HR 1.67, 95% CI 1.28–2.18), and Military/VA insurance with a 92% increase (HR 1.92, 95% CI 1.15–3.20). These findings highlight disparities in mortality linked to insurance coverage and likely access to care or treatment differences.

These data collectively suggest that improved survivorship in early-stage melanoma seen at the VA may be due to factors such as enhanced preventative screening or selective patient referral, whereas insurance-related barriers influence outcomes in advanced melanoma across institutions.

Expert Commentary

This study provides a unique comparison leveraging shared physician staffing between two very different healthcare systems, reducing provider variability and allowing better isolation of systemic factors influencing melanoma outcomes. The finding of more localized patients at the VA with better survival illuminates the potential benefits of integrated screening programs within the VHA. Conversely, the worse outcomes for regional and distant disease stages at the VA, which attenuate when controlling for insurance, point to broader socioeconomic factors and healthcare resource disparities affecting advanced melanoma management.

Limitations acknowledged by the authors include the smaller sample size of VA-insured patients at the tertiary center, which may reduce statistical power in subgroup comparisons. Additionally, retrospective design limits causal inference, and unmeasured confounders such as comorbidities or treatment regimens were not detailed. Nevertheless, the study fills a critical knowledge gap by highlighting institutional and insurance-related disparities influencing melanoma survival, an area ripe for policy interventions.

Conclusion

This cohort study illustrates the complex interplay between institutional setting, insurance type, and melanoma outcomes. Enhanced early-stage melanoma survival at the VA center likely reflects improved preventative screening and referral practices within the integrated VHA system. However, advanced-stage melanoma outcomes remain impacted by insurance-related disparities within and between healthcare systems. These findings underscore the urgent need for standardized melanoma care pathways and systemic interventions to mitigate healthcare inequities and improve outcomes, especially for patients with advanced disease.

Future efforts should focus on prospective analyses to elucidate how screening programs, access to novel therapies, and social determinants of health intersect to influence melanoma prognosis across diverse healthcare environments.

Funding and ClinicalTrials.gov

No funding sources or clinical trial registrations were reported for this retrospective cohort study.

References

Chen J, Fernandez K, Tang AS, Zhong X, Stewart C, Griffin A, McGuire J, Geisinger L, Grimes B, Wei ML. Differential melanoma outcomes in a regional VA center and a tertiary care center with shared physician staffing: A cohort study. Journal of the American Academy of Dermatology. 2026 Jul 8. PMID: 42419594. Available from: https://pubmed.ncbi.nlm.nih.gov/42419594/