Medicare Advantage is not an advantage for many seniors with cancer

When America’s seniors enroll in Medicare, they enter the most medically vulnerable stretch of their lives. And if they are unfortunate enough to be among the 1.9 million Americans each year who hear the terrifying words “you have cancer,” it is imperative they have access to the support and care they need to survive. About 60 percent of cancers occur in people ages 65 or older, accounting for approximately 70 percent of all deaths caused by the disease.

But as recently diagnosed cancer patients embark on this unwanted, unexpected care journey, what many seniors do not realize is that their Medicare Advantage (MA) plan can often put them at a disadvantage by restricting access to the care they need and deserve.

Nearly half of all Medicare beneficiaries are enrolled in MA plans, which equates to an estimated 29 million Americans. Unlike traditional Medicare, which allows patients to visit any hospital or physician that accepts Medicare, MA beneficiaries are only able to use physicians and hospitals within their plan’s — and in some instances, their sub-contracted medical group’s — network and service area.  

While MA plans are ostensibly held accountable to maintain appropriate “network adequacy” to manage the primary and specialty care needs of their enrollees, many MA networks are woefully inadequate to ensure access to the latest advances most likely to help beneficiaries with cancer. This is because the industry has accepted, even encouraged, under the banner of affordability and, ironically, the catchphrase “value-based care,” plans to develop narrow networks. And for those developing these networks, the focus is on cost containment, and not the attributes most valued by cancer patients: survival, quality of life and additional years with friends and loved ones.

While this outcome may be unintended, it was not unforeseeable. Narrow networks can successfully provide coverage for less complex illnesses where expertise is abundantly available. But to understand why MA’s narrow networks negatively impact cancer patients, one must understand how cancer is different from other health concerns.

Cancer is not one disease but hundreds, and the expertise needed to treat each cancer is often unavailable through the narrow networks of MA. With our burgeoning knowledge driven by genomics and precision medicine, the oncology field no longer behaves as one specialty, but rather many sub-specialties defined by tumor origin and specific genetic blueprint. These advances are reflected in the 33 percent cancer death rate reduction in the last 30 years and more than 3.8 million cancer deaths that have been averted. But as new treatments emerge, the need for specialized expertise increases.

Breakthrough advances — such as cell-based and immuno-oncology therapies — are first and sometimes only available at academic medical centers (AMCs) or National Cancer Institute-designated comprehensive cancer centers (NCI-CCCs). But MA beneficiaries are far less likely than traditional Medicare beneficiaries to receive cancer care at a teaching hospital (23 percent with Medicare versus 8 percent with MA), Commission on Cancer-accredited hospital (57 percent versus 33 percent) or NCI-CCC (15 percent versus 3 percent).

Cancer surgery statistics provide sobering evidence of the impact a lack of appropriate expertise has on outcomes: Cancer patients with MA who had their stomach or liver removed were 1.5 times more likely to die within the first month after surgery compared to their peers with traditional Medicare. And MA beneficiaries who had oncologic surgery on the pancreas were two times as likely to die within the first month.  

To further illustrate the importance of access to academic centers, consider your potential journey if you were diagnosed with metastatic lung cancer 10 years ago — you would be likely to die in six to eight months. However, if you visited an AMC conducting a trial with a life-changing medication, you could have potentially extended your life by six years or longer. Today, there are complex or advanced cancer cases that can only be appropriately diagnosed and safely treated at academic centers that uniquely provide cell-based therapies or newer, emerging immune-based and targeted therapies.

Access to these specialized centers has impact beyond immediate care needs. The clinical research that takes place at these comprehensive cancer centers paves the road to launching the next generation of new, more effective medications. Products with narrow network designs restrict access, adding to the burden already posed by social determinants of health. The combination of these barriers also deepens the pattern of under representation of minorities in clinical trials particularly as minority representation is greater among MA beneficiaries.

Put another way, by accepting narrow networks that restrict beneficiaries from accessing the leading academic centers, we’re broadly depriving future generations of cures and perpetuating a system that results in unacceptable disparities in health outcomes.

By recognizing that cancer care is different, these unintended outcomes become foreseeable. We can avoid them by modernizing our definition of “network adequacy” to keep pace with the innovation, and by establishing a new oncology ecosystem where academic medical centers and community oncologists work in harmony. This would allow for patients to receive the right care at the right place at right the time. Some critics may argue that expanding access to these centers is too disruptive to manage care norms and a threat to affordability. But those arguments fall flat when you consider the layers of organizations involved and the profit they each make. At the end of the day, disruption that benefits the patient creates value. 

In this new paradigm of value-based care, MA administrators should require health plans and other risk-bearing entities to demonstrate they have processes and networks in place to ensure that timely and appropriate care will not be restricted to a cancer patient in need.

Government programs, such as MA, should reflect the best of society’s values and aim to democratize access to leading-edge cancer expertise so every cancer patient, regardless of race, socioeconomic status, geography or insurance product, has access to care that gives them the best chance of living.

Harlan Levine, M.D., is the president of health innovation and policy at City of Hope (COH), a National Cancer Institute-Designated Comprehensive Cancer Center dedicated to ensuring optimal cancer care through patient focused treatments. Levine also serves as the chair of the board of AccessHope™, a spinout company from COH that is focused on serving the employer market and making leading-edge cancer care available to all regardless of geographical location.