Access Limitations to Cancer Care for Medicare Advantage Beneficiaries

A recent study published in JAMA Network Open reveals potential access limitations to specialized cancer care for Medicare Advantage (MA) beneficiaries. From 2016 to 2019, only 7% of medical or surgical oncologists serving traditional Medicare beneficiaries were accessed by approximately 800,000 MA members. Additionally, these beneficiaries utilized merely 12% of available oncology organizations.

The study further highlights that only 25% of MA plans facilitated patient access to comprehensive cancer centers recognized by the National Cancer Institute (NCI) for their clinical expertise and research capabilities. This contrasts with network directories indicating that 59% of MA plans list NCI centers. Geographical distance, appointment scheduling challenges, potential ghost networks, and utilization management tools like AI-driven prior authorization delays may reduce practical access to these centers.

Nancy Keating, a Harvard Medical School professor in healthcare policy and medicine, emphasized that the study does not shed light on treatment efficacy or cancer outcomes for these patients. She theorized that MA patients might opt for fewer providers due to accessing optimal care. Conversely, Susan Reilly from the Better Medicare Alliance referenced another study indicating that MA cancer patients reported fewer financial burdens from healthcare costs compared to those on traditional Medicare.

Medicare Advantage aims to improve care quality over original Medicare's fee-for-service model, which traditionally emphasizes volume over value. Despite its intentions, Keating expressed concerns about the narrow networks associated with oncology care, citing the challenge of consistently identifying high-quality oncology providers for these networks.

The study authors propose that existing network adequacy standards may not provide sufficient access for cancer patients. Current regulatory compliance from the Centers for Medicare and Medicaid Services (CMS) mandates just one specialist per service area, which may not suffice for comprehensive cancer care needs.

With estimates suggesting that 13.4% of the Medicare population, representing 7.8 million beneficiaries, had cancer diagnoses in 2022, the study advocates exploring value-based payment models. These models, already piloted by CMS, could potentially enhance accountability for quality and cost within oncology practices. CMS continues to assess these models’ effectiveness, although some providers have noted operational challenges in adapting to the new frameworks.