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Is Medicare Advantage Fit For Cancer Patients? · CareTalk: Healthcare. Unfiltered.

• 0:00
  Choosing between traditional Medicare and Medicare Advantage is hard.
• 0:03
  But the stakes are even higher for cancer patients. Does the flexibility to choose any hospital or doctor under traditional Medicare outweigh Medicare Advantage enhanced benefits like dental, vision and OTC drugs? So are Medicare Advantage plans good for cancer patients?
• 0:28
  Welcome to CareTalk America's home for incisive debate about healthcare, business and policy. I'm David Williams, president of Health Business Group. And I'm John Driscoll, president of Walgreens Health.
• 0:39
  Well, it's time to join our ever growing community on LinkedIn, where you can access CareTalk content, contacts and interact with the hosts. That's John and that's me.
• 0:48
  And be sure to leave us a rating on Apple or Spotify while you're at it. So David, where do you stand on this complicated question?
• 1:00
  40% of all adults are going to get cancer in their lifetime.
• 1:05
  I think it's as much about how you think about getting care under traditional Medicare fee for service as it's referred to often, or Medicare Advantage, which is when HMO manages your care. But maybe we should start by just unpacking how Medicare works and what it is, and then talk about or argue about what patients with cancer or worried about it should be thinking about as they make this choice, this very critical choice at this critical time of year.
• 1:34
  John, there's not all that much information published on your main question about whether regular fee for service Medicare is better than Medicare Advantage as it relates to cancer, which leaves us free to bloviate with our general opinions. There is information published, though, about what's the difference between regular Medicare and Medicare Advantage to start with. And regular Medicare is programmed mostly for people over 65, but also those with disabilities or end stage renal disease. Put that aside for a minute. About half the beneficiaries are on the traditional Medicare. There's Part A, which is hospital insurance, also covers skilled nursing facilities and home. Part B is doctor visits and other outpatient services. And also some infused and oral drugs are in that category too. And there's Part D, which is outpatient drugs. So that's traditional Medicare. Now to make it a little more complicated, most people will get Medigap, which is actually things to cover, the things that traditional Medicare doesn't cover. So you've got your deductibles, your co insurance, your copays, et cetera. What about part C? Yeah, exactly. John, we skipped over know Abd was also confusing because Abd is age blind and disabled, which is another type of a health plan. Can we just focus on Medicare for the moment? So part C is actually also known as Medicare advantage, and that has basically your part A, your part B, and your part D usually altogether. And it provides at least the same coverage as regular Medicare, but there's some different rules and costs and it's run by private health insurance companies that's more like regular managed care. Main differences are there's limited networks.
• 3:08
  It's not any willing provider. There's some prior authorization, cost sharing and other tools that are typical of managed care.
• 3:15
  You say, why would people even bother with that? Well, there's added benefits like dental vision, transportation, meals that are often there and it can be more coordination. Those are the two main types of Medicare jobs. Well, and to be fair, David, under fee for service Medicare, which is, again, maybe the simple way to think about this, is traditional Medicare where most of your coverage, no matter what letter you're talking about, is provided on fee for service basis. The coinsurance and copays really do add up, which is where the Medigap insurance comes in. And Medicare Advantage, in addition to having things like dental coverage, vision coverage and over the counter drugs coverage, often limited but often not available to be covered at all under traditional Medicare, the out of pocket costs historically for Medicare beneficiaries is substantially lower when you go with Medicare Advantage. That's really the critical thing that I think drives a lot of seniors, particularly on a fixed budget, to pick Medicare Advantage. But you've also got coordination of care.
• 4:23
  But, okay, now that we've teed up what the differences are, why don't you lay bare your cards as to whether patients who are worried about cancer or have cancer, what they should be thinking about as they make a decision between traditional Medicare and Medicare Advantage? It's fine, John. My view is a little bit nuanced and I'm not definitely in one or yes, indeed, John. So I would say so if I have to go one way or the other, I would say that I would go with the traditional Medicare that is the fee for service Medicare. And that is actually based on my own experience in my family. We've had relatives, first degree relatives who have Medicare and when they have had cancer, they don't live in the Massachusetts area, but we actually, after diagnosis, brought them to Massachusetts for care in a very advanced medical center here in Boston.
• 5:16
  And we're glad that we did. That would have probably been difficult to do, if not impossible, under Medicare Advantage. That's where Lean, you're kind of a productive snob is what that comes across. They have to come to you. They have to go to Cambridge in Would.
• 5:31
  Why do you think that's the case for me in particular?
• 5:35
  So I'm even more of a snob junk because I'm the healthcare business guy and then my brother is a physician who trained the people that are currently in senior clinical spots at those hospitals. So that's not going to be useful for most people that are there.
• 5:48
  But the main reason, John, is the ability to go to any provider in the country. And that is a bigger issue with cancer than with other things. Right?
• 5:55
  If you're going to go get a colonoscopy or you're going to have even a knee surgery, there's a lot of places that can do it. But cancer, there's hundreds or thousands of diseases and you want to go where there's a lot of specialization.
• 6:06
  And the regular idea of having a managed care network where you look at like what's network adequacy it isn't adequate for cancer.
• 6:13
  Well, I think it should be nuanced because often the early diagnosis can be done effectively by an internist. But what about all of mean medicare advantage is based on the notion of coordination of care and certainly you're much more likely to get or typically more likely to get screened in a medicare advantage plan because that's one of the ways they get paid and what they're evaluated on. So if you're getting more screening, why do you recommend that people consider medicare fee for service where know patients are bouncing around and there's less coordination of care?
• 6:52
  John, as I said, there's not that much research on this topic. And so I think the best thing to do is to go to those that are really advocates for medicare advantage in cancer and see what they have to say and sort of picket their arguments. So there's the better medicare alliance published a study, a white paper really on this topic and they said, hey, there's more focus on prevention, although that's not necessarily quantified. They did say there's lower out of pocket costs. To go to one of your points, they had, at least in their sample, they were showing that the out of pocket cost for somebody with cancer with traditional medicare was about $6,100 versus about $4,000.
• 7:26
  So that's significant $2,000. And also this more access to the ancillary services that could be helpful. So you have this transitional hospice care. You've got cancer screening that can occur during in home assessments, care management, financial navigation, transportation, palliative care, et cetera. So that's the argument there.
• 7:46
  Now they also would say that they serve generally a lower income population.
• 7:51
  About half of those people who have cancer within medicare advantage are at under 200% of the federal poverty level, and that compares to one third in traditional medicare. So it's not an apples to apples comparison with populations, but I do think it's a nuanced point. I was giving you a hard time about thinking that the world sort of all the best health care kind of revolves around you and your brother in Boston.
• 8:14
  But there is a substantial amount of evidence that if you've got most forms of cancer and particularly anything close to esoteric, that you're much better taken care of and have access to more drugs that are life saving and life extending. If you're in a national cancer institute center and one of their best centers of excellence, the national cancer institute actually puts much of its research dollars as the NIH around these academic medical centers that are doing cutting edge research.
• 8:51
  The average lifespan for cancer patients has extended quite substantially since the 90s because of new drugs in the areas of immunotherapy and otherwise.
• 9:01
  And half of all of the biotech drugs in development are addressing and attacking cancer and extending life. And so in addition to having specialists who look at cancer all day long, because that's who the National Cancer Institute primarily supports, you're also getting access to the best information about stuff, about drugs that are potentially life saving in clinical trials, or people who know the most about them, because those trials happen with either they or their colleagues. And I think that while there's a big concern about prior authorization and narrow networks and those are kind of legitimate concerns whether you're in fee for service Medicare or Medicare Advantage if you have the misfortune of getting cancer. And it's going to be 40% of all adults. I think you want to make absolutely certain you have access to some of these great academic medical centers that are researching it and getting the research funds wherever you are in the country. And if you aren't in an area of the country where that's available, you should, to your point, travel there.
• 10:08
  I think it's much more in terms of survival and success where you go versus how you're covered. John, there was an article that is actually a peer reviewed article that appeared in the journal of clinical oncology.
• 10:24
  It was by researchers at city of hope, which is one of those advanced cancer centers that you're describing. It's actually getting a lot of play at the moment as people are looking into this very question that we're answering. And they did a study about cancer surgery, and these are particularly for these advanced cancers where you're doing removal of the stomach, the pancreas, or the liver.
• 10:40
  So that's pretty serious and highly specialized. And what they showed is that the people that were on traditional medicare were about a quarter of them ended up being at a teaching hospital versus 8% of those in medicare advantage, and that there were some significant differences, including mortality.
• 10:56
  So there was a significantly higher likelihood to die within 30 days if you were in medicare advantage. And also there was typically a delay of a couple of weeks of treatment due to prior authorization and so on that slowed people down. This is what they showed in the study. Now, this is in california. It's limited to specific surgeries, and there's an interested party that's writing it. But this would argue that at least for those most complicated types of cancer, the type of coverage you have is going to be at least correlated with your outcome. I think there's a lot of indicative research that if you look at observed over expected mortality, in other words, what happens when you risk adjust it, that outcomes are better at some of the better academic medical centers. To your point, the comparison of the population in medicare advantage versus not fee for service medicare is a little bit unfair because we know that you're at much greater health risk and much more likelihood of showing up at healthcare with a lot of more comorbidities if you are under 200% of the federal poverty line. So if you're disproportionately the poor and who disproportionately have less access to health care, are disproportionately in Medicare Advantage, they're going to have worse outcomes by definition.
• 12:19
  So you really ought to look at that observed over expected mortality, risk adjusted, and still it's less about, again, coverage and more about care. John, can we talk a little bit about drug coverage? Because this is relevant difference between traditional Medicare and Medicare Advantage and also as it relates to cancer drugs.
• 12:40
  And it's confusing to me, I would say, about what's the medical benefit versus the drug benefit.
• 12:46
  Could you say a bit about that? Well, I think that it's actually pretty complicated because what happens is outpatient drugs and inpatient drugs are handled differently and then you've got certain inpatient drugs are actually part of a bundle that the hospital charges for.
• 13:06
  So it's pretty complicated.
• 13:10
  I think the most important thing from a patient perspective is to make sure that you're challenging your doctor to not just give you what has been historically available, but that you are asking questions about clinical trials and recently approved drugs in your area. Because it takes about 17 years between the time that a new drug or a new technique actually comes on the market and becomes standard of care.
• 13:35
  And we have drugs, as I said, percent of the whole pharma pipeline is all these new drugs for cancer. So they're coming out all the time.
• 13:42
  And you want to make sure if you're a patient, caregiver or family member that you're pushing to know, well, what's the most recent set of drugs and where can I get them and whether they are available by pill. Because a lot of traditional infusible drugs, those that are injected into your arm on like an IV drip, are now available in pill form and some of those ones that are novel are injectable biologics or injectable in other forms. And so I think it's less about where you get it than making sure that you're getting the best and the newest available drugs for your treatment. John in any circumstance when you're sick, it's good to have an advocate with you or to be your own advocate. Cancer is particularly hard because it's so frightening and also because it's exhausting the treatments and the disease itself. And so I know we were I don't know if you were joking or not about bringing my brother and all that. I mean, if you have a physician, family nurse or something like that, or you're just a well educated layperson, you got to get in there. That makes a big difference with how you're one of the great things about the patient advocacy communities, whether you're talking about breast or prostate or lung, is that a lot of it's now available online. A lot of it's.
• 14:48
  Available on some of the better websites like mayo provide a heck of a lot of information about exactly what's going on and how to get care. And so I think the most important thing is to, again, less about coverage and more about content and care.
• 15:03
  Make sure you've got access to that content and your own patient advocate.
• 15:06
  Even in a managed care context, the most aggressive patients and families are going to make sure that their parents, their siblings themselves are going to get the care they need, where they need it. Let's talk about switching plans, because one idea would be, hey, I'll start on maybe medicare advantage, and then if I get cancer, I'll switch over to traditional medicare. No can do. One of the things that's super important for seniors to realize and those that are helping those seniors make a decision is that that is not a qualifying event in the context of you're basically signing an annual contract with the managed care company if you're signing up for medicare advantage. And I think we're in the midst of annual enrollment right now. People like my parents and your parents are being deluged with ads on TV about medicare this, Medicare that, and all these happy, smiling, incredibly healthy people who appear to be covered by managed care suggesting that everyone enroll. You really want to be kind of thoughtful about that whole choice because you are locked in for a year.
• 16:17
  So I would agree it's not a good strategy to just think you could just flip from one to the other. There is the regular open enrollment period, which we're in now up until early December in most places, and the coverage starts January 1. Now there's this Medicare advantage open enrollment the first quarter of the year, and the coverage starts the first day of the month that you ask to join.
• 16:37
  Now, you can switch between one medicare advantage plan and another during that time, and you can switch from medicare advantage to traditional medicare.
• 16:45
  So if you're unlucky enough to get cancer but lucky enough to get it exactly the right time, you might be able to make it happen.
• 16:52
  I wouldn't count on it. I wouldn't mean I think you need to make the principle. You need to balance the short term out of pocket cash advantage two versus $6,000 for someone on a fixed income is a pretty material difference. And remember that whatever choice you make, understand the content and advocate with your family members to get at the care you need. So John, what about you talked about the sort of lifetime possibility of getting cancer, something like 40%. So should somebody take this into account when they're choosing from one ear to the other, or is this just not really the thing to consider? Well, as you get older, the probability of you getting cancer increases. We know that.
• 17:42
  And we're getting better and better at extending life, at providing life extending treatments and modalities. But I think it absolutely should be an input.
• 17:54
  And again, you ought to weigh because there are plenty of cancers that I'm sure are caught in managed care earlier because there's such an incentive for the plans to be paid to actually do the screening and make sure they risk adjust because it drives their payment, their population.
• 18:19
  And the docs and the plans who are in managed care are going to be typically better at screening than those in fever service Medicare. But your point that once you're in managed Medicare and your care is being coordinated, it's also being managed and that's where the prior authorization where you have to go through a mother may I process with a doc and a nurse or sometimes an executive in the managed care to make sure that you get the care.
• 18:51
  And that does add time to the process. I'll also say that some of the best managed care plans actually have specialized groups that just focus on cancer care and focus on the most modern protocols.
• 19:03
  So the other thing to think about if you're making the choice as 50% of all Medicare beneficiaries and it grows every year, are joining those managed care plans because of the economic advantage, is to make sure that across those plans that they really have access to great hospitals, as you were suggesting. Check the network, but also try to determine what the quality of that care and coordination means. Do they have a specialized centers of excellence in Medicare?
• 19:29
  How are they in cancer? And you can often do that research up front, but I guess the bottom line is if you're going to go manage care, you have to do a bit more research. I think it's been very fascinating discussion today and at least my view has shifted a little bit to say that it's less about the type of coverage you have and more about how you approach your care, your family's care, once somebody is diagnosed with cancer and is undergoing treatment.
• 19:58
  Well, that's it for yet another episode of Care Talk. We've been talking today about big C cancer and whether you go for traditional Medicare or Medicare Advantage. I'm David Williams, president of Health Business Group. And I'm John Driscoll of president of Walgreens Health. If you liked it, you heard, or you didn't, we'd love you to subscribe on your favorite service.