Medicare Advantage for People with Blood Cancers: Friend or Foe?

Dr. Chino welcomes Hari Raman, MD, MBA, author of “End-of-Life Care for Older Adults With Blood Cancers With Medicare Advantage Versus Medicare Fee-For-Service Insurance,” to discuss new research highlighting how insurance type may affect receipt of quality end-of-life care for patients with blood cancers.

TRANSCRIPT

Dr. Fumiko Chino: Hello, and welcome to Put into Practice, the podcast for the JCO Oncology Practice. I am Dr. Fumiko Chino, an associate professor in radiation oncology at MD Anderson Cancer Center with a research focus on access, affordability, and equity.

People with blood cancers may have prolonged clinical courses lasting years or decades and requiring specialty care. Prior research has shown that end-of-life care in this population may be suboptimal with higher hospitalization and lower hospice enrollment. Capacity for receiving appropriate specialty care has been a known concern with Medicare Advantage plans, but paradoxically, there may be unique advantages for those at the end of life. I am excited to welcome a guest today to discuss new research highlighting how insurance type may affect quality of end-of-life care for patients with blood cancer.

Dr. Hari Raman, MD, MBA, is a clinical fellow in hematology-oncology at Dana-Farber Cancer Institute. He got his MBA from Harvard Business School in 2023 while doing his internal medicine residency at Brigham and Women's. His research focuses on quality care delivery and value in healthcare with a focus on hematological malignancies. He is the first author of the manuscript, "End-of-Life Care for Older Adults With Blood Cancer With Medicare Advantage Versus Medicare Fee-for-Service Insurance," which was featured in JCO OP's February print issue.

Our full disclosures are available in the transcript of this episode, and we have already agreed to go by our first names for the podcast today.

Hari, it is really wonderful to speak to you today.

Dr. Hari Raman: Thank you so much, and I really appreciate this opportunity to join you.

Dr. Fumiko Chino: I have been hosting this podcast for over a year, and I think you are actually our first guest who is still in their training. So, I love this, I am excited to have you here. Do you mind giving us an overview of kind of where you are in your career and what got you interested in this topic?

Dr. Hari Raman: Yeah, no, of course. And again, I am really grateful to be here in training. I knew I wanted to care for patients, but as I continued training, particularly in my residency, I came to realize how many considerations around care delivery and the administration of healthcare actually exerts a significant influence on the patient care itself. And so while I was in training, I was really fortunate enough to receive an MBA while in residency to gain kind of a foundational understanding of how the business and financing of healthcare in the US, particularly, impacts care delivery and access. And as a clinical fellow at Dana-Farber, I have just been incredibly grateful to join Dr. Oreofe Odejide's lab here at Dana-Farber. She is actually the senior author of this study, where we have been able to examine care delivery and outcomes research for patients with blood cancers. This is really the intersection of both my clinical and academic interests given that my clinical focus will be caring for patients with lymphomas.

Dr. Fumiko Chino: And you are at the tail end of your training, right? So, you are, you know, out the door, correct? Or maybe you are not out the door.

Dr. Hari Raman: No, exactly. You hit it right on the head. I will actually be staying on as faculty here at Dana-Farber next year, and I am really excited to continue our research and also be able to care for patients with lymphoma starting quite soon, actually.

Dr. Fumiko Chino: That is so exciting. So, within this calendar year, you will be setting up shop on your own.

Dr. Hari Raman: That is the plan.

Dr. Fumiko Chino: Wonderful. And it is amazing to have built this large group of collaborators again within the same hospital system and academic world where you did your MBA and your additional training, so that is phenomenal. Hopefully, you will continue working with the same people.

Dr. Hari Raman: Yeah, exactly. You are exactly right. It is really so inspiring and also really we are really quite lucky here to be able to go down the hall and ask experts in healthcare policy what they think about some of our findings and really be able to get a rich discussion even within the walls of our own institution. So, I have been really grateful for that.

Dr. Fumiko Chino: Now, before you discuss this specific new research, do you mind giving our listeners a little bit of an overview of what you see as the key differences between the traditional fee-for-service Medicare and Medicare Advantage? I know personally and, you know, I think within oncology we really commonly encounter problems with the MA plans. We have network restrictions, we have coverage limitations, we have obviously prior authorization burdens. But there is obviously a lot of advantages, otherwise, it would not have proliferated at such a rapid rate in sort of the modern era.

Dr. Hari Raman: So crucially, the payment model for Medicare has been what we call fee-for-service, where the government or the Centers for Medicare and Medicaid Services, in this case, pays providers a set amount per service that they provide to their Medicare patients. In Medicare Advantage plans, private plans are actually paid on a risk-adjusted basis by the government or CMS to assume the total cost of care for patients. Theoretically, this would allow the government to have a somewhat predictable cost of care given that they are paying these monthly or bimonthly payments on a risk-adjusted basis and then also incentivize private plans to essentially limit the overall cost of care through various levers that they may be able to pull. I think you alluded to a really good point that part of these levers include things like restrictions on networks as well as potentially allowing patients to only go to certain providers or have certain hospitals in network.

While this is something that we think about from a restriction perspective, the other part of this to note is that Medicare Advantage is a voluntary program that patients choose to go onto. As you can imagine, the way in which these payers are able to get patients to go onto their plans is through other offerings, such as lower premiums, more add-ons such as dental or vision insurance, including other things such as care coordination, which is really important for oncology patients, or even access to lifestyle things such as gyms and other services.

Dr. Fumiko Chino: Yeah, I know that at least based on my own prior research that the populations that have traditional Medicare and the populations that have Medicare Advantage really are a little different. Do you mind commenting on that?

Dr. Hari Raman: Yeah, and I think this also speaks to the offerings that Medicare Advantage plans often provide. What we have seen, particularly in the last decade, has been that Medicare Advantage plans tend to have enrollees that are more likely to be of a racial and ethnic minority group. Also, these patients tend to have lower incomes and are frequently dually eligible for Medicaid as well. I think this is both in part to the populations that Medicare Advantage payers are deciding to roll out to, but also in part because of the offerings that may be provided and may be disproportionately more attractive for patients who may have lower sociodemographic means.

Dr. Fumiko Chino: One thing that has always struck me with some of the literature and the research around Medicare versus Medicare Advantage is that Medicare Advantage offers more to patients when they are well, but it may be more challenging to use if you have serious and complex medical conditions, and ironically, it is actually more expensive to CMS than traditional Medicare. It is a little push-pull with the sort of the rapid proliferation of the program. There is more than 50 percent of enrollees are now in Medicare Advantage as opposed to traditional Medicare.

Now, do you mind walking us through your actual JCO OP study, what you did, what you found, why it matters?

Dr. Hari Raman: So, I think as you astutely pointed out early on the podcast, we know that for patients with blood cancers or hematologic malignancies, they really face significant challenges at the end of life. This is even in comparison to patients who have solid cancers. This primarily manifests as having increased rates of hospital admissions, ICU stays, and even dying in the hospital near the end of life. This really detracts from the ability for patients to be able to spend more time with their loved ones at home, which is something that they frequently voiced when folks have done studies examining patient preferences. Furthermore, we have seen that patients with blood cancers actually have decreased hospice utilization. We know that hospice, which is a multidisciplinary support service that is really tailored to offer maximal comfort and support and care for both patients and their caregivers at the end of life, is quite diminished in patients with blood cancers, particularly in comparison to whether it is patients with heart failure or solid cancers and any other really end-of-life illness.

And lastly, along the same piece of hospice, patients with blood cancers are also uniquely situated in a situation where they are required to have blood transfusions to support their quality of life, but also their blood counts. Oftentimes patients who are near the end of life require access to these transfusions, and the problem right now in our current models of hospice care is that hospice agencies are not equipped to provide access to palliative transfusions. This is primarily due to a mismatch in the financial reimbursement that they receive and the cost of providing access to transfusions. And so patients with blood cancers at the end of life are often forced to make really difficult tradeoffs between preserving access to blood transfusions versus enrolling onto hospice and then receiving all the benefits of hospice care that they may be able to receive once they enroll onto hospice.

Our question really was to understand whether there may be modifiable risk factors, such as insurance type, which I mentioned in Medicare is optional in terms of either enrolling onto Medicare Advantage or fee-for-service, and see if that may impact the quality of care patients at the end of life, particularly with those with blood cancers. We performed a retrospective analysis using data from the Centers for Medicare and Medicaid Services. Our data spanned about five years from 2016 to 2020, and we really focused on patients who had insurance coverage by either the traditional Medicare fee-for-service or Medicare Advantage plans. Patients had to have had coverage for at least 15 months in a continuous fashion prior to their passing. In terms of how did we assess quality of care at the end of life, we focused on administrative metrics that have previously been validated both in surveys as well as focus groups of both patients and providers. This really focused on three key aspects: hospice use, rates of high-intensity healthcare utilization, which is broken up into things such as emergency department visits, ICU stays, as well as rates of in-hospital death, as well as rates of advanced care planning to see whether patients and their providers have had these discussions about what is important to them at the end of life before they ended up dying. We had access to about 70,000 patients in our study, about two-thirds of whom had fee-for-service insurance and about a third of whom had Medicare Advantage.

When we thought about these individual metrics of quality of care at the end of life, we saw that about a little bit more than half of patients were enrolled in hospice across both cohorts. However, the Medicare Advantage patients tended to have higher odds of hospice enrollment with a nearly 11 percent increase in the odds of receiving hospice before they passed, as well as a decreased likelihood of having a very short hospice stay, which meant that patients who enrolled onto hospice with longer stays were able to more fully capture all the benefits of hospice. In terms of healthcare utilization, we also again saw that patients with Medicare Advantage plans were less likely to have two or more ED visits, less likely to have any ICU admissions in the last month of life, and had a nearly 25 percent reduction in the odds of dying in the hospital compared to those patients who were enrolled onto fee-for-service plans. In general, we found that overall that patients with Medicare Advantage seemed to have at least met administrative metrics for higher quality of end-of-life care compared to those with fee-for-service insurance across patients with blood cancers.

Dr. Fumiko Chino: One thing I think that was really compelling about your research was that it actually showed a sort of flattening out of what are very large gaps in health equity in terms of different patient populations that may be more likely to die in the hospital, be more likely to receive aggressive care, and it did not seem that you were able to find a difference, which is, I think, good. Do you mind speaking more about that?

Dr. Hari Raman: Yeah, exactly. To your point, we know that prior research has shown that patients who are particularly of racial and ethnic minority backgrounds tend to have higher rates of high-intensity healthcare utilization at the end of life and decreased hospice. As you mentioned earlier, similar to what we have seen in the national cohort, our Medicare Advantage cohort was also more likely to be from a racial and ethnic minority background. And so we then asked the question, well, do we see any differential changes in the benefits of Medicare Advantage, particularly at the end of life, across different racial and ethnic groups? We found that across our entire study, patients who were white versus patients who were non-white were equally as likely to receive benefits with regards to the kind of differential impact of Medicare Advantage versus fee-for-service, which I think was really interesting for us because we know that these patient populations are at very high risk for poor quality end-of-life care.

Dr. Fumiko Chino: Now, your findings are really consistent with some other research that I have seen that shows that Medicare Advantage may really improve some metrics of end-of-life care, and I think this is mostly likely due in part at least to the hospice carve-out for MA plans where Medicare steps in to actually cover hospice payments and that kind of makes it free for MA plans to deliver. I would love your thoughts on this and please correct me if I am misunderstanding this situation.

Dr. Hari Raman: I think you are exactly right, and I think this is a really interesting example of how policy can actually drive behavior. You see that as you mentioned, there is a financial incentive for Medicare Advantage plans to have patients enroll onto hospice. Just briefly to review, once patients enroll onto hospice, these Medicare Advantage plans are no longer responsible for the cost of care associated with that terminal diagnosis, and they stop receiving the risk-adjusted payments from CMS. However, they still receive rebates from CMS for the minimal amount of care not related to the terminal diagnosis. A study actually that came out of Brown earlier this year found that CMS may be spending up to 50 million dollars a year in extra payments to these Medicare plans after patients enroll onto hospice. I think the flip side really is that, you know, there is also a theoretical benefit for patients if we think that we are increasing access and enrollment to this valuable service. But I think it is very important to not ignore the fact that this is definitely incentivized from a financial perspective for Medicare Advantage plans to have patients enroll onto hospice.

Dr. Fumiko Chino: There is one thing you mentioned in your manuscript that I actually thought was really great in that, in thinking about how the money monies, because MA plans, they have that financial incentive to enroll people in hospice, they actually invest more into things like coordination of services and navigation. Do you mind speaking a little bit about that?

Dr. Hari Raman: Yeah, of course. And I think this kind of came out of the question that we had when we were discussing and we said, when we are in the clinic, we do not necessarily know what insurance a patient has and we do not really use that to drive a lot of our decision making. And so we thought, how are we seeing these differences? I think one thing that came up was that, you know, there is a lot of communications and interactions that patients have outside of the clinic with their payers and with other ancillary service providers. I think one key piece is that with Medicare fee-for-service, patients are not given additional services by default, and there is no real exposure to other services unless patients ask for it. However, in these Medicare Advantage plans, when you have things like care coordination and navigation, patients may be having these discussions with other providers where either things such as hospice enrollment or end-of-life care planning are reinforced and these ideas are kind of explored further at home. I think partly what we are seeing is that while we may not see a difference in the provider behavior whether patients have Medicare Advantage or fee-for-service, there may be exposures to things like care coordination that are driving a lot of these patient and caregiver behaviors in terms of thinking about when to enroll onto hospice or when we think about focusing more on the quality of life rather than extending life through hospital visits and ED admissions.

Dr. Fumiko Chino: There was a recent JCO OP analysis looking at switching from MA to traditional Medicare after a new cancer diagnosis because switching can be challenging if patients did not actually sign up for a gap plan at their initial enrollment, i.e., some people actually end up being trapped in an inadequate MA plan for their cancer needs and that has been unfortunately well-covered in the media at this point. There is a very limited number of states that actually have Medigap consumer protections. So the study that just recently came out found that people are more likely to switch if they live in these states. And so kind of in my mind, that means that clearly MA plans are not just wine and roses at the end of life; some people really do have a lot of problems with them for their cancer diagnosis. So I am not actually sure if there is a clear answer to the friend or foe question, but I wanted to ask you what the kind of nuances that you pulled out of this, you know, doing this type of work.

Dr. Hari Raman: Yeah, I think you are exactly right. I think it is, it is hard to know if there is a clear answer to the friend or foe question. But I do think what is really helpful here is that our analysis at least somewhat adds to the broad body literature that demonstrates that there are certain policy levers that we may be able to isolate from different alternative payment models such as Medicare Advantage or other new innovations that may be playing a significant role in impacting the quality of care that patients receive at the end of life. But I do think the important part you mentioned is something that our study was not structured to examine, was that we did not look at the quality or access to care for these patients prior to the end of life. And so we really focused on that last year period. And I think a key question here and a key concern for a lot of us is that we really need to ensure that patients have access to high-quality care across their entire cancer treatment journey from the diagnosis and ultimately to their end of life. I think our study here was focused at the end of life, but we really need more information as to the restrictions that patients may have when they get a diagnosis or when they start seeking treatment because these are all things that patients are concerned about and may not necessarily be focused on at the end of life.

Dr. Fumiko Chino: It is ironic because I thought about after reading your piece that we know historically it is hard to switch from MA to traditional Medicare, but if traditional Medicare has better access concerns for active treatment and Medicare Advantage has better end-of-life metrics, maybe, you know, we should be advising people have traditional Medicare for their treatment and then switch over to Medicare Advantage for their end-of-life needs, which seems insane, but weirdly could help, question mark?

 

Dr. Hari Raman: I think that is something that you bring up is a really good point. And I think, you know, the one thing I would say particularly in patients with blood cancers is that their disease trajectories are often quite unpredictable. And I think to your point, you know, it would be really nice if say we have these modifiable factors where we can things like switching insurance can allow us to either get more access at the beginning and then towards the end have different forms of insurance that give us more access to palliative care services. But I think the key nuance here is that patients and their providers may not know when that end-of-life phase occurs.

 

And so one thing that we are thinking about is, well, how can we incorporate some of these policy levers that are more pervasive throughout all insurance forms so that patients are not necessarily having to take that upon themselves while they are sick to think about insurance coverage? Because I think as I can attest for my patients, the last thing patients want to think about is insurance coverage when they are facing things such as a terminal diagnosis or even advanced cancer. And so I think you bring up a really interesting point and it often almost seems like the burden is on the patients to figure out a workaround while there may be an opportunity for us to think about implementing new policies to kind of ease that burden for patients.

 

Dr. Fumiko Chino: Very well said. We are at the tail end of our conversation, but I want to leave a little bit of space if there is anything that you feel like we did not address. I know for example that you also evaluated advanced care planning conversations and I was kind of sad to see that they were not had that often or at least not documented as being had.

 

Dr. Hari Raman: Yeah, I think it is kind of a quirk of the data a little bit. And so we used claims-based data and I think what we saw was that patients who enrolled onto hospice may not have had an advanced care planning documented. And so it did not really make sense to us right away. And I think part of this is due to the capitated structure of Medicare Advantage where providers are not getting reimbursed for having additional claims for advanced care planning and things like that. And so I think it is safe to assume that if patients were thinking about enrolling onto hospice they would have had some form of advanced care planning discussion. And I do think from a fee-for-service perspective this speaks to potentially the incomplete penetration of some of these billing codes that were initially designed to capture quality of care and quality of discussions at the end of life but may not necessarily be as disseminated throughout all these practices.

 

And so I am not entirely sure that the low rates of advanced care planning that we saw in our claims analysis necessarily reflects actual treatment patterns because it may just be that the providers are not enrolling onto these relatively new billing codes or billing for these new codes. But I do think it is a good point that you are making and I think one piece is that we do really need to capture that information through other means if possible, things such as large language models as well as NLP processing is starting to come out of there where they are looking at the actual notes that providers write for patients and we are starting to see some of these conversations really be able to be measured and calculated in a more accurate way.

 

Dr. Fumiko Chino: Yeah, that is such a good summary of it, which is that if I am not going to get paid more for documenting the conversation or specifically filing a claim for it, why would I do that? Because it is just extra paperwork on my part.

 

So, do you have a next step in terms of where you want to go? I mean you are going to start your faculty career within this year. Do you know what your first project is going to be?

 

Dr. Hari Raman: Yes, we shared some of our work at ASH earlier this year, but we examined-  we tried to take a similar approach looking at insurance coverage to try to focus on a younger population. So we did an analysis on patients aged 18 to 64, and the really neat thing in that population is there is kind of a natural experimental cohort because the majority of patients are either covered under Medicaid or commercial insurance plans. And we tried to ask some similar questions asking, you know, are there differences that we see in the quality of end-of-life care that patients receive with regards to Medicaid and commercial insurance? I think this is particularly relevant in this current time because of upcoming federal legislation looking at limiting access to Medicaid. And we actually found that, similar to what we have had here, patients under Medicaid were actually more likely to have higher quality end-of-life care compared to those with commercial insurance.

 

And I think again, a lot of this could be driven by many factors, but one key piece is that most of Medicaid around the country nearly 70 percent is actually in a managed care fashion and it is contracted through accountable care organizations. And so again we are seeing that some of these policy levers may actually be driving a lot of behaviors on both patient and providers particularly at the end of life in this very vulnerable population.

 

Dr. Fumiko Chino: I am excited to read more about that work, maybe even in the pages of OP.

 

Dr. Hari Raman: We are looking forward to working on that, thank you.

 

Dr. Fumiko Chino: Thank you so much for this great conversation today. Many thanks to Dr. Hari Raman as well as our listeners. You will find the links to the papers that we discussed in the transcript of this episode. If you value the insights that you hear on the JCO OP Put into Practice podcast, please take a moment to rate, review, and subscribe wherever you get your podcasts.

 

I hope you will join us next month for Put into Practice's next episode. And until then, please stay safe.

 

The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.

 

 

 

 

 

Disclosures:

 

Hari Raman

No Relationships to Disclose

 

 

Fumiko Chino

Employment

Company: MD Anderson Cancer Center

 

Consulting or Advisory Role

Company: Institute for Value Based Medicine