Study finds cancer patients on Medicare Advantage access fewer providers than Medicare patients

A new study finds Medicare Advantage plans may limit access to specialized cancer care.

The study, published June 15 in JAMA Network Open, found 800,000 MA beneficiaries accessed just 7% of the medical or surgical oncologists traditional Medicare beneficiaries saw from 2016 through 2019 and went to just 12% of oncology organizations.

Patients in only one-quarter of plans accessed a comprehensive cancer center designated by the National Cancer Institute (NCI) for clinical and research leadership and resources, the study found.

Past research suggests that, on paper, 59% of MA plans included NCI centers in their network directories. But barriers such as distance, appointment availability, ghost networks, and Medicare Advantage tools like prior authorization can limit which in-network providers patients have realistic access to.

The industry responds. The best-case scenario is that MA patients saw fewer providers because they were only seeing the best providers and didn’t need to see more, Nancy Keating, a professor of healthcare policy and medicine at Harvard Medical School who was not involved with this study, told Healthcare Brew.

It’s not clear from the current study whether that’s the case because the authors state they didn’t measure treatment or cancer outcomes, but Susan Reilly, VP of communications at industry group Better Medicare Alliance, pointed Healthcare Brew to a 2023 study commissioned by the group that found MA cancer patients were 35% “less likely to be overwhelmed” by healthcare costs than those in traditional Medicare—plus they were screened for cancer as often or more.

A history lesson. Medicare Advantage was created in large part to incentivize quality care, Keating explained, because original Medicare “has its own limitations.”

For instance, a fee-for-service payment scheme means providers make more money by administering more treatments, even if the treatments aren’t actually helping the patient, Keating said.

But there’s not enough data to confirm whether MA is actually improving the quality of oncology care, Keating said, and the June 15 study’s finding that MA plans have narrow oncology networks “raises many concerns.”

“If MA plans are choosing the highest-quality providers with which to contract, then [smaller networks] could be OK, or even good. But given how challenging it is to identify high-quality providers of oncology care using data available to most health plans, the concern is that this is not how providers are being identified for inclusion in these networks,” she said.

Reform on the horizon? The JAMA study authors write that their results suggest existing network adequacy standards don’t “ensure meaningful access” for cancer patients. Currently, Centers for Medicare and Medicaid Services (CMS) requires only one physician per specialty within a service area.

Keating agreed, saying “one oncologist is not enough to treat the many different diseases that comprise cancer.”

An estimated 13.4% of the Medicare population—7.8 million beneficiaries—had a cancer diagnosis in 2022 according to an analysis of CMS data.

In the future, cancer care management could also transition to value-based models that hold oncology practices accountable for the quality and costs of patient care, Keating said.

CMS has piloted this type of structure in the past, and though research suggests the agency ultimately spent more to run the model than it saved in costs, Keating believes the idea had potential. CMS started piloting a related model, the Enhancing Oncology Model, in 2023, but some participating clinicians say there have been hiccups.

“Alternative payment models…are another strategy to address traditional Medicare’s limitations of fee-for-service payment without accountability,” Keating said.