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 …