Private Medicare Plans Lead to Worse Oncologic Surgery Outcomes vs Traditional Medicare

Mustafa Raoof, MD, MS

Patients with cancer enrolled in private Medicare plans have less access to high-volume hospitals and face increased 30-day mortality rates for certain surgeries than those who are enrolled in traditional Medicare plans (TM), according to findings published in the Journal of Clinical Oncology.

Medicare Advantage (MA) beneficiaries faced significantly higher 30-day mortality rates than their TM counterparts for gastrectomies (adjusted risk difference [ARD], 1.5%; 95% CI, 0.01-2.9; P = .036), pancreatomies (ARD, 2.0%; CI, 0.80-3.3; P = .002), and hepatectomies (ARD, 1.4%; 95% CI, 0.1-2.9; P = .04). The median cost of index hospitalization and the global 90-day costs of all hospitalizations were significantly lower for MA beneficiaries compared with TM beneficiaries, which was consistent with privatized Medicare offerings.

“MA beneficiaries have significant barriers in accessing optimal surgical cancer care,” wrote Mustafa Raoof, MD, MS, surgical oncologist at City of Hope, and coinvestigators. “Except for pancreatic operations, MA beneficiaries were more likely to wait longer between diagnosis and therapy compared with TM beneficiaries. Furthermore, MA beneficiaries were significantly less likely to receive care at teaching hospitals, [Comission on Cancer (CoC)]-accredited hospitals, or [National Cancer Institute (NCI)]-designated centers. We also observed a significantly lower access to high-volume hospitals among MA beneficiaries (compared with TM) for lung, esophagus, stomach, liver, pancreas, or rectal operations.”

MA plans are gaining popularity in the United States, according to study authors. These plans can be differentiated from TM by the way the government requires that private insurers limit the beneficiaries’ out-of-pocket spending. These plans also integrate prescription-drug coverage and supplemental benefits, such as dental care, vision, and gym memberships, which is unique from TM. Part of how private insurers provide these services is by restricting beneficiary options to certain in-network providers and hospitals and regulating the use of specialists through utilization-management techniques, including prior authorization.

It was estimated that 29 million Americans were enrolled in privatized Medicare health plans (Medicare Advantage) as of April 2022, comprising 46% of Medicare beneficiaries nationally. Over 6 million patients are California residents, and nearly half (47%) are enrolled in MA plans.

This study looked at a sample of 76,655 patients requiring a cancer operation in California, where cancer care reporting is mandatory. Most evaluated patients (61%) were TM beneficiaries (n = 46,494), fewer (39%) were MA beneficiaries (n = 30,161). The median age was 74 years and just over half (51%) were female. The sample included 31,913 colectomies, 10,358 proctectomies, 4604 gastrectomies, 2895 pancreatectomies, 3639 gastrectomies, 1555 esophagectomies, and 21,691 lung resections.

Insurance played a role in what type of hospital patients were likely to attend. For example, patients with TM were more likely than MA beneficiaries to receive treatment at teaching hospitals (23% vs 8%), CoC-accredited hospitals (57% vs 33%), and NCI-designated cancer centers (15 vs 3%). Additionally, these patients were more likely to undergo procedures at institutions with a higher volume of available beds (median, 374 vs 286), intensive care unit beds (28 vs 24), operating rooms (18 vs 14), and annual inpatients surgical volume (4276 vs 3690).

Access to Optimal Surgical Cancer Center

Except for esophagectomy and pancreatotomy, MA beneficiaries experienced greater delays (> 2 weeks) between diagnosis and frontline therapy than TM beneficiaries. The percentage of patients who underwent resection within 2 weeks, respectively, was 29% and 22% for lung resection, 36% and 30% for gastrectomy, 26% and 15% for hepatectomy, 45% and 34% for colectomy, and 29% and 22% for proctectomy.

Regardless of operation, TM beneficiaries had more opportunities to receive care at a teaching hospital, CoC-accredited hospital, or NCI-designated cancer center than MA beneficiaries. They were also more likely to receive their operation at a high-volume hospital for higher-complexity operations. The percentage of patients able to have their higher-complexity procedures conducted at a high-volume hospital, respectively, was 22% vs 9% for lung resection, 11% vs 4% for esophagectomy, 31% vs 21% for gastrectomy, 36% vs 8% for pancreatomy, 74% vs 61% for hepatectomy, and 46% vs 40% for proctectomy. Compared with MA beneficiaries, TM beneficiaries were less likely to receive intermediate-complexity operations, such as colectomies, at a high-volume hospital (32% vs 42%).

MA beneficiaries needed to travel more for Herfindahl-Hirschman Index (HHI)-low regionalized operations, including colon, rectum, and stomach operations. The difference between the median distance traveled for these operations were clinically, yet not numerically, significant, (0.6-1 mile), according to investigators. Yet, for even more regionalized operations, or ones with high HHI, or esophagus, pancreas, or liver procedures, those with TM traveled 1.3 times farther than MA beneficiaries, suggesting that TM beneficiaries were more likely to receive care at higher-volume hospitals than MA beneficiaries, even if it required travel, and MA beneficiaries are more likely to receive cancer surgery at a low-volume hospital.

Ultimately, insurance type did not wield significant influence in 30-day mortality rates for lung, esophagus, colon, or rectal operations, although it did for stomach, pancreas, and liver operations. The failure-to-rescue was identified as higher in MA beneficiaries for liver operations alone (ARD, 5.5%).

Complication rates, both serious and total, were higher among TM beneficiaries for lung, esophagus, colon, or rectal operations, but were not different between the 2 beneficiaries for liver, stomach, or pancreas operations. TM beneficiaries were also more likely to have a prolonged length of stay compared for lung, liver, colon, or rectal operations, and they were also more likely to be discharged to another facility, as well as more likely to be readmitted.

“Our data demonstrate that managed care imposes decreased mobility for more regionalized operations,” study authors concluded. “Although MA beneficiaries incur less hospital costs, limited access to high-volume hospitals for liver, stomach, and pancreas operations may explain significantly worse postoperative outcomes after adjusting for covariates. For policymakers and insurers, these data suggest that ensuring access to high-volume hospitals for MA beneficiaries needing complex cancer surgery may improve short-term surgical outcomes.”

Reference

Raoof M, Ituarte PHG, Haye S, et al. Medicare Advantage: a disadvantage for complex cancer surgery patients. J Clin Oncol. Published online November 10, 2022. doi:10.1200/JCO.21.01359