Study reveals cost differences between Medicare Advantage and traditional Medicare patients in cancer drugs
Medicare Advantage insurance may lead to lower use of high-cost cancer drugs, particularly for colorectal cancer
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University of Colorado Anschutz Medical Campus
A new study examining the use of high-cost drugs among patients with colorectal cancer and non-small cell lung cancer found those insured through Medicare Advantage received less expensive cancer drugs compared to others on Traditional Medicare.
The findings were published today in JAMA Health Forum.
"Lung cancer is the leading cause of cancer-related deaths in the United States and colorectal cancer ranks third. Gaining a better understanding of treatment options and their costs under different insurance plans is important for assessing the overall healthcare landscape and how insurances manage patient costs,” said the study’s first author Cathy Bradley, PhD, Dean of the Colorado School of Public Health.
The study found Medicare Advantage patients received less expensive cancer drugs, particularly for colorectal cancer, when compared to Traditional Medicare.
But this was not the case for non-small cell lung cancer. The researchers found there are less low-cost treatment alternatives available, resulting in high-cost drugs regardless of insurance.
“We are among the first to explore how cancer treatments differ for patients enrolled in Medicare Advantage compared to Traditional Medicare, which is crucial given that millions of Americans rely on one of these Medicare plans for their insurance,” said Bradley, who is also the Deputy Director of the University of Colorado Cancer Center located on the University of Colorado Anschutz Medical Campus.
The findings, she said, suggest that Medicare Advantage plans, with their cost containment strategies may result in lower treatment costs. At the same time, it could also result in reduced access to certain cancer treatments. The pattern wasn’t as clear for non-small cell lung cancer due to high-cost drugs seen as necessary for survival regardless of insurance type.
The researchers used a retrospective cohort from the linked Colorado All Payer Claims Database (APCD) and Colorado Central Cancer Registry (CCCR) to compare the use of cancer-directed drugs between Medicare Advantage and Traditional Medicare patients diagnosed with either cancer.
They focused on adults aged 65 years and older diagnosed with colorectal or non-small cell lung cancer and analyzed the records of nearly 4,000 patients.
They then estimated the likelihood that patients would receive either any cancer drug or a high-cost cancer drug. They adjusted for factors like patient characteristics (e.g., age, health status) and ecological characteristics (e.g., geographical location, market factors) to make sure the comparison between groups was fair and accounted for these influences.
The research showed patients with local or regional colorectal cancer who were insured by Medicare Advantage were six percentage points less likely to receive a cancer drug compared to similar patients insured by Traditional Medicare. This means that Medicare Advantage patients were less likely to be treated with a cancer drug. Patients who did not receive a cancer drug may have had surgery alone or opted for palliative care.
Patients with distant non-small cell lung cancer who were insured by Medicare Advantage were 10 percentage points less likely to receive a cancer drug compared to those insured by Traditional Medicare.
The research showed among patients who did receive a cancer drug, those insured by Medicare Advantage were less likely to receive high-cost drugs for colorectal cancer, specifically:
- 10 percentage points less likely for local or regional colorectal cancer
- Nine percentage points less likely for distant colorectal cancer
However, for non-small cell lung cancer, the study notes that few low-cost treatment options exist, so even though Medicare Advantage patients were less likely to receive a cancer drug, when cancer drugs were prescribed, they were as likely to be a high-cost therapy.
“We hope this research can help determine whether the cost-control strategies used in Medicare Advantage effectively reduce the use of high-cost drugs,” said Bradley. “The policy significance is Medicare Advantage appears to control cost of drug prescribing but only to a modest extent. Future studies are needed to determine if health outcomes are similar between the two plans. For more extensive cost controls, lower drug prices are needed.”
The researchers plan to extend this study, look at other databases and compare the differences between cities and rural areas.
About the University of Colorado Anschutz Medical Campus
The University of Colorado Anschutz Medical Campus is a world-class medical destination at the forefront of transformative science, medicine, education and patient care. The campus encompasses the University of Colorado health professional schools, more than 60 centers and institutes and two nationally ranked independent hospitals - UCHealth University of Colorado Hospital and Children's Hospital Colorado – which see more than two adult and pediatric patient visits yearly. Innovative, interconnected and highly collaborative, the CU Anschutz Medical Campus delivers life-changing treatments, patient care and professional training and conducts world-renowned research fueled by $910 million in annual research funding, including $757 million in sponsored awards and $153 million in philanthropic gifts.
Journal
JAMA Health Forum
Article Title
High-Cost Cancer Drug Use in Medicare Advantage and Traditional Medicare
Medicare rules may reduce prescription steering
Weill Cornell Medicine
Weill Cornell Medicine researchers have found that pharmacy benefit managers (PBMs)—organizations that negotiate access to medicines for most patients in the United States—steer patients to use their own pharmacies. However, these pharmacies appear less used in Medicare than in other market segments. These PBMs are part of integrated health care conglomerates that own insurance companies and pharmacies, which may create conflicts of interest.
The study, published Jan. 10 in JAMA Health Forum, found that in 2021 a third of all Medicare Part D pharmacy spending and almost 40% of specialty drug spending within Medicare Part D was through pharmacies owned by the four largest PBMs: CVS, UnitedHealth Group, Cigna or Humana. However, this represents a far lower market share in Medicare than the nearly two-thirds national market share noted by a Federal Trade Commission’s 2024 report. The findings may help guide future policy decisions on how these entities are regulated.
"It is striking that, on average, these companies have significantly lower market share in Medicare than the national estimates suggest,” said the study’s lead author Dr. Pragya Kakani, an assistant professor of population health sciences at Weill Cornell Medicine. “For high-cost specialty drugs, these pharmacies have almost half the market share in Medicare which is still lower than that observed across all other payer segments nationally.”
Dr. Kakani believes one reason for the reduced market share of these pharmacies in Medicare could be due to the Center for Medicare and Medicaid Services’ “any willing pharmacy” rules that ensure patients have access to their prescriptions at any pharmacy willing to meet the conditions set by Medicare Part D.
“While we don’t test this directly, our work raises the possibility that these rules may be powerful in preventing PBM firms from getting huge market share," she said. Outside of Medicare Part D, insurers generally have more leeway to exclude certain pharmacies from their networks, meaning patients have fewer choices about where they can pick up their prescriptions.
“However, despite Medicare's ‘any willing pharmacy’ rules, insurers integrated with PBMs are still capable of steering a substantial portion of their Medicare Part D plan enrollees to their own pharmacies,” noted senior author on the study Dr. Amelia Bond, associate professor of population health sciences at Weill Cornell Medicine. This is especially true among some high-cost specialty drugs. On average, Medicare patients used their own PBM’s pharmacies at nearly 20 percent higher rates than what would be expected without steering.
For example, for pulmonary arterial hypertension, idiopathic pulmonary fibrosis and multiple sclerosis, PBM-owned pharmacies captured over 60% market share in Medicare. “Because there is a lot of variation by disease area in terms of the prevalence of these pharmacies, policymakers concerned about this issue should pay special attention to drug classes where these PBM-owned pharmacies are most used.”
The market power of PBM pharmacies and firms’ ability to steer patients to their own pharmacies may impact costs, access to independent pharmacies and patient experience. Thus, some states may consider expanding protections like “any willing pharmacy” in general commercial markets.
"Steering can amplify the potential harms as well as possibly potential benefits of this type of integration, justifying further research in this area," Dr. Kakani said. Dr. Kakani, Dr. Bond, and their research team will continue examining some of these issues, focusing on the quality of care PBM-owned pharmacies provide, including access, timely filling of prescriptions, patient adherence to treatment plans and pricing.
Journal
JAMA Health Forum
Article Publication Date
10-Jan-2025
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