Confronting the Dynamics of Medicare Benefits When Those Eligible Are Still Working

The bright lines are being erased between retirees with Medicare coverage and those still working, who are covered by commercial plans, as more Americans are staying in jobs past age 65. This creates a new dynamic for employers and benefits administrators, according to panelists who appeared on the first day of the 2023 Community Oncology Alliance (COA) Payer Exchange Summit, meeting Monday and Tuesday in Reston, Virginia.

Ferreyros

Practices and benefits managers will be getting questions about this shift, said moderator Nick Ferreyros, COA managing director for Policy, Advocacy & Communications, who joined the following panelists:

• Toni Gress, commercial value-based care lead, The US Oncology Network
• Bobby Green, MD, cofounder, president, and chief medical officer, Thyme Care
• Barry Russo, MBA, CEO of the Center for Cancer and Blood Disorders in Fort Worth, Texas; and
• Eric Mounce, CEO of Oncology Care Partners.

Community oncology practices are experiencing this shift both as providers of cancer care and as employers who must navigate the nuances of Medicare Advantage (MA) for staff or their spouses, said Russo.

“More than a quarter of Medicare beneficiaries have a form of employer-based coverage,” he said. And increasingly, their Medicare coverage is an MA plan; Russo said MA creates certain challenges for practices, but its rapid growth means it can’t be ignored—in his area, it accounts for 60% of the volume. Oncologists must also recognize that many referring primary care practices are capitated and will be looking for subcapitation arrangements, he said, and employers are also looking at value-based programs to hold down costs.

Having experience with MA plans can create opportunities when dealing with employers, Gress said, because any employees who are enrolled in MA can be attributed to national value-based care programs that employer may have in place. “If you have a larger number of beneficiaries involved in the [MA] program, this will be very good if you’re in a risk-based contract,” she said.

Practices can then contract directly with the plan and focus on things that matter to both sides, Gress said.

Ferreyros asked Mounce to discuss the launch of Oncology Care Partners; this entity is providing care through subcapitation, with gold carding—a process that eliminates prior authorization processes—and a limited revenue cycle process. Mounce exlplained that dollars are reinvested in a “high-touch” program to offer patients wrap-around services. Early results are very successful, he said.

Mounce agreed with Russo that MA plans cannot be overlooked, and he went further, describing the population that uses these plans: 50% of Medicare enrollees use MA plans; of those in MA plans, 37% have diabetes, almost 50% are Latino, and almost 50% live on less than $24,000 a year. As the MA population grows, he said, “It will be more and more important for us as providers to figure out how to provide care.”

Thyme Care seeks to address some of those needs, Green said, as it forms partnerships with oncology practices to offer virtual navigation services. He agreed with Mounce’s characterization of the MA population and also noted that just as practices have to work hard to help these patients, getting reimbursed can be more challenging because of the absence of the fee-for-service model. “So, it’s actually a lot harder to take care of these patients,” Green said.

Russo noted that when patients in MA plans get cancer, they are often shocked at the thousands of dollars in Part B out-of-pocket costs they face. “This is not something they fully understand a lot of times,” he said, noting that this is the biggest driver for requests for charity care in his practice.

“They’re not prepared for that,” he added. “They don't really grasp that concept because you think your Medicare pays for everything.”

Added Gress, “If this is an employer-based managed care contract, the employer is responsible for communicating the benefits to the employee.” She explained that depending on how well the employer explained the MA benefits to an employee’s retired spouse, “the retiree may not understand how that works.”

And the sheer number of MA plans makes extremely difficult for a typical benefits manager to keep track of an individual person’s benefits. “If you’ve seen one Medicare Advantage plan, you’ve seen one Medicare Advantage plan,” Ferreyros said.

Despite all this, Russo, Mounce, and Green agreed that the growth of MA plans mean that practices must learn to deal with their challenges and nuances. “There's cool stuff going on in Medicare Advantage,” Russo said. “There's unique value-based programs that are interesting, and potentially good places for practices like ours to learn a little bit more about, like navigation.”

Green offered the example of a large MA plan that would not work with Thyme Care, and for a while the company didn’t press the issue because the plan was notoriously difficult. But as the plan grew, Thyme Care realized the standoff could not continue. “It just came to this tipping point when you started to realize, ‘Oh, if we don't figure out how to contract with them, we're going to be in trouble.’”

Green added, “One of the unifying themes that we’ve seen with a lot of Medicare Advantage plans is at least they recognize that figuring out how to deliver higher-value cancer care is a problem—that they don’t fully understand how to do it, and that they are looking for partners and practices and other companies to help figure it out.”

Mounce created a stir when, without naming Barbara McAneny, MD, of New Mexico Oncology Hematology Consultants—a former president of the American Medical Association—he referenced her well-known description of “Medicare Disadvantage,” while noting that the plans continue to draw new members. “It’s a priority of ours to try and show that Medicare Advantage could work in the right place,” he said.

McAneny later responded, saying that it’s a problem when MA plans cherry pick relatively healthy seniors and bill for as many hierarchical condition categories as possible, while punishing specialists “for the crime of actually delivering health care.”

In cancer care, she said, specific chemotherapy drugs have been designated as not covered, and oncologists are expected to ask pharmaceutical companies for free drugs. Is this value-based care, McAneny asked?

Russo agreed there are issues with MA plans, including their marketing. But having watched many of the glossy ads during MA open enrollment, he believes the plans are likely to keep growing, and confronting the new reality just makes sense, given the effects on employers and the referral base.

“As somebody who's running a community oncology practice a long time, Medicare Advantage has happened to us, right?” he said. As much as possible, he said, Russo wants his practice to be proactive in the decision-making process with employers and primary care groups. “We can be more proactive in the way we structure things with Medicare Advantage, as opposed to reactive.”