Medicare and Disparities in Gynecologic Cancer Care | Anna Jo Smith, MD, MPH and Daniella Pena
My dad recently got a $3,000 bill from his oncologist and hospital for labs. Like too many of our patients, he panicked as much about the cost as what his labs showed. He is on Medicare, and his bill shows the incredible complexity—and potential inequity—of Medicare insurance.
In gynecologic oncology, the majority of our patients are 65 and older and, like my dad, have some form of Medicare. But their costs—and access to quality cancer care—can vary widely by which Medicare plans they can afford. Medicare Part A is premium-less but only covers hospital care. Additional coverage for physician services, outpatient care, and diagnostic exams under Medicare Part B, the traditional fee-for-service component, comes at a premium ranging anywhere from $150 to $500 monthly based on income level. Those who buy into Medicare Part C, i.e., Medicare Advantage (privately administered insurance plans), have additional coverage for dental, hearing, and vision services that are essential as we age, yet only accessible to those who can pay the additional premium. Medicare Advantage costs include Part B, plus an additional premium up to $200 a month. Patients who do not have the resources to pay for any of these aspects of Medicare will often qualify for Medicaid at no cost, financially that is. Medicare-Medicaid dually insured beneficiaries have 60% lower cancer screening rates than traditional Medicare or Medicare Advantage patients, leading to later-stage cancer diagnosis in these individuals.1
Such disparities in Medicare type contribute to the one-third of women with gynecologic cancer who never see a gynecologic oncologist. Seeing a gynecologic oncologist is the standard of care and recommended by the Society of Gynecologic Oncology and the American Society of Clinical Oncology. Yet access to our specialty is not included in the network adequacy standard for Medicare Advantage plans, resulting in 33% of silver plans and 44% of narrow network plans not including in-network gynecologic oncology.2 On top of this, even when our specialty is in a plan’s network, Medicare FFS (Part B) has a coinsurance rate of 20% for all services covered, such as physician visits, imaging, and IV chemotherapy infusions. This results in nearly a third of patients on traditional Medicare spending in excess of $5,000 out-of-pocket annually, most of who are on retired and on fixed incomes.
Disparities in Medicare type may adversely impact treatment decisions, even when you can see a gynecologist oncologist. Like many of our patients with ovarian cancer, after his next recurrence, my dad may be recommended for PARP inhibitor maintenance. This could cost over $12,000 monthly and may not be approved by his insurance, despite its FDA approval. For the 25% of Medicare enrollees who do not purchase Part D coverage for prescription drugs, they would bear this entire cost or turn to patient assistance programs that require complex navigation by patients and often their oncologists. Unlike traditional intravenous chemotherapies covered under Medicare Part B (fee-for-service), oral chemotherapies are covered under optional Part D. Even patients who purchase Part D prescription drug plans may find themselves in the donut hole of coverage where they are responsible for paying the 25% of the prescription price.
With these high costs and coverage gaps, 50% of gynecologic oncology patients face financial toxicity. This financial strain often results in patients acquiring debt, delaying treatment, and, in severe cases, declaring bankruptcy.3 Patients with cancer who declare bankruptcy have an 80% increased risk of mortality.
But paying a lot doesn’t mean you have access to the highest quality care. My dad was able to retain supplemental private insurance, giving him access to an in-network National Cancer Institute (NCI) designated cancer center for his care. Had his supplemental insurance been a Medicare Advantage plan, he could have been one of the 40% of Medicare Advantage enrollees, whose plan does not include an in-network NCI cancer center, limiting specialized care access and clinical trial opportunities. In contrast, traditional Medicare enrollees can go anywhere they choose for their cancer care. Yet the source of care is only half the story, 95% of Medicare Advantage plans require some form of prior authorization, which often makes even “covered” services temporarily inaccessible at a time when patients don’t have time to lose.
All of us will one day rely on Medicare as our primary insurance source. But what Medicare plans we can afford will impact our care—and impacts our patients’ cancer outcomes today. While my father is fortunate to have a supplemental plan to cover his $3000 bill and ongoing treatment at an NCI center, most of our patients are not so fortunate. As gynecologic oncologists, we need to recognize these insurance-driven disparities and work to mediate them, with either practice changes or federal advocacy. It is in the interests of our patients and our future selves.
 P. AL, B. N, G. BI, P. PE, The association between health care coverage and the use of cancer screening tests. Results from the 1992 National Health Interview Survey, Med. Care. 36 (1998) 257–270. https://doi.org/10.1097/00005650-199803000-00004.
 D.I. Shalowitz, W.K. Huh, Access to gynecologic oncology care and the network adequacy standard, Cancer. 124 (2018) 2677–2679. https://doi.org/10.1002/cncr.31392.
 S. Bouberhan, M. Shea, A. Kennedy, A. Erlinger, H. Stack-Dunnbier, M.K. Buss, L. Moss, K. Nolan, C. Awtrey, J.L. Dalrymple, L. Garrett, F.W. Liu, M.R. Hacker, K.M. Esselen, Financial toxicity in gynecologic oncology, Gynecol. Oncol. 154 (2019) 8–12. https://doi.org/10.1016/j.ygyno.2019.04.003.
In this column, SGO member Anna Jo Smith, MD, MPH, reflects on the cost of oncology treatment for her own father and the importance of access to quality cancer care. Dr. Smith is a second-year gynecologic oncology fellow at the University of Pennsylvania in Philadelphia, PA.
Daniella Pena is a senior at Cornell University. She worked with Dr. Smith this summer through the Summer Undergraduate Minority Research Program at the University of Pennsylvania’s Leonard Davis Institute of Health Economics in Philadelphia, PA.
This column is sponsored by an unrestricted grant from GSK. Sponsorship excludes editorial input. Content developed by the SGO Diversity, Inclusion & Health Equity Committee.