Medicare Advantage fails to cut radiation therapy costs, despite heavy prior authorization burden

Medicare Advantage is failing to cut radiation oncology costs, despite the specialty’s heavy prior authorization burden in the program, according to new research. 

Congress established Medicare Part C in the hopes of offering more choice while also cutting costs, with private insurance companies managing this alternative. However, comparing data from patients with traditional Medicare against their Advantage counterpart shows little benefit, experts wrote April 2 in JAMA Network Open. 

Medicare Advantage cancer patients undergoing radiation therapy tallied higher spending and longer average treatment duration compared to their counterparts on traditional Medicare. Radiation oncologists treating patients on private plans also used less-advanced technology, such as proton therapy, when compared to traditional Medicare. 

“While MA demonstrates potential advantages for patients—such as lower monthly premiums and enhanced primary care access—concerns persist regarding limited networks, prior authorization, and rising out-of-pocket expenses,” Jacob Hogan, MD, with the Harvard Radiation Oncology Residency Program at the time of the study, and co-authors advised. “There is growing concern that efforts by MA health plans to decrease utilization may also result in lower quality of care.”

The findings are based on analysis of 31,563 radiotherapy episodes, logged in 2018. Researchers used a 20% random sample of Medicare claims for the study, pinpointing patients 65 and older who underwent radiotherapy for 1 of 15 cancer types. The final tally included 30,941 patients, about 72% of whom were covered by traditional Medicare. 

Adjusting for various mitigating factors, Advantage patients faced lower odds of undergoing the more-advanced proton or stereotactic radiotherapy. They also saw higher chances of receiving 2- or 3-dimensional radiotherapy, greater treatment length and higher estimated spending—at $8,677 versus $8,393 among traditional Medicare beneficiaries. 

The analysis comes after another 2021JAMA study found that radiation oncology faces the heaviest burden from prior authorization—a payer utilization-tactic used to manage costs. Hogan and colleagues speculated that prior authorization may have contributed to longer treatment durations and use of lesser technology among Advantage beneficiaries. Study subjects faced “significantly longer” care episodes in MA, a fact that persisted across all technologies and the three most common cancer types. 

“Research suggests that use of proton therapy has enhanced value only for certain cancer types and patient subsets, meaning efforts to curb its use may reflect appropriate cost-saving measures,” the authors noted. “However, as proton therapy remains an area of active investigation for other disease sites, with new studies further refining and expanding the role of proton therapy since 2018, it is crucial to ensure that prior authorization does not restrict access when use of such technologies is evidence based.”