Medicare Advantage Reduces Use of High-Cost Cancer Drugs Compared With Traditional Medicare
Medicare Advantage (MA) enrollees with colorectal cancer (CRC) and advanced non–small cell lung cancer (NSCLC) were less likely than traditional Medicare (TM) beneficiaries to receive cancer-directed drugs and, when treated, were less likely to receive higher-cost regimens, according to study results published in JAMA Health Forum.
TM fee-for-service payment can reward higher-cost care, whereas MA uses capitated payments, formularies, prior authorization, and step therapy to control spending. With MA covering about 54% of beneficiaries, its influence on cancer prescribing is increasingly important. Oncology poses a tougher test than other diseases because targeted agents can exceed $10 000 per month and may improve outcomes, leaving uncertainty about treatment differences between MA and TM.
“To address this question, we used Colorado All Payer Claims Database (APCD) linked with the Colorado Central Cancer Registry (CCCR) to provide evidence derived from Part B and Part D drugs, as well as supplemental prescription drug plans, to assess whether patients insured by MA are more likely to receive lower-cost drugs compared to patients insured by TM,” explained Cathy Bradley, PhD, Department of Health Systems, Management, and Policy, University of Colorado Cancer Center, Department of Health Systems, Management, and Policy, Colorado School of Public Health, in Aurora, CO.
In the study, adults 65 years and older with a first primary CRC or NSCLC, continuous enrollment for 3 months after diagnosis, and evidence of both medical and pharmacy claims within 12 months were included. Analyses focused on metropolitan residents and stratified disease as local/regional vs distant using SEER summary stage. Outcomes were receipt of any systemic cancer-directed drug and receipt of a “high-cost” drug among treated patients, defined as exceeding $6500 per month for CRC or $8000 per month for NSCLC.
The final cohort included 4240 patients (mean age 75 years; 54.9% women). In adjusted models, MA enrollment was associated with lower treatment intensity in several settings. Among local/regional CRC, patients with MA were 6 percentage points less likely to receive any cancer-directed drug and, if treated, 10 percentage points less likely to receive a regimen above the high-cost threshold. For distant CRC, patients with MA were 9 percentage points less likely to receive high-cost drugs. In NSCLC, the clearest difference was observed in patients with distant disease. Indeed, MA enrollees were 10 percentage points less likely to receive cancer-directed drugs, while differences in high-cost drug use did not reach statistical significance. Sensitivity analyses varying follow-up time and the high-cost threshold produced similar patterns.
“The results of this cohort study suggest that MA may reduce the use of high-cost drugs when there is an interchangeable alternative to more expensive options,” concluded the study authors. “This finding suggests MA may control treatment costs, even if only modestly.”
Reference
Bradley CJ, Liang R, Lindrooth RC, Sabik LM, Perraillon MC. High-cost cancer drug use in Medicare Advantage and traditional Medicare. JAMA Health Forum. 2025;6(1):e244868. doi:10.1001/jamahealthforum.2024.4868
