Medicare Is Greater Than the Sum of Its Parts

No longer will older Americans be denied the healing miracle of modern medicine. No longer will illness crush and destroy the savings that they have so carefully put away over a lifetime so that they might enjoy dignity in their later years. No longer will young families see their own incomes, and their own hopes, eaten away simply because they are carrying out their deep moral obligations to their parents, and to their uncles, and their aunts.

At the center of the President Lyndon B. Johnson’s great society was Medicare, a federal program designed as a partial safety net primarily for America’s older adults. It was signed into law (https://www.ssa.gov/history/lbjsm.html) on July 30, 1965. Controversial at the time, it is now sacrosanct and often referred to as the “third rail of politics”: touch it and die.

During the past 50 years, the program has grown dramatically, expanding into a complex and comprehensive institution that encompasses broad and specific segments of the population; it now has several parts. Individuals may have overlapping eligibilities, depending on qualifications, or may be restricted to certain parts through other qualifications. Housed in the Centers for Medicare and Medicaid Services (CMS), Medicare is complicated and often viewed as a labyrinth of laws and codes designed to ensure compliance but cumbersome for consumers to use.

How Parts A–D Affect Patients With Cancer

Medicare currently has four parts, known as A, B, C, and D (https://www.medicare.gov/what-medicare-covers/index.html). Patients with cancer may find that they cross over into more than one section.

• Medicare Part A: for inpatient hospital stays, nursing facilities, hospice care, and some home health care
• Medicare Part B: covers certain physicians’ services, outpatient care, medical supplies, and preventive services
• Medicare Part C: commonly known as Medicare Advantage Plans, these are private insurers working with Medicare to provide expanded benefits of HMOs, PPOs, fee-for-service plans, and savings account plans, and prescription drug coverage
• Medicare Part D: the most recently created section, designed to add prescription drug coverage to some of the plans in part C

It also covers preventive services, and many screenings for cancers are included—breast, cervical, colorectal, lung, prostate, and others. Finally, Medicare encourages enrollees to maintain a healthy lifestyle with access to providers, medications, and supplies. For millions of Americans, having this kind of guaranteed coverage for emergencies, major medical, medical office visits, preventive care, treatments, and chronic care is literally a life saver.

Questions and Barriers

But it’s not always as straightforward as it may seem. Many questions follow a cancer diagnosis, and not having the right information can lead a survivor down a path that may include financial toxicity. The American Cancer Society reminded patients and their caregivers (https://www.cancer.org/treatment/finding-and-paying-for-treatment/understanding-health-insurance/health-insurance-options/medicare/medicare-part-d/things-people-with-cancer-need-to-think-about.html) to consider these questions when enrolling in Medicare programs.

• Which part is my cancer drug covered under?
• Are off-label medications covered?
• Are ancillary medications for cancer also covered?
• Will oral medications be covered at the same rate as IV ones?

Patients must understand their own circumstances and make determinations for their own care. Medicare is not meant to be a panacea. It was designed as an additional benefit to coverage, and although it often is the first to step to cover care, if enrollees are unfamiliar with the agency or have not signed up for the correct program, the final cost of care can be a daunting personal responsibility that is too much to bear. 

Medicare Payments Through the OCM

As government agencies often do, CMS looked inward in 2015 and created the Oncology Care Model (OCM) (https://voice.ons.org/news-and-views/how-the-oncology-care-model-is-redefining-quality-care). The goal was to initiate and evaluate a new payment model for cancer that might reduce the financial burden on Medicare spending (https://downloads.cms.gov/files/cmmi/ocm-baselinereport.pdf), while maintaining quality care for “a broad array of cancer types.” The first report on OCM (https://voice.ons.org/advocacy/cms-releases-report-on-oncology-care-model) was published in February 2018, and some of the finding bore out these results, including:

• This is a medically complex population with many complicated chronic conditions associated with and by a patient’s cancer diagnosis.
• Patient-centered medical home care can reduce service usage and costs for cancer survivors.
• Using clinical guidelines can reduce costs and improve pain management and other patient outcomes.

The Future of Medicare

Medicare is frequently evaluated; new programs are suggested through administrative and congressional support, or programs are eliminated because of costs or inefficiencies. Age is a leading factor (https://www.nih.gov/news-events/news-releases/nih-study-offers-insight-into-why-cancer-incidence-increases-age) in cancer incidents. This means that Medicare is at a crossroads in the healthcare discussion. With an aging population and a determination to fight cancer at every step, the agency is on the front lines of care. 

ONS Perspective

ONS continues to promote patient-centered care, symptom management education, and evidence-based research. One of ONS’s key position statements (https://www.ons.org/advocacy-policy/positions/policy/access) posits, “Essential services include prevention and risk reduction, screening, early detection, access to clinical trials, and treatment, as well as palliative, psychosocial, survivorship, and end-of-life care.” Translating this principle into action, oncology nurses work in coordinated care, helping patient access the best treatment options for them. Stay up to date with ONS’s public policy activity (http://www.ons.org/advocacy-policy).