The Washington Post - USA (2021-10-26)

E6 EZ EE THE WASHINGTON POST.TUESDAY, OCTOBER 26 , 2021

ies still generally end up with sig-
nificant out-of-pocket costs for
many of these services, a recent
study by KFF (Kaiser Family Foun-
dation) found.
That’s partly because the pri-
vate plans limit benefits. While
people in traditional Medicare
paid on average about $992 for
dental care in 2018, those in Medi-
care Advantage plans paid $766,
according to the study. For vision,
people with traditional Medicare
paid $242, compared with $194
for those covered by a Medicare
Advantage plan.
“It stands to reason there would
be lower out-of-pocket spending
in Medicare Advantage than in
traditional Medicare, but the dif-
ferences are not as large as one
might expect,” said Tricia Neu-
man, a senior vice president at
KFF and executive director of its
Medicare policy program.
More than 26 million people
were enrolled in Medicare Advan-
tage plans for this year — 42 per-
cent of all Medicare beneficiaries.
Enrollment in the private plans
has doubled since 2012 and tripled
since 2007. Unlike traditional

MEDICARE FROM E1 Medicare, these private plans gen-
erally allow coverage through a
limited network of doctors, hospi-
tals and pharmacies.
Open enrollment for 2022 plans
began Oct. 15 and ends Dec. 7, and
some Advantage plans offer en-
ticements such as hundreds of
dollars’ worth of groceries, home-
delivered meals or $1,000 of over-
the-counter items such as adhe-
sive bandages and aspirin.
But many seniors don’t realize
there are restr ictions on these
bene fits. They may cover extras
only for enrollees with certain
health conditions or have a n ar-
row network of providers or an-
nual dollar limits, often about
$100 for vision or $1,300 for den-
tal.
“All these extra benefits encour-
age people to sign up, but people
don’t know what they have until
they try to use it,” said Bonnie
Burns, a training and policy spe-
cialist for California Health Advo-
cates who helps Medicare benefi-
ciaries evaluate their health plan
options.
Seniors typically can choose
from more than 30 Medicare Ad-
vantage plans sold by several in-
surers. The choice is so daunting

that fewer than a third of seniors bother to shop and compare during the open enrollment window — even though costs and benefits change every year. And for those who want to shop around, comparisons are not easy. The Medicare.gov website pro-

vides an overview of health plan costs and benefits and lets seniors compare plans’ premiums based on what medications the benefici- ary uses. But it doesn’t offer a comparison of which doctors, dentists or hospitals are in the Medicare Advantage network or provide details about limits on dental, hearing and vision care. For th at information, consumers must go to each insurer’s website and read through a s ummary of

benefits that can be dozens of pages long. Mary Beth Donahue, CEO of the Better Medicare Alliance, a t rade group representing Medicare Ad- vantage plans, sees things differ- ently. “Medicare Advantage’s flexible benefit design means that beneficiaries can choose a plan tailored to their needs — whether that means more robust coverage , or more basic coverage, potentially for a l ower cost,” she said. Casey Schwarz, senior counsel for education and federal policy at the Medicare Rights Center in New York, an advocacy group for seniors, said the extra benefits of- fered by plans have increased con- fusion among many beneficiaries. Those benefits come at a price. “There is almost always a t rade- off such as narrower provider net- works, tighter drug formulary or restrictions in other areas,” she said. Jenny Chumbley Hogue, an in- surance broker near Dallas and an analyst at MedicareResourc- es.org, which helps seniors navi- gate the program, said marketing misleads some of her clients. “They see a TV ad that says they

can get everything for free when they may not qualify for those ben efits,” she said. “It’s hard to know if they are misinformed or not reading the fine print.” She added that consumers should be choosing a p lan based on whether their doctor is in that network or their drugs are being covered at the lowest cost. For example, while most plans offer a hearing aid benefit, it’s usually for only a certain type of aid from a single company, Chumbley Hogue said. “The devil is in the details, par- ticularly when it comes to dental,” she said. “The coverage is not typically what they are used to coming from an employer plan.” Medicare Advantage dental benefits are becoming more robust, however. Nearly 90 percent of the private plans offer dental benefits for no extra cost and most offer coverage for treatment as well as cleanings and checkups, according to a report by the consulting firm Milli- man. The percentage of plans of- fering preventive and comprehen- sive dental has jumped to 71 percent this year from 48 percent in 2019.

Plans also are increasing benefits so they meet Medicare’s re- quirement to spend at least 85 percent of enrollees’ premium dollars on health services, Neuman said. Plans that don’t reach that threshold can face sanctions, in- cluding not being allowed to en- roll new members. While some may find the dental benefit alluring, not everyone uses the coverage. The Medicare plan may not cover their existing dentist, so they continue to pay out-of- pocket, she said. Medicare Advantage beneficiaries use their dental benefits less frequently than people with dental coverage through their employer, said Joanne Fontana, a principal with Milliman. “Not everyone buys a plan because it covers dental,” she said, “and it’s not top of mind or th ey [don’t] think to go the dentist every year.” — Kaiser Health News

Kaiser Health News produces in-depth journalism about health. It is a program of the Kaiser Family Foundation, an endowed nonprofit organization that provides information on health issues to the nation.

Considering your Medicare options? Pay attention to the fine print.

Jenny Chumbley Hogue,

an analyst at

MedicareResources.org,

said marketing misleads

some of her clients.

completion of recommended
treatments for breast and lung
cancer.
The study identified barriers to
patients receiving care, such as
lack of transportation. The health
system set out to remove these
impediments, doing so by em-
ploying real-time warnings from
the electronic medical record that
notified nurse navigators to en-
gage with patients to ensure they
completed treatments. This proc-
ess included immediate follow-up
with patients if they missed
sch eduled visits — identifying
and eliminating obstacles to
those visits, the same process lat-
er used by Cone to get Shuford to
her appointments.
At the American Society of Ra-
diation Oncology (ASTRO) an-
nual meeting in Chicago on Mon-
day, the ACCURE authors pre-
sented the survival results of
those earlier interventions. The
new study shows that overall sur-
vival went up for all patients who
completed recommended treat-
ments. Previous differences in
rates of survival between races
were eliminated.
This study is the product of
nearly 20 years of community
engagement focused on achiev-
ing racial equity in cancer care.
ACCURE, funded by the National
Cancer Institute, was a collabora-
tive effort among the University
of North Carolina at Chapel Hill
(UNC), The Partnership Project,
Cone Health, and the University
of Pittsburgh Medical Center
(UPMC). It is the first prospective
clinical trial implementing a solu-
tion to address racial disparities
in cancer treatment. Many stud-
ies have observed that some pa-
tients don’t get prompt or ad-
equate cancer care because of
their race, but until ACCURE no
programs were developed and
proven to successfully address
these disparities.
Matt Manning, chief of oncolo-
gy at Cone Health Cancer Center
in Greensboro and a co-author of
both studies, said “this study
should be lifted up to raise aware-
ness and inspire people that insti-
tutional racism can be eliminated

... through community engage-
ment to create systems-based in-
terventions applying transparen-
cy and accountability. The excit-
ing thing is that this study shows
how our community is pioneering
solutions to champion diversity,
equity, and inclusion. This inter-
vention can be applied to other
parts of health care and other
institutions like education, crimi-
nal justice, and law enforcement.”
Founded in 2003, the Greens-
boro Health Disparities Collabor-
ative (GHDC) brought together
community, clergy, health care
and public health members, and
academic leaders. They created a
model of community-based par-
ticipation in research from which
the ACCURE study developed.
The collaborative has pub-
lished over 25 papers on improv-
ing health disparities at the com-
munity level. It’s not surprising
these studies have emerged from
Greensboro, a small Southern city
with a long history of leadership
through the civil rights era, from
the nonviolent Woolworths coun-
ter sit-ins of 1960 to the Simkins v.
Moses H. Cone Memorial Hospi-
tal federal court ruling in 1963
that prohibited racial discrimina-
tion in hospitals that had received

CANCER FROM E1

public funds. Rather than focusing on the implicit bias of providers, the intervention is a systems change that aims at eliminating the chance for disparate outcomes by race by tracking results and then acting immediately to correct these differences. This includes interventions such as providing transportation, patient assis- tance funds to help meet the costs of utilities, rent and gasoline, as well as telehealth access for patients and family members to at- tend visits without having to miss work. The GHDC believes this is the best strategy for eliminating institutional racism.

The ACCURE intervention is meant to remove the possibility of different outcomes by tracking patient compliance and outcomes according to race and by building organizational accountability into achieving racial equity among patients. This approach seems more conducive to improv- ing equity in health-care delivery than trying to ascertain, or change, the motives and biases of individual practitioners. AC- CURE was performed at Cone Health and UPMC, and the pre- liminary results were published in Journal of the National Medi- cal Association (JNMA) in 2020. JNMA is published by the Na- tional Medical Association, a his- torically Black physician organization. The paper was rejected by the Journal of the American Med- ical Association (JAMA), because, according to some accounts, it said it was not sufficiently important for their readership and be- longed in a journal focused on race and health. The culture at the AMA is beginning to accept the

concept of institutional racism, but before 2020, JAMA ques- tioned the very existence of racism in medicine, a controversy that led to the resignation of its editor, Howard Bauchner, earlier this year. The AMA had missed the larger point: racism and bias are inher- ent in the institutions which pur- port to serve us all. Currently, systems permit different experiences according to race. This is plain to see by studying the effects of race in cancer care. In the current study, 302 patients with early stage breast or lung cancer were enrolled at two cancer centers between April 2013 and March 2015. Data from patients seen with these diagno- ses between January 2007 and December 2012 were obtained as historical controls to establish control completion rates. The intervention included a real-time registry derived from the electronic health records of participants to indicate missed appointments or unmet care milestones; a nurse navigator; and clinical feedback. The pri- mary outcome was “Treatment Complete,” representing completion of surgery, recommended radiation and chemotherapy for each patient. Treatment completion in the historic controls showed statistically significant Black-White differences (Blacks (B) 79.8 percent vs. Whites (W) 87.3 percent). The disparity less- ened within the interventions (B 88.4 percent and W 89.5 percent). The real-time registry, com- bined with feedback, improved completion of treatment for all these patients and narrowed disparities between groups because of immediate intervention to improve completion. This included anti-racism training for the navigators as well as opportunities for them to meet patients and their families at the outset of treatments, allowing them to ask ques- tions and make connections. The meetings, in turn, led to more personal interventions and communication because the patient became a familiar person, rather than a name on a list. The result was that patients missed fewer care milestones. These factors would prove to be crucial for Emma Shuford. Only by better understanding her

personal concerns and priorities was the cancer center able to solve her immediate transportation problem. Similar multifacet- ed interventions could mitigate disparities in the treatment of other cancers and chronic conditions. The previous publication in the JNMA fulfilled the study’s goal of ensuring equity in completion of treatment. Since treatment completion is directly linked to outcomes, this was felt to be an adequate endpoint. But now that additional time has passed, the current project is a follow-up study of the overall survival of patients treated during the historical control years vs. the AC- CURE study years. This showed that there were differences in five-year overall survival between Black and White in the historic period. As they found in the earlier study, the survival disparity disappeared during the ACCURE period and survivals improved for all. Shuford was able to complete her cancer treatments because people acted in real time to identi- fy her personal needs and solve obstacles to completing care milestones, thereby addressing underlying disparities. Dispari- ties in survival will improve for all patients if we track recommended cancer care and intervene in innovative ways. Manning hopes that other cancer centers will take notice of ACCURE’s effectiveness. If adopt- ed, these interventions could have beneficial effects, eliminating disparities at other institutions and in different health-care specialties. Further, he hopes that “hospitals will be held accountable for quality measures, reported by race. Hospitals measure catheter- associated urinary tract infec- tions, mammography screening rates, and length of stay. Why don’t they report these common metrics by race, gender, and Zip code? Until we turn on the light, we are blind to the injustice in medicine.”

Joseph Stern is a neurosurgeon in Greensboro, N.C. He is the author of “Grief Connects Us: A Neurosurgeon’s Lessons on Love, Loss, and Compassion.” His website is josephsternmd.com.

Pushing for completion of medical

therapies for the poor, people of color

CONE HEALTH CANCER CENTER Under ACCURE, the cancer center at Cone Health in Greensboro, N.C., provided much-needed transportation to Emma Shuford, 84. This allowed her to complete her multiple cancer treatments.

Currently, systems

permit different

experiences according

to race. This is plain

to see by studying

the effects of race in

cancer care.

BY NANCY BRIER

I sat at the edge of her mattress stroking her head as I often did before she fell asleep. “Mommy,” Lauren said in the dark, “are you going to die?” Her question lingered in the stillness, sharp like a shard of broken glass on the floor. It was expected and a surprise at the same time. Maybe that was the hardest moment of my cancer journey, to hear that little voice asking the big question we all wanted to ask. My husband, Gary, and I hadn’t wrapped our heads around my new cancer diagnosis long enough to acknowledge out loud what life might look like with one of us missing, or more accurately, if I were missing. I wanted to ignore her question, to go back to the way things were when Gary and I were dreaming about vaca- tion plans. But now that seemed like a lifetime ago. Earlier in the month, my husband found a lump in my breast, a moment he calls a romance bust- er. He guided my fingers to the spot, and there it was, as firm and defined as an almond just under the surface of my skin. Soon after, I was diagnosed with stage three triple negative breast cancer that had spread to my lymph nodes and sternum. This type of cancer typically strikes younger women. It’s rarer, deadlier and more ag- gressive than other breast cancers. Because it doesn’t respond to hormonal therapy medicines, fewer tre atment options are available. “Best-case scenario,” the oncol- ogist shockingly said, “you’ll be stuck with a frankenboob. But more likely, you’ll be dead in three months.” He looked at my husband and me and told us to get our affairs in order, a line I thought they only used in movies. Later that night, my husband said out loud the words I dreaded most: “We have to tell Lauren.”

Worrying about the impact Our daughter had just turned 10, and birthday pa rty debris still littered the floor of her room. The only thing worse than having cancer was how it would impact my daughter, and telling her about it was something I never wanted to do. “Give me a little more time,” I said, “just a few days .” But we couldn’t wait because I n eeded to start treatment immediately. I’d need to t ravel four hours each way to get it and spend some nights away from home. The following night, the three of us gathered on the living room couch, Lauren squeezing in the middle. I wondered how much she knew about cancer, and I searched for the right words to explain what I didn’t fully under- stand myself. Lauren looked like she was witnessing something incomprehensible, like her brain was concurrently rejecting and assimilating the news. Gary and I told her what we thought she needed to know, just the basics. My sister would stay with her while we were out of town. She’d still be able to go to school, and we’d stock up on her favorite foods. Gary described the giant grand piano in the lobby of the hospital and how it almost looked like a hotel.

But Lauren had other things on her mind. Later that night, Lau- ren and I climbed the stairs to her room. “Let’s get you tucked in,” I said, situating Scruffy and Rex under the covers. With glow-in- the-dark stars twinkling over- head, I stroked her hair and as- sumed she was drifting to sleep. Instead, she asked me the question, obviously the only one on her mind — Was I going to die? Of course that’s what she wanted to know. Am I going to die? I w ondered too, but I didn’t dare say it. It hung there for a minute, but then, as horrible as it sounds, I recognized it for the gift that it was. That question, spoken in a child ’s voice, was liberating. It gave me clarity to think straight and give my child the parenting she needed. I realized my answer would shape her perspective of our family’s journey with cancer, regardless of the outcome. It would set the tone for all of us for whatever was to come. And while I wanted desperately to soften real- ity, I also needed to tell the truth.

Statistically, I had a 40 percent chance of survival. Until that moment, I’d accepted those odds as a death sentence. Her question, though, simple and direct, com- pelled me to make a clear and unequivocal decision: I would embrace my odds and hope for the best. “It’s true that some women die from breast cancer,” I s aid slowly, taking my time with my answer. “But I believe I’m going to live.” It was both optimistic and true. I told her more details about the treatment and the doctors who would take care of me. I described the medical facility and some of the machines I’d seen. It was real stuff, not good or bad — just what was. When Lauren was born, a frie nd told me that like all babies, she would be my teacher, that from her I would learn many lessons. That prediction has come true in more ways than I ever could have imagined, but this particular lesson has been last- ing. It’s important to tell the truth. It’s okay to believe in optimism, and it’s a g ift to say out loud what needs to be said.

Epilogue I survived 16 weeks of aggres- sive chemotherapy, breast cancer surgery and a month and a half of daily radiation. I’ve now passed my five-year mark, and my chances of dying of triple negative breast cancer are statistically about the same as everyone else’s. And that little girl who helped me grapple with the truth? She is now a flourishing high school student with dreams of becoming a filmmaker.

 More at washingtonpost.com/ lifestyle

PARENTING

With breast cancer,

my daughter taught

me to be direct with her

It’s okay to believe in

optimism, and it’s a gift

to say out loud what

needs to be said.

The Washington Post - USA (2021-10-26)

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