In 2024, ASCO updated its guideline for the integration of palliative care in oncology, which recommends that clinicians refer patients with advanced solid tumors and hematologic malignancies to specialized interdisciplinary palliative care teams beginning early in the course of a patient’s disease in conjunction with active treatment.1 However, despite ASCO’s recommendations, utilization of palliative care in the oncology setting remains low, with about one-third of patients globally receiving this service, with the highest utilization rate of nearly 56% in Africa and the lowest, 30%, in the United States.2
The results from two studies by Xin Hu, PhD, and her colleagues evaluating the use of early palliative care among traditional Medicare and Medicare Advantage beneficiaries with advanced cancers find that systemic and structural barriers in the health-care system are contributing to the underuse of palliative care among these patients.
We need to make sure, either through exemptions or designing more flexible benefits, that vulnerable patients with cancer are not constrained in their care by Medicare Advantage plans.— XIN HU, PhD
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In the first study, which examined trends in early palliative care integration among 102,032 traditional Medicare recipients diagnosed with advanced-stage female breast, colorectal, non-small lung, small cell lung, pancreatic, or prostate cancers, the researchers found that only 10% of these patients received early palliative care in 2019. The study also found that differences between individual physicians and hospitals accounted for between 30% and 50% of the variation in patients receiving this early care, suggesting that where patients receive their cancer treatment influences whether they get guideline-recommended palliative care.3
“One of the most striking findings from this study is who treats you and where you receive care may impact access to early palliative care more than a patient’s clinical condition,” said Dr. Hu, Assistant Professor, Department of Radiation Oncology at Emory University School of Medicine and a visiting scientist at the American Cancer Society. “This underscores the need to minimize systemic and structural barriers, so access to this important care is not limited. Fighting cancer should also mean fighting unnecessary suffering.”
In a more recent study by Dr. Hu and her colleagues, which was presented during the 2026 ASCO Annual Meeting, the researchers compared utilization of palliative care between patients with advanced cancer enrolled in traditional Medicare and Medicare Advantage plans, and how provider network contributes to differences between these two programs.
The study, “Palliative care for advanced cancer: Medicare Advantage and provider networks,” included 135,402 beneficiaries; 67.7% were enrolled in Medicare and 32.3% were enrolled in Medicare Advantage. The primary outcome was the cumulative incidence of palliative care billing within 6 months of diagnosis. To assess the role of provider networks, the researchers assigned each patient a treating oncologist based on the plurality of visits with cancer diagnosis codes. [Next, they] conducted 1:1 matching of patients enrolled in a Medicare Advantage plan to those enrolled in traditional Medicare treated by the same oncologists within the same county.
The study results show that palliative care billing was significantly higher, 13.3%, among Medicare Advantage enrollees compared with 9.3% among traditional Medicare beneficiaries, primarily through differences in oncologists’ network composition.4
A third study by Dr. Hu and her colleagues evaluated hospice utilization implications among decedents with advanced cancers who had been enrolled continuously in Medicare Advantage or traditional Medicare or who had switched between these two types of plans in their last year of life. Understanding these differences is important, according to Dr. Hu, because Medicare Advantage plan benefits, including care coordination, utilization management, and provider networks, may shape patients’ transitions to end-of-life care and the settings in which they receive hospice care.
“Hospice care is an excluded benefit under Medicare Advantage, with coverage instead provided by traditional Medicare after beneficiaries in this study elected to have this end-of-life care, potentially creating different financial incentives for the transition to hospice care,” said Dr. Hu.
In this large retrospective cohort study of 196,536 beneficiaries who died between 2010 and 2020, the results show that patients enrolled in Medicare Advantage plans continuously were slightly more likely to receive hospice care at home, 1.93 percentage points. Those who switched from Medicare Advantage plans to traditional Medicare were more likely to receive hospice care in nursing homes, 2.45 percentage points, especially among dual Medicare-Medicaid enrollees, 6.01 percentage points.5
“In particular, those who switched from Medicare Advantage back to traditional Medicare may represent a subgroup of patients with greater nursing home needs and access under Medicare Advantage,” said Dr. Hu.
In this wide-ranging interview with The ASCO Post, Dr. Hu discussed the results from these studies, why palliative care remains underutilized in the United States, and how the new work requirements for Medicaid eligibility may negatively impact patients with cancer.
Palliative Care in Medicare Advantage and Traditional Medicare
The results from your study “Palliative care for advanced cancer: Medicare Advantage and provider networks” show that individual clinicians and specific hospital networks play a role in whether patients receive a referral to palliative care. While Medicare Advantage was associated with higher initial palliative care billing compared with patients enrolled in traditional Medicare, these differences were substantially reduced after accounting for treating oncologists and provider networks.4 Please explain the significance of your finding.
The U.S. health-care system is very different from other health-care systems around the world. Although traditional Medicare is operated directly by the federal government, over the last 2 decades, more than one-half of eligible beneficiaries enrolled in schedule-operated private insurance plans called Medicare Advantage.
Unlike traditional Medicare, in which beneficiaries can visit any provider who accepts Medicare, Medicare Advantage insurers contract with a limited number of providers. We hypothesized that provider network is the major mechanism that drives differences in palliative care between Medicare Advantage and traditional Medicare, because of our prior finding that organization-level factors—specifically, organizational employment of palliative specialists—is a major driver for the receipt of palliative care.
Other plan features of Medicare Advantage, such as prior authorization, may not be as relevant for explaining the differences in the utilization of palliative care services. Palliative care is typically billed by evaluation and management codes that are less frequently subjected to prior authorization requirements, unlike active cancer treatment, which has to be approved through an almost universal prior authorization process.
In our study, we indeed found that higher palliative care utilization among Medicare Advantage beneficiaries was primarily explained by differences in oncologists’ network.
In addition, when stratified by plan types, palliative care was particularly higher among patients enrolled in health maintenance organization (HMO) plans, but not other plan types. In our study, Medicare Advantage beneficiaries matched to traditional Medicare beneficiaries, for example, those who were seen by the same oncologists, were less likely to have HMO plans than those not matched. After limiting the comparison of palliative care among the beneficiaries who shared the same oncologist network, the differences in palliative care utilization were largely attenuated.
The main problem is that there are only about 9,000 hospice and palliative medicine specialty-trained and board-certified clinicians in the United States,6 which is substantially fewer than specialists in other medical fields, and geographically more concentrated. That means if there is not a palliative care specialist within a beneficiary’s Medicare Advantage provider network, that patient will not be able to get a palliative care referral.
The bottom line is with the provider network restrictions it is likely that there are fewer palliative care providers covered by Medicare Advantage plans than those available under traditional Medicare.
Addressing Care Coordination to Improve End-of-Life Care
Another recent study by you and your colleagues examining the implications for hospice utilization between patients with advanced cancer who died while enrolled in either traditional Medicare or Medicare Advantage plans found that continuous Medicare Advantage enrollees more often received hospice care at home, whereas those switching from Medicare Advantage plans to Medicare more often received hospice care in nursing home facilities. Medicare Advantage plans do not directly pay for or manage hospice care; those fees are covered by original Medicare Part A.5 Please talk about the significance of this finding. How is it that Medicare Advantage enrollees more often received hospice care at home?
The findings from this study are particularly interesting, and show that plan switching near the end-of-life may reflect access barriers that could lead to differences in downstream hospice settings, which highlights the importance of addressing care coordination to improve end-of-life care. Typically, Medicare Advantage plans provide care management services, for example, advanced care planning or nurse navigation services, which play a role in the transition to hospice care in the community settings, such as the home.
We were not able to reach a definite conclusion as to why patients who switched from Medicare Advantage to traditional Medicare were more likely to receive hospice care at a nursing home. One explanation may be that some older patients with advanced cancers may have a decline in their physical function status after surgery and need to be discharged to a skilled nursing facility for more comprehensive support. Because Medicare Advantage plans have a restricted network of skilled nursing home facilities, patients enrolled in these plans may switch to traditional Medicare to get greater access to a nursing home facility. And this setting eventually becomes the final end-of-life setting for these patients.
I want to emphasize that Medicare Advantage was originally designed to increase care efficiency through controlling costs. But cancer is a serious disease and we need to make sure, either through exemptions or designing more flexible benefits, that vulnerable patients with cancer are not constrained in their care by Medicare Advantage plans.
Factors Driving Low Utilization of Palliative Care
Please talk about the importance of palliative care services in patients with advanced cancer. And why is this care still so underutilized in patients with both early- and late-stage cancers?
Palliative care is crucial in reducing symptom burden in patients with either advanced or early-stage cancer and in improving their quality of life from the time of diagnosis, during active treatment, and throughout long-term survivorship.
The reasons that palliative care is so underused in cancer care are multifactorial. Patients often conflate palliative care with hospice care, so we have to do a better job of raising awareness that palliative care provides supportive care throughout the cancer journey. Another major factor constraining the use of this care is the specialist shortage.
Fighting cancer should also mean fighting unnecessary suffering.— XIN HU, PhD
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In the United States, there are about 9,000 hospice and palliative medicine specialty-trained and board-certified clinicians, and more than 90% of those clinicians practice in metropolitan areas of the country.6 Further, many hospitals in rural and even urban areas lack dedicated, interdisciplinary palliative care staff.
In addition, although implementing early palliative care has been shown to improve patients’ quality of life in clinical studies, oncologists often wait until life-prolonging therapies fail before referring patients to interdisciplinary palliative care. So, there are many contributing factors driving low utilization of this care.
Defining ‘Medically Frail’ in Medicaid Work Requirements
Finally, I was wondering if you would like to comment on the U.S. Centers for Medicare & Medicaid Services interim final rule on work requirements for Medicaid recipients, which makes it more difficult for individuals who are medically frail, including patients with cancer, to be exempt from the work requirements, and states that enrollees aged 19 to 64 must complete at least 80 hours per month of qualifying work or community engagement activities.7 What impact will this new rule have on patients with cancer?
Although the new work rule provides operational parameters for federal “medically frail” and “complex medical condition” exemptions, every state must define and apply a medical frailty exemption to the new work requirements. My fear is that patients with life-threatening diseases like cancer may have difficulty meeting the work requirement and/or a medical frailty exemption to the new work requirements, and lose their Medicaid health-care coverage, which includes not just the cost sharing for cancer treatments, but coverage for long-term nursing home care, as well.
I am deeply concerned that this new work requirement will add to the inequity in the delivery of health care in this country.
(Editor’s Note: On June 1, 2026, ASCO issued a statement on the Centers for Medicare & Medicaid Services guidance detailing how states must implement mandatory work and community engagement requirements for individuals receiving Medicaid. ASCO’s statement calls for exemptions for patients with a cancer diagnosis (www.asco.org/news-initiatives/policy-news-analysis/asco-responds-cms-medicaid-work-requirements). Additional advocacy tools and resources regarding Medicaid changes and their impact on cancer care are available at (www.asco.org/get-involved/advocacy/advocacy-agenda-initiatives/medicaid.)
DISCLOSURE: Dr. Hu has received grants from the National Institutes of Health, Patrick and Catherine Weldon Donaghue Medical Research Foundation, American Cancer Society, PhRMA Foundation, St. Jude Children’s Research Hospital, Pfizer, and Johnson & Johnson.
REFERENCES
- Sanders JJ, Temin S, Ghoshal A, et al: Palliative care for patients with cancer: ASCO Guideline Update. J Clin Oncol 42:2336-2357, 2024.
- Getie A, Yilak G, Ayenew T, et al: Palliative care utilization globally by cancer patients: Systematic review and meta-analysis. BMJ Support Palliat Care 15:e005000, 2025.
- Hu X, Kwon Y, Jiang C, et al: Trend and provider- and organizational-level factors associated with early palliative care billing among patients diagnosed with distant-stage cancers in 2010-2019 in the United States. J Clin Oncol 43:1789-1799, 2025.
- Hu X, Jiang C, Kwon Y, et al: Palliative care for advanced cancer: Medicare Advantage and provider networks. Abstract 11050. 2026 ASCO Annual Meeting. Presented June 1, 2026.
- Hu X, Jiang C, Kwon Y, et al: Medicare plan switching and hospice care among decedents with advanced cancer. JAMA Netw Open 9e260755, 2026.
- Frydman JL, McKendrick K, Chen Y, et al: Disparities in the geographic distribution of palliative care specialists in 2022. J Gen Intern Med 39:1528-1530, 2024.
- Centers for Medicare & Medicaid Services: Medicaid Community Engagement Requirement for Certain Individuals Interim Final Rule With Comment Period (CMS-2454-IFC). June 1, 2026. Available at www.cms.gov/newsroom/fact-sheets/medicaid-community-engagement-requirement-certain-individuals-interim-final-rule-comment-period-cms. Accessed October 20, 2026.
