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John R. Fischer, Senior Reporter | October 25, 2021
From the October 2021 issue of HealthCare Business News magazine
To help with this, many proton therapy programs have partnered with hotels, Airbnb, and charities such as Ronald McDonald House programs to help cover lodging. In this way, some patients are able find accommodations they otherwise might not have.
Meanwhile, technological enhancements such as single-room centers in place of multi-room ones have also made it easier for areas with smaller populations to afford the construction costs of proton therapy facilities. These smaller-footprint centers require a fraction of the construction cost, (although still typically several millions of dollars) and can serve a smaller patient throughput.
Jennifer Maggiore, executive director of the National Association for Proton Therapy, says that for providers and academic centers to continue to introduce proton therapy in areas currently underserved, they need to be assured that they will be appropriately reimbursed. “It is concerning when commercial insurance providers exclude coverage for proton therapy despite clinical research supporting its value.”
Dealing with denials
About 70% of patients seeking proton therapy are initially rejected by their insurance provider and appeal. Of these, about 70% are eventually approved over time, according to Weinbach. “They eventually get there. It just takes a lot of time, effort and resources. For a lot of patients, it’s time they don’t have. If you need cancer treatment, you really don’t want to wait.”
Insurers often will make the case for denials on the basis that proton therapy is experimental or not medically necessary, according to Tim Rozelle, an attorney with the law firm Kantor and Kantor, who has experience litigating coverage decisions around proton therapy. He says that insurers often require proof that shows that proton therapy is no longer investigational and that it is superior to conventional photon radiation treatment, making it medically necessary.
“If you can’t establish that proton therapy is superior to IMRT, you’re out of luck,” he said. “If you can’t establish that proton therapy is less expensive than IMRT, then you’re out of luck. The argument there is that you really need to be able to show that proton therapy is superior to IMRT, in order to circumvent the cost argument.”
Resourceful patients denied coverage may, in some cases, pay out of pocket or tap into the generosity of others using resources such as GoFundMe, but of course that is not the way healthcare is supposed to work. Many will ultimately resort to conventional radiotherapy treatment, even in cases where doctors have warned insurance providers that such treatment poses long-term risks, such as infertility and nerve damage that can lead to physical pain and deformities.
