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John R. Fischer, Senior Reporter | October 25, 2021
From the October 2021 issue of HealthCare Business News magazine
It’s important to note that there are many cancers where conventional treatment methods appear to be comparable to proton therapy in terms of outcomes. Research on other types of tumors has helped secure greater coverage, with pediatric tumors universally insured and more coverage now available for head and neck tumors. While not universal, proton therapy for breast cancer is also being insured more, says Weinbach.
But Rich Collins, a trial attorney with Callahan & Blaine who specializes in insurance and healthcare law, says insurance companies often rely on outdated research for their guidelines to substantiate why they do not want to cover certain cases and take years to incorporate more relevant studies into their guidelines. “They know it’s not experimental or investigational, but they still use that as a basis for their denial. For the medical necessity component, it’s how they define that and what factors they consider and the lack of uniformity.”
Another obstacle that patients are expected to face soon comes from the government’s Radiation Oncology Alternative Payment Model. Set to go into effect in January 2022, the ROAPM calls for cuts in reimbursement for proton therapy, according to Mahajan. She says such an action has the potential to create hesitancy around building more proton therapy centers and may negatively impact the financial earnings of currently established ones.
“There’s going to be more anxiety about reimbursement and being able to keep a center open if they’re even able to come up with the initial investment,” she said. “I do think these types of pressures that are pushing the technology down might suppress innovation that could allow it to become better, faster and cheaper.”
Access and awareness
Despite being around for decades, referring physicians may be hesitant to send a patient for proton therapy due to not understanding the benefits it holds for certain cancer cases. They also may be conflicted with a sense of loyalty to their own institution, and the treatments they are capable of offering.
“There may be a financial overlay of ‘why are you referring patients out’ and ‘proton therapy isn’t that great,’” said Mahajan. “You know things that are around you and you’re comfortable with those things. So, reaching out to another group causes a bit of discomfort and you may not be aware of what other places offer. It’s multilayered.”
Deville with Johns Hopkins adds that external referring providers may be worried about delays to care or possibly losing their patients to a competitor. "The referral and intake process can be complex and requires a variety of healthcare and administrative team members with varying expertise — from a proton coordinator to the billing and insurance authorization team to the nurse, physician, advanced practitioner, social worker, radiation therapist, physicist, and dosimetrist.”
