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The cost-value argument for expanding proton therapy coverage

por John R. Fischer, Senior Reporter | April 17, 2023
Insurance Rad Oncology Proton Therapy
It may sound counterintuitive, but evidence suggests proton therapy for some indications costs less in total than conventional radiotherapy. Although the treatment is more expensive, it pays for itself through better long-term outcomes. Radiation oncologists, researchers and cancer advocates point to proton therapy’s value as a reason for insurers to update their guidelines and expand coverage.

Payers continue to classify the treatment as “experimental” and “investigational” for the majority of cancers, saying that it is not “medically necessary.” This analysis may emphasize the cost of treatment over the clinical well-being of the patient and fail to account for costly side effects, particularly those that do not occur until years later.

Additionally, all radiotherapy procedures account for around 2.5% of all oncological spending in the U.S., and proton therapy spend is 1.3% of radiotherapy, making overall costs for it less expensive than those for other cancer treatments, according to Dr. Andrew Chang, a radiation oncologist and president of California Protons in San Diego, California.

“We spend 50-60 times more on systemic therapies such as immunotherapy that have a lot less impact, overall, on patients,” he told HCB News.

Chang and other experts say that providers and insurers must reach a consensus on the definition of medical necessity, one that accounts for the clinical care of the patient during initial treatment and the side effects that may occur right after and years in the future, as only then will they be able to effectively care for patients and in the process, save on costs.

Looking at the overall value
By only looking at initial treatment costs, which are more expensive for proton therapy than radiotherapy, insurers set themselves and patients up to potentially spend tens of thousands and in some cases, hundreds of thousands more on care should side effects occur. For example, when undergoing radiotherapy, throat cancer patients often suffer a severe sunburn from the irradiation that prevents them from eating and swallowing food, forcing them to rely on a feeding tube, as well as pain medication continually for relief and frequent visits to the ED.

These post-treatment needs fly in the face of value-based care clinically and financially, by forcing patients to have to dole out more money on medical expenses, many of which may require the insurer to contribute under the contracts they have with patients.

According to a 2014 study in Oncology Payers, when compared to one another, the price of care during throat cancer patients’ initial treatment was just 6% more with proton therapy than with intensity-modulated radiotherapy, with IMRT patients losing three times more body weight. When factoring in the cost of re-simulation due to the weight loss, along with those for a feeding tube, pain medication, hospitalizations and visits to the ED, overall costs for IMRT were 20% higher than those of proton therapy.

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