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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

“Course-correcting the prior authorization dilemma requires a slate of new or modified laws or administrative agency rules to help curtail poor PA practices throughout the industry to better safeguard you, our families, and future generations from an arduous process that is becoming increasingly clear to impact outcomes on care,” he said.

As care continues to become more personalized and value-based, referring oncologists also need to have a bigger say in coverage decisions. In Virginia, Hampton University is currently advocating for legislation that will ensure patients receive the treatment their physicians prescribe for them. “These decisions should be made by oncologists trained to treat cancer,” said Thomas.

But providers and insurers must communicate and have agreed upon criteria for what is medically necessary. To do this, providers need to conduct and present more research that proves the long-term financial benefits of proton therapy, and insurers must be open to hearing and incorporating this feedback into their coverage policies.

Collins says that in addition to saving on side effect treatments, expanding coverage will help them save even more by avoiding lengthy and costly litigations and appeals over denials.

“If they do not, then insurers risk losing business with their members and their employers’ business by denying companies the return of healthy workers with no long-term disruptions brought on by avoidable radiotherapy side effects,” he said.

He suggests that they instead initiate programs that value membership longevity and reward plan renewals. “They can use their warehouses of claims data to identify providers for network inclusion, or to establish a center of excellence or blue ribbon panel of providers, to expand access while containing the cost of proton therapy.”

The continued use of inconsistent policies and guidelines in proton therapy coverage only seeks to further the burden of other obstacles, such as the limited number of centers available for treatment in the U.S. and worldwide. By opening up access, insurance companies can create more incentives to obtain funding to build these centers in more places. Chang says this approach should be region-based.

“Instead of having half a dozen centers in southern California, we should probably have one or two in Southern California and one in Northern California, one in Arizona, and one in Nevada. We should really make them a regional resource, rather than every healthcare system wanting to own one in order to have it as a competitive device to differentiate themselves from their crosstown rivals, which unfortunately is what’s happened, especially in the East Coast,” he said.

A recent string of court victories for patients and those who have brought cases on behalf of patients have sent a message to insurers that they must make some changes to their guidelines. While these situations are likely to help push insurers to expand their guidelines, greater cooperation between payers and providers and an agreed upon consensus of what constitutes as medically necessary are key to ensuring that patients are getting the best care for the long run.

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