Contrary to popular belief, research indicates that there are some instances when proton treatment is less expensive overall than traditional radiotherapy. Despite being more expensive, the treatment is worthwhile because the long-term results are better. Proton therapy’s benefits are cited by radiation oncologists, researchers, and cancer activists as justification for insurers to alter their policies and provide more coverage.
Payers continue to categorize the therapy as “experimental” and “investigational” for the majority of malignancies, claiming that it is not “medically necessary.” This approach could prioritize treatment costs over the patient’s clinical wellbeing and neglect to take into account expensive side effects, especially those that might not manifest themselves for several years.
According to Dr. Andrew Chang, a radiation oncologist and president of California Protons in San Diego, California, all radiotherapy procedures account for about 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.
He told HCB News, “We spend 50–60 times more on systemic medications like immunotherapy that have a lot less overall impact on patients.
Chang and other experts assert that in order to effectively care for patients and reduce costs as a result, providers and insurers must agree on a definition of medical necessity that takes into account the clinical care of the patient during initial treatment as well as potential side effects that may develop shortly after and years in the future.
By focusing primarily on the upfront costs of treatment, which are higher for proton therapy than radiotherapy, insurers expose themselves and patients to the possibility of incurring additional medical expenses in the tens of thousands, and in some cases, hundreds of thousands, should adverse effects arise. For instance, patients with throat cancer who receive radiotherapy frequently develop a severe sunburn from the radiation, which makes it difficult for them to swallow food and forces them to use a feeding tube. They also frequently need to attend the emergency department (ED) and are continuously on pain medication.
By requiring patients to pay more for medical expenses—many of which may require the insurer to contribute under the contracts they have with patients—these post-treatment needs run counter to value-based care both clinically and financially.
Even for inclusion in clinical research, insurers frequently categorize proton treatment as experimental and exploratory, hence reducing the number of recruits required for complete evaluations.
In contrast to Medicare, which provides proton therapy for a variety of cancer patients, insurers are independent businesses that are free to choose how much of a patient’s treatment is covered. According to Brooks, legislation that holds such reviews accountable and establishes penalties for when health insurance companies act in a way that is contrary to this consensus or fail to respond to patients in a timely manner to prevent harmful delays is the only way to ensure that they quickly determine coverage with fair and contractually appropriate reviews based on an agreed-upon consensus of what is medically necessary.
Insurers need to adjust their policies as a result of a recent spate of victories in court for patients and individuals who have brought cases on their behalf. Although these circumstances may encourage insurers to loosen their restrictions, ensuring that patients receive the best care over the long term requires greater collaboration between payers and providers and a shared understanding of what qualifies as medically necessary.
While this approach has the potential to drastically increase success rates, it also makes it possible to treat tumors that are currently inaccessible.
Proton therapy truly is the future of cancer care, and Dr. Williams and the team at SFPTI are humbled to bring it to the Palm Beach County community.
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