When it comes to health coverage, most Americans face an unnerving reality-they have no idea what is covered under their health insurance policy until after they are affected by illness or disease.
When it comes to health coverage, most Americans face an unnerving reality—they have no idea what is covered under their health insurance policy until after they are affected by illness or disease. Further complicating matters are the often illogical differences in why certain treatments are covered by some insurance providers and others are not.
As an oncologist at one of the world’s leading cancer centers, these unexplainable discrepancies in insurance coverage—which inhibit physicians from prescribing and patients from receiving the most appropriate treatment for their illness—have become a part of my everyday work life, and they are far too common in the field of proton therapy.
Picture yourself as having just received a diagnosis of cancer. After the immense shock of hearing that diagnosis, you consult a doctor about the path that lies ahead. A medical team consisting of a surgical oncologist, a medical oncologist, and a radiation oncologist weigh the most recent clinical evidence to date, and prescribe proton therapy to treat the cancer. This seems like great news because proton therapy is a highly precise form of treatment that can specifically target and destroy cancer cells while eliminating unnecessary radiation exposure to surrounding healthy tissues.
At that point, the anxiety over the cancer diagnosis and potential outcomes is tempered by having an established treatment plan, but suddenly, your insurance company slams on the brakes. With no reasonable explanation, you discover that your health insurance will not cover proton therapy. Or, worse yet, the company says the treatment—despite the guidance of an informed group of the world’s leading oncologists—is not “medically necessary” and is deemed experimental.” The fear, disappointment, and frustration are indescribable—now, your focus must shift from preparing for a life-changing battle against cancer to fighting your own insurance company.
Now picture the same scenario from the doctor’s perspective—something I experience time, and again. As a physician, I am frustrated when insurance companies respond with indifference toward what our oncology team, the experts in state-of-the-art cancer care, have considered, reviewed, and recommended. Not only are my patients denied care that is critical to fighting their cancer, but now I must take time away from other patients to get on the phone and start lobbying with the insurance company on my patients’ behalf. For each individual patient denied coverage, I explain our medical team’s cancer care management plan to the insurance company and the published data that support our decision. Insurance company representatives usually have little, if any, experience with oncology, let alone highly advanced forms of radiation or proton therapy. Consequently, patients’ access to cancer treatment is often limited by insurance panels that do not understand proton therapy or have expertise in the field of radiation oncology. During the so-called “peer-to-peer” review of each patient’s case, these panels simply quote their insurance company’s medical policy and move the case to another step in the complicated, multilayered, and lengthy appeals process. Most patients do not have the time, knowledge, or inclination to navigate the insurance process on their own, to lobby on their own behalf to prove that the treatment recommended for them is indeed medically necessary.
WHO DEFINES “MEDICAL NECESSITY?”
Each insurance company’s medical policy tends to have a unique definition of “medical necessity,” and this is the heart of the problem for patients and doctors alike. Patients, physicians, and policy makers seem unaware that the definition of “medical necessity” is not standardized and can be changed at the discretion of each insurance company to suit their own medical policies. This definition is critical; if the cancer treatment recommended by the oncology team does not fit within the policy definition of “medical necessity,” then the recommended treatment will be considered “experimental and investigational” and will not be covered by the insurance company. The burden of assuming the financial risk for treatment thus is shifted from the insurance company to the patient during the very moment they are diagnosed with cancer.
So what does “medically necessary” really mean? In reality, it is impossible to tell, because the evidence used by insurance companies not only varies widely, but also changes often. Why should insurance companies—whose financial incentives direct them toward cost savings—be dictating what is medically necessary for cancer treatment?
Physicians have experienced inconsistency in the labeling of “medically necessary” procedures for years. However, our colleagues from The University of Texas MD Anderson Cancer Center and the Boston University School of Medicine have now reinforced anecdotal evidence of the effectiveness of proton therapy with facts. In a study recently published in the International Journal of Particle Therapy,1 we found that insurance coverage of proton beam therapy in the State of Texas varied not only among payers, but also for the type of cancer. Even more concerning, a previous decision to cover proton therapy for prostate cancer was reversed and proton therapy was determined to be “not medically necessary” after the removal of key published references from the payer’s updated medical policy.
The solution to this part of the problem is clear: we need a consistent definition of “medical necessity” and uniform coverage that ensures patient access to proton therapy when that therapy is recommended by multidisciplinary medical teams.
Still more frustrating in the ongoing arguments over proton therapy is evidence showing that coverage of proton therapy could actually reduce healthcare costs. The episodic cost of care can be reduced when proton therapy decreases the amount of radiation to parts of the body that are not affected by the cancer by eliminating or reducing the severity of treatment-induced acute and long-term side effects and by reducing the risk of secondary cancers. One such study showed that hospital stays were longer for patients with esophageal cancer treated with older techniques (mean length of stay 13.2 days after conventional 3-dimensional radiation therapy, 11.6 days for intensity-modulated radiation therapy, and 9.3 days for proton therapy).2 Using advanced radiation therapy technologies like proton therapy can reduce postoperative complications and shorten hospital stays, which reduces healthcare costs.
There are pockets of hope for expanding access to proton therapy for treating cancer. In Texas, a new pilot program between The University of Texas System’s employee benefit program, Blue Cross Blue Shield of Texas, and The University of Texas MD Anderson Cancer Center allows proton therapy to be covered for employees of The University of Texas and their families for cancer of the head and neck, esophagus, breast, and lung, as well as for patients participating in clinical trials of proton therapy. This pilot program is an example of how insurers and employers can work together to develop better cancer coverage policies and to demonstrate the value of proton therapy. Over the next year, the program will not only serve patients, but also enable clinicians and researchers to collect and share information about proton therapy and its costs, which will help to make the case that broader coverage should be extended to other states and healthcare systems. By starting small and serving patients in the MD Anderson community in Texas, we can set an example for others across the United States.
Cancer touches thousands of lives each year in a truly indiscriminate way. However, we should not be arbitrary in the way we combat the disease and define medical necessity. If we wish to defeat cancer once and for all, all parties—both doctors and insurers—must finally unite in support of best practices such as proton therapy. Let’s start now and be advocates for all patients with cancer. EBO
Steven J. Frank, MD, is medical director of the MD Anderson Proton Therapy Center, and associate professor, Department of Radiation Oncology at The University of Texas MD Anderson Cancer Center.
Address for correspondence
Steven J. Frank, MD
Proton Therapy Center—Houston Associate
Professor and Director of Advanced Technologies
Department of Radiation Oncology
The University of Texas MD Anderson Cancer Center, Unit 1422,
1400, Pressler St.
Houston, TX 77030-4008
Funding source: Funded in part by Cancer Center Support [Core] Grant CA016672 from the National Cancer Institute to The University of Texas MD Anderson Cancer Center.
1. Thaker NG, Agarwal A, Palmer M, et al. Variations in proton therapy coverage in the State of Texas: defining medical necessity for a safe and effective treatment [published March 24, 2016]. Int J Particle Ther. doi: 10.14338/IJPT-15-00029.
2. Lin SH, Merrell KW, Bhooshan N, et al. Radiation modality and the incidence of postoperative complications and length of hospitalization after trimodality therapy for esophageal cancer: a multi-institutional analysis. Int J Radiat Oncol Biol Phys. 2015;93(Suppl 3):S12. doi: http://dx.doi.org/10.1016/j.ijrobp.2015.07.035.