MD Anderson pleads necessity of protons

Posted by on Thursday, August 25th, 2016

A call for change in proton therapy coverage

Insurance companies may not consider proton therapy a “medical necessity,” but a growing body of medical evidence and doctors opinions disagrees.

In a cover column featured in The American Journal of Managed Care, Dr. Steven Frank, medical director of the MD Anderson Proton Therapy Center, makes the case that it’s past time for insurance companies to include protons as an accepted, and covered, treatment for a variety of cancers.

Citing the many patients who are denied proton therapy by companies who deem it not “medically necessary” and “experimental”—or simply dismiss the claim without explanation—Frank argues that the term, “medical necessity” should be standardized rather than left to the subjective whims of business-oriented institutions.

“Why should insurance companies—whose financial incentives direct them toward cost savings—be dictating what is medically necessary for cancer treatment?” he writes. “Physicians have experienced inconsistency in the labeling of ‘medically necessary procedures for years. … In a study recently published in the International Journal of Particle Therapy, 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.”

Research is also showing that proton therapy can actually result in decreased overall medical costs for cancer patients, Frank writes.

“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). Using advanced radiation therapy technologies like proton therapy can reduce postoperative complications and shorten hospital stays, which reduces healthcare costs.”

There are steps being taken toward broader insurance coverage for proton therapy. University of Texas System’s employees are participating in a one-year pilot program with Blue Cross Blue Shield of Texas (HCSC) and MD Anderson allowing proton therapy coverage for cancers of the head & neck, esophagus, breast, and lung as well as patients participating in proton therapy clinical trials. Information will be collected and shared 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.

“We need insurers across the country to think innovatively and provide leadership similar to Blue Cross Blue Shield of Texas by partnering with employers and providers to find ways to provide broader coverage for patients that will benefit from proton therapy, “  says Scott Warwick, Chairman of the National Association for Proton Therapy.  

Proton therapy has been proven an effective and, in many cases, cost effective treatment option. It’s time for all of those involved in providing patient care acknowledge that reality, Frank concludes.

“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.”

Read More

Brazilian tackles Olympic-sized feat of his own in cancer

Posted by on Sunday, August 21st, 2016

BrunoFaria

As his home country has hosted the world’s largest sporting spectacle, Bruno Faria found himself watching the games, not in nearby stadium but in another continent in a different hemisphere, facing an Olympic-sized feat of his own.

Nine years ago, just one month after Faria’s 18th birthday, he discovered the cause of nagging headaches that ultimately could not be ignored. Cancer.

The malignant tumor originated in his skull bone, and since diagnosis Faria has endured eight surgeries, two rounds of chemotherapy and one regimen of conventional radiation in Brazil. The first tumor was located behind his eye, he says, but the growths have recurred, moving their way back along the right side of his head.

Read More

Patients & providers must team for insurance fight

Posted by on Thursday, August 11th, 2016

blog-ft-image-insurance-help-us-help-you

Qualifying for proton therapy is one thing. Paying for it can be another.

Although Medicare covers proton therapy for seniors with cancer and most private policies provide coverage for children, patients who fall in between can have difficulty getting payment from their private insurers.

There are things that patients can do to help. All incoming patients to Provision Center for Proton Therapy receive a fact sheet (click here to download fact sheet) to give them tools to fight for coverage of proton therapy—for themselves and for others.

 

“We believe it’s important for patients to be empowered to fight for the coverage they deserve when facing a cancer diagnosis,” says Rhonda Turner, manager of financial services at Provision Center for Proton Therapy. “We know that we won’t always win every case, but together we can improve our chances for success.”

Here’s what financial services does to assist in the insurance process:

  1. Letter of medical necessity and/or recommendation fo treatment choice from other provider(s)
  2. Peer-to-peer review calls
  3. Individualize appeals
  4. Multiple levels of appeals, including external reviews
  5. Assist with patient appeal/grievance

Here’s what patients can do to help:

  1. File a patient grievance letter (supported by Provision staff)
  2. Conference call with us and your insurer
  3. Contact your employer—some employers can override insurance coverage decision

Provision patients can also help in the fight for others, writing letters to insurance providers, sharing their stories on social media and contacting elected officials.

“Public pressure is the best way to ensure coverage of proton therapy in the future,” Turner says. “Nobody can communicate the need for proton therapy better than those who are being denied access to it.”

Read More

Sport bike racer makes career of patient care

Posted by on Thursday, August 4th, 2016

SamanthaKirkBike

When Samantha Kirk picks up the phone, many times the person on the other end is not having a very good day.

“Whenever patients call, it’s usually the worst day of their life,” says Kirk, a care coordinator at Provision Center for Proton Therapy. “They are very emotional and overwhelmed.”

Read More

Throat cancer patient high on proton therapy

Posted by on Thursday, July 28th, 2016

TerryVinson

When Terry Vinson first felt a small grown the size of a pinkie fingertip on his neck, he dismissed it as a harmless cyst.

Even two weeks later, when it had doubled into the size of a thumb and then doubled again the following week, he had not yet sought medical help.

“I’m in medical sales,” Vinson says. “I should have known better.”

Read More

Patient-focused care starts here

Posted by on Thursday, July 21st, 2016

blog-ft-image-care-coordinaters-provision-proton-therapy

When you’re a cancer patient who is considering proton therapy, sometimes there are more questions than answers. Am I going to be a candidate? How many treatments would I need? How do I even get started?

Questions like these are answered every day by Provision’s care coordinators. We are a team of three full-time employees who love to talk with patients and help them with their questions. We also feel strongly that every patient’s situation deserves individual attention and consideration.

Read More

Provision physicist making her mark

Posted by on Thursday, July 14th, 2016

blog-ft-image-the-other-half-of-the-nucleus

In a family full of engineers, it had never occurred to Sammie Hedrick that she could be one too.

“I wanted to be a doctor, but I couldn’t do blood,” she says. “I was thinking about graphic design.”

Read More