Three bills aimed at helping patients get better insurance coverage for proton therapy are making the rounds of committees in Nashville this week, and Provision is urging patients and their friends and families to get involved.
For too many, trying to obtain the best treatment has brought them to blows with their insurance companies.
That was the case for Alexa Gash, who at 29 was diagnosed with throat cancer. Her father had recently suffered from the same diagnosis, and on the advice of the family’s physician, the couple began researching proton therapy. Because of Alexa’s age, they wanted to find a treatment that would be most effective but also spare her from unwanted long-term side effects. With conventional radiation, she risked permanent damage to her salivary glands, taste buds and teeth as well as the potential need for a feeding tube during and post-treatment due to a painful condition called mucositis caused by the excess radiation dose delivered outside of the tumor.
But, although Gash was determined a good candidate for proton therapy, her insurance company, BlueCross BlueShield of Tennessee, disagreed and denied her request for coverage. The company designated her treatment “experimental” and denied appeals to reconsider her case based on the potential ramifications of conventional radiation therapy.
Even though Medicare has covered proton therapy for more than 20 years and the National Comprehensive Cancer Network guidelines support proton therapy in the treatment of head and neck cancer, BlueCross simply said “No.”
In recognition of the gap in coverage and the beneficial impact that proton therapy can have for cancer patients, several legislators have introduced several bills in the Tennessee General Assembly that would require insurance companies to cover proton therapy under specified conditions at no additional cost to the insurance companies. They include:
• House Bill 0883 (Rep. John Holsclaw) & Senate Bill 0210 (Sen. Dr. Mark Green): Requires the state group health insurance program to cover hypofractionated proton therapy for treating cancer under certain conditions.
• House Bill 0523 (Rep. Bob Ramsey) & Senate Bill 0367 (Sen. Doug Overbey): Requires health insurance coverage to cover hypofractionated proton therapy in the same manner as it covers intensity modulated radiation therapy under certain conditions.
• House Bill 0899 (Rep. Mark Pody) & Senate Bill 0758 (Sen. Mae Beavers): Prohibits certain health benefit plans that provide coverage for cancer therapy from holding proton radiation therapy to a higher standard of clinical evidence for medical policy benefit coverage decisions than the health plan requires for coverage of any other radiation therapy treatment.
Currently, the insurance company lobby is fighting the legislation in spite of this increased support for proton therapy in both research and legislative circles, as well as the growing development of proton therapy centers around the world. Instead, they wear out their own insureds with an endless appeal process forcing frustrated patients, their families and healthcare providers to seek redress in the courts or the legislature.
Over the coming days and weeks, the bills will be heard in the Joint Pensions and Insurance Committee chaired by Chattanooga’s Sen. Bo Watson, the Senate Finance and Labor Committee chaired by Franklin’s Sen. Jack Johnson and the House Insurance and Banking Subcommittee chaired by Rep. Kelly Keisling from Pickett County, Tennessee. Sen. Johnson has previously spoken out in favor of proton therapy in publicly supporting the development of Tennessee’s third proton center in his district.
Find out more about how to contact your legislator and help promote these proton therapy bills.
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Nearly five years ago, 32-year-old Lindsay Rumberger was diagnosed with epithelioid hemangioendothelioma, a long name for a rare cancer that had originated in her liver and metastasized to her lungs. She underwent chemotherapy, but when a tumor close to her spine showed signs of growth, radiation was part of the recommended course. Because conventional radiation treatment threatened to cause peripheral damage to this most sensitive part of the body, her doctors recommended proton therapy instead. However, the insurance provider disagreed, calling the treatment “experimental” and refused coverage. Read More
It was a promising year for legislation that would nudge insurance companies toward coverage of proton therapy for cancer patients.
However, after two bills promoting commercial payment for proton therapy were tabled in Tennessee House of Representatives committees, it’s the third year such bills have met with the same result. In both cases the House committees failed to take up a vote on the measures, leaving them to essentially die on the vine—at least for this legislative year.
While the measures didn’t pass, there were some positives takeaways. The bills were proposed by legislators themselves and had grassroots support. This showed that local awareness of proton therapy is growing and that our legislators are increasingly viewing it as an important cancer treatment option.
We encourage patients and their families to connect with their legislators, whatever the state, to promote the importance of proton therapy and encourage insurance coverage. A bill promoting the use of proton therapy passed in the Oklahoma state legislature last year and this year a proton therapy measure was proposed in Virginia, in addition to the two in Tennessee.
But legislation is not the only tactic for combatting the problem of insurance coverage.
Provision will work to increase public awareness of insurance companies’ failure to widely cover proton therapy for cancer patients—resulting in some patients seeking alternative treatments with undesirable side effects or scrambling to pay the costs out of their own pockets, according to Scott Warwick, vice president of program development and strategic initiatives for Provision Center for Proton Therapy
“We believe when the public realizes that insurance companies are preventing patients from getting the medical care they need, they will help put direct pressure on insurance companies to pay for proton therapy,” he says.
Another strategy is for companies that are self-insured is to request providers add proton therapy coverage to their policies. Provision, for example, covers its own employees for proton therapy through Cigna. Seventy percent of people covered for health care under commercial insurance are included in these company-funded plans, affording the opportunity for proton therapy to be included in the policy at little extra cost.
At the same time, he says, Provision will continue, as it has for the past several years, to dialogue with insurance companies in an effort to “come to agreement on reasonable coverage terms for proton therapy.”
Thanks to all the patients who contacted our legislators this year to urge passage of the bills. With a consolidated effort by continued patient support your voice will be heard. Please voice your opinion to legislators and your insurance companies in support of proton therapy, a life-changing cancer treatment.