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Top Line: With most large-scale randomized trials still pending, proton therapy can be tough to get reliably reimbursed.
The Study: Even with prior authorization as a potential avenue to establish coverage, resulting delays in treatment starts are deterrents enough in themselves. Enter this pilot partnership between MDACC and a local private insurer to develop a cost (read: total medical cost) effectiveness coverage policy ensuring immediate access to proton therapy for cases that have the most to gain. Such cases included prospective trials and five evidence-supported anatomic sites (head and neck, esophagus, breast, thoracic, and prostate). Over three years, 33 of 185,000 enrollees were approved for proton therapy, of whom 25 received treatment. When matched with controls receiving photon therapy, there was no difference in total medical costs accrued during treatment and the 6 months following—in fact, costs were 5% less with proton therapy. More striking was the decrease in average authorization time for proton therapy from 17 days to less than a day. While this is excellent for cancer care, let’s speak the language of private insurers: Administrative costs for the approval process were slashed.
TBL: Recognizing the evidence is a moving target, adopting an evidence-based approach to proton therapy coverage as opposed to relegating all cases to prior authorization purgatory is a win-win-win for all parties involved. | Ning, JCO Oncol Pract 2020