Make comment about blog Blog Titles Home Page Blog submission guidelines Link to Newsletters Frequently Asked Questions Blog archives

Recalcitrant Insurnce Companies
Break the Law and Kill People

October 9, 2017

It is a full-time job to try to keep up with the battle with insurance companies and their refusal to cover proton therapy. While there are some rays of hope, the overall situatio continues to be glum.

One frontier for gaining insurance coverage for proton therapy is state law. A number of states have passed laws against holding proton therapy to a higher standard than other modalities. But even in those states, insurance companies continue to ignore (which is to say, break) the law. This article is an update on several such cases, plus other on going insurance issues.

When I was being treated at Provision in Knoxville, they had an active program of promoting passage of a state law in Tennessee to assure coverage of proton therapy.That effort is ongoing. Check here for an update and to help advicate for legal coverage: http://tncancerpatient.org/advocacy-efforts/

In my book about my proton therapy experience, I included the following.

“Oklahoma House Bill 1515 promises to prohibit health benefit plans from subjecting proton therapy to a higher standard of evidence than other types of radiation therapy when making coverage decisions. The House approved the legislation by a vote of 97-0. At this writing the bill heads to the Senate for consideration. The bill’s sponsor says:
Proton therapy went through several years of doing what they needed to and then the insurance companies took it and they were paying for it. For some reason now, they want them to go back and take several more years of testing. So they’re trying to hold them to a higher standard than what they are with traditional radiation.

The bill was subsequently passed and is now law. But that doesn’t mean it is being adhered to. Here is a news article I found from 2016:

A cancer treatment facility using proton therapy is suing Blue Cross and Blue Shield of Oklahoma for denying coverage for a patient's prostate cancer treatment. Oklahoma ProCure Management, which operates a proton therapy center in Oklahoma City, and Randy Farland, who is seeking treatment at the facility, have filed a lawsuit against the health insurance company, which denied Farland's proton therapy claims last year.

“Before April of last year it was covered,” said Les Yonemoto, a radiation oncologist at ProCure. “But they changed their coverage policy and all of sudden it's not covered and there is no medical reason for it.” And so they have had to sue the insurance company. (See http://newsok.com/article/5497314).

Things aren’t any better in California, where some insurance companies have a reputation for providing bad faith insurance — a widespread practice where companies willingly do not pay, delay or deny payment on claims that are considered legitimate. So, a patient treated for a brain tumor has also had to sue for coverage. (See https://topclassactions.com/lawsuit-settlements/lawsuit-news/285563-i/). The article suggests actions to take if you are denied coverage. They are also seeking examples of bad faith insurance denial for a possible class action suit. It amazes me that insurance companies would rather pay high legal bills than use that money to provide coverage. At the end of this article I quote Amy Austin, the Appeals Review Nurse for the proton center in Loma Linda, California. She verifies that they often must go through multiple levels of appeals, but assures me that they are altimately successful in getting approval in most case. Even ten, they must work very hard for it.

The same situation exists around the country. Here’s the story of a fight for coverage by Anthem Blue Cross Blue Shield in Virginia which was ultimately approved by a state insurance body after appeals to the insurance company were fruitless. The approval was based on a Virginia law that sounds similar to the Oklahoma one, which, again, the insurance company was ignoring, breaking the law. (See: http://www.richmond.com/life/health/following-fight-with-anthem-virginia-woman-s-proton-radiation-treatment/article_d456ddbf-0e97-5a33-b179-63b868ff4a30.html)

Hampton University, which has a proton therapy center, has joined the cause for insurance coverage. They gave a news conference due to the constant denial of coverage for proton therapy for cancer patients. Here is their press release: http://wavy.com/2017/08/31/hu-proton-institute-calls-for-insurance-companies-to-cover-therapy-for-cancer-patients/ Further, here is a link to the Virginia law itself: https://law.lis.virginia.gov/vacode/title38.2/chapter34/section38.2-3407.14:1/. There are two provisions that I would like to note. First, while stating that proton therapy can’t be held to a higher standard of evidence, it also makes clear that nothing in the law compels the insurance company to accept proton therapy. Therefore, rejection in and of itself is not a criminal act, unless they hold proton therapy to a higher and unreasonable standard of proof. In addition, the law makes an exception for those covered by Medicare, as it has its own standards of acceptance.

Here is a segment from the HU ress release:

After a long battle at the Virginia Capitol, the Virginia General Assembly passed a bill in February making it illegal for insurance companies to hold proton therapy to a higher standard than other forms of cancer treatment — such as traditional radiation and chemotherapy — in their coverage determination. This bill, sponsored by Delegate David Yancey (R-Newport News), Hampton University President Dr. William R. Harvey and Bill Thomas, the Associate Vice President of Governmental Relations at Hampton University, emphatically said, “You can’t put a price on someone’s health.”

Anthem Blue Cross and Blue Shield, after fighting tooth and nail to prevent coverage, hypocritically responded as follows:

Each year, loved ones, family members and friends are impacted by cancer. We want to help ensure our members battling this disease have access to safe and effective, evidence-based medical treatment that improves health outcomes. Ms. Weber’s case was reviewed by Anthem and two independent doctors. Subsequently, it went through a review process administered by the Virginia Bureau of Insurance and her treatment was approved. Unique situations like this are why we have our appeals process in place. We are pleased the treatment Ms. Weber was seeking will be a covered benefit under her Anthem health insurance plan.

A bit disingenuous, don't you think? Their system is that they deny coverage as long as possible, so that the patient must go all the way to the state insurance bureau, and then they concede and say they are happy for the patient. Sure they are. The message is clear. If you want us to cover you, it’s going to be a long and difficult row to hoe. Their actions are typical, in that many insurance companies have a policy of first rejecting claims, and then later paying them if the patient protests. That has been my personal experience. It is the great weakness of a capitalistic for-profit system, which costs twice as much as universal coverage in other developed countries, while getting much poorer and more limited care.

I hope that every denial for proton therapy is followed by this kind of persistence. Perhaps insurance companies will ultimately be forced to do the right thing. More pressure is being put on insurance companies by a new organization called the Alliance for Proton Therapy Access. Their website is: www.allianceforprotontherapy.org

The University of Hampton Proton Center confirms the following: We previously implemented all necessary steps to comply with the law, and will continue to operate accordingly when it comes to making coverage decisions for our members.

When I was treated for prostate cancer at Provision in Knoxville, they had seven people working full time just to get the best insurance coverage and payment. When the proton therapy center in Bloomington, Indiana, went out of business a while back, one of the reasons given was their failure to get properly reimbursed by insurance companies and even Medicare itself. I personally didn’t need United Healthcare, which does not cover proton therapy for prostate cancer, because I joined a national registry to track me for life to study the effectiveness of proton therapy. (The registry is for all types of cancer.) So if your insurance company won’t cover you, perhaps you should ask Provision or anyone else who has a registry if you qualify. If so, Medicare will pay 80% of your cost.

After that was accomplished, Provision got me two other benefits. They got United Healthcare to pay the remaining 20% not covered by Medicare (less my copays), and they got United Healthcare to treat me as if I was in my network, even though I was in a distant state (since proton therapy is not available yet in San Antonio).

Certainly all proton centers provide assistance with insurance coverage. The Seattle Cancer Care Alliance proton therapy center has this to say: Proton therapy is covered by some private insurance plans, Medicare, and some state Medicaid programs. The Center provides each patient with a Financial Coordinator to help navigate insurance coverage, estimated costs associated with treatment, and assist in finding alternative financial solutions for individuals without insurance coverage.
Financial assistance/charity care is available to those who reside within Washington State, and who fall below certain income thresholds. Your Financial Coordinator can help you determine if you might qualify and assist with the completion of applications. The Financial Coordinator can also help you apply for public insurance programs such as Medicaid.

How complicated is all of that? Beaumont Health System in Royal Oak, Michigan, just went online with their new ProteusOne IBA proton therapy gantry (summer, 2017). I took this information from their news release: Medicare and health insurance companies, such as Blue Cross Blue Shield of Michigan, can reimburse for proton therapy at about twice the rate that they do for X-ray radiation cancer therapy. But successful reimbursements typically require detailed side-by-side comparisons between proton and X-ray treatment options for a specific patient to demonstrate the necessity.

In challenges that have succeeded, most have had to supply copious supporting documentation from their medical provider showing medical necessity. One of the harder ones to cover is prostate cancer, as it is fairly easily accessed and treated with x-rays or with surgery. Alas, the Beaumont center made the following decision: . . . proton therapy is usually not the preferred, fastest nor cheapest treatment method for prostate cancer, for example. Prostate cancer, for now, won't be treated at the new proton center.

With only one gantry, it might make some sense to specialize in more difficult cases. Their first patient was an 86-year-old man treated for a brain tumor. Given his age, more aggressive (which is to say, damaging) treatments might not have been suitable. (It reminds me of Senator John McCain. When he went to the Mayo Clinic in Arizona, why didn't they use proton therapy? Why have it if you aren't going to use it?)

Prostate cancer is the bread and butter of many proton centers. I am grateful that I was able to be treated with protons (which should be rather obvious judging from my books and websites).

Some medical insurers even deny proton therapy for pediatric cases because, they claim, randomized clinical trials haven’t proven protons to be superior to conventional radiation. Bullroar. Poppycock. After the theoretical benefits of treating young children with protons are explained to reviewers, almost all denials are overturned. Pediatric Blood & Cancer investigators reported that between 2010 and 2015, 97% of pediatric proton denials at the University of Pennsylvania Roberts Proton Therapy Center were overturned on appeal.  (See https://www.specialtypharmacytimes.com/news/majority-of-insurance-coverage-denials-for-pediatric-proton-therapy-approved-on-appeal). That means it was still necessary to make such an appeal.

In previous articles I have pointed out that insurance coverage may be more likely at proton centers that charge the same for protons as for x-rays. In an email recently I pointed out that the two Mayo Clinics (Arizona and Minnesota), the University of Pennsylvania and the University of Maryland charge nomore for protons. I received a response from Amy Austin, the Appeals Review Nurse at the James. M. Slater MD Proton Treatment and Research Center, commonly just called “Loma Linda.” It was the first proton center to open, in 1990, and has treated more than 25,000 patients. They got the best web address: www.protons.com. Amy assures me that she has tremendous success with the appeals process, getting virtually all proton therapy for prostate cancer approved. That’s great news. She also assured me that their costs are low, in keeping with others that I have listed above. Do you have to live in California? I don’t know. Contact Amy at: AAustin@llu.edu. Thanks Amy.

Despite pressure from competing technologies and medical insurers, Globe Newswire reports that proton therapy is growing at an annual rate of 6.04 percent. The U.S. holds 40 percent of the world’s proton therapy market and is projected to grow to $15 billion by the end of 2021. Being from San Antonio, I’ll use the following analogy. I see hold-out insurance companies like the Texans holed up in the Alamo and proton therapy as the forces of Antonio de Padua María Severino López de Santa Anna y Pérez (let’s just call him General Santa Anna). Despite heroic resistance by insurance companies clinging to their profits, we know how this battle will eventually come out. Wouldn’t a peace accord be a lot easier and less destructive?

Well, maybe I'm being a bit optimistic in the present political climate. It seems incongruous to me that a populist uprising supports the elimination of health benefits and the undoing of laws and regulations that support our health and environment, all out of anger and frustration with Washington. Some of us feel that Mar-a-Lago IS the swamp. Think for a moment about ISIS and the Taliban, who want to take civilization back to the Middle Ages to make Islam great again as it once was when it ruled much of the world. In a modern world, it is a very bad fit and such a movement is ultimately doomed. If making America great again means similarly going back to some earlier unregulated time when the people had few rights or protections against the actions of monied interests, billionnaires and corporations, I suspect that effort will eventually fail. It's not a populist solution. But in the meantime, our insurance coverage certainly can't be taken for granted. We hope to gain coverage for proton therapy, not lose what coverage we already have.

END OF ARTICLE

Here are links for some of the organizations I have mentioned in this article:

Provision Center for Proton Therapy: www.provisionproton.com
Ackerman Cancer Center: www.ackermancancercenter.com/proton-therapy/
Texas Center for Proton Therapy: www.texascenterforprotontherapy.com
(The above three centers share the same MEdicare registry that allowed me to get proton therapy for my prostate cancer.)
Roberts Proton Therapy Center (Philadelphia): www.pennprotontherapy.org
Maryland Proton Treatment Center: www.mdproton.com
James M. Slater Proton Tretment and Research Institute at Loma Linda: www.protons.com

I would like to know of successful insurance strategies. Please contact me at this address: robert@protontherapybook.com.

Here again are my other two related websites:

www.ProtonTherapyBook.com
This is for Best Prostate Cancer Treatment: Proton Beam Therapy and other books I have or soon will have written. It has updates and additional information, photos, and more.

www.proton-therapy-centers.com
This site has an up-to-date list of proton therapy centers in operation in the United States, as well as a number planned or under construction. Currently 27 centers listed as operational and 16 in the planning or construction stages.

Return to BLOG PAGE.