Proton beam therapy coverage considerations

May 21, 2024

Proton Beam Therapy (PBT) is a newer specialized form of radiation therapy which can deliver radiation more precisely. The proton beam does not diffuse, or “spill over” outward as it goes into the body, so may cause less damage to nearby tissue that is not being treated This is important for highly sensitive areas, like small tumors in the neck, eye, or brain tumors, as well as for pediatric cancers. This could also be important for left chest treatment to avoid exposure of coronary arteries to radiation.

There are currently only 45 proton beam centers available nationwide. These facilities can cost as much as $220 million to build, and allowable prices for PBT are much higher than the traditional IMRT (Intensity-modulated radiation therapy) beam.

Most health plans currently cover proton beam therapy  for limited situations where a high level of precision is needed. The data comparing PBT versus traditional IMRT is at early stages and more is coming. So far, PBT has not been shown to have superior clinical outcomes to IMRT for most cancers. Based on this, and the much higher cost of PBT, most health plans cover PBT for a very limited set of diagnoses.

Providers which have invested in PBT centers want to use this therapy for common cancers like breast or prostate cancer, which would help them make these centers profitable. While PBT seems intuitively like it should be superior to IMRT, the data does not bear this out at this time. That said, Medicare’s coverage policy does cover PBT treatment of some more common cancers, like breast and prostate cancer.

As more data becomes available, more clinical recommending bodies may update their recommendations around PBT, leading to changes for carriers and more employers. Medicare’s decision to cover PBT for more common cancers means that the pressure to cover this expensive technology is likely to increase. Currently, most employers and carriers restrict PBT to specific cancers for which there is strong evidence that it leads to better outcomes.

 Implications for employers

-        Many self-insured employers may want to wait for additional data and stronger clinical recommendations before they expand access more broadly. Carriers have well-established procedures to assess new technologies and will continue to evaluate under what circumstances to cover PBT.

-        Employers that expand this coverage will incur higher oncology costs with an unproven (at this time) additional benefit to patients.

-        PBT is geographically limited to the centers that offer it. Employers that provide coverage may consider travel benefits to allow access to members who live far from centers.

-        In some instances, Expert Medical Opinion (EMO) services could recommend PBT, and plans that do not provide coverage could face appeals of noncoverage.

Thanks to my colleague Patricia Toro, MD MPH for authoring today’s post.

Thanks for reading.  You can find previous posts in the Employer Coverage archive

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