As costly high-tech cancer facilities eye CT market, insurance coverage a hurdle

Photo | Mevion Medical Systems A physician-owned group proposing to build an $80-million cancer facility in Danbury would use a proton therapy system made by Mevion Medical Systems, based in Littleton, Mass. The Mevion system pictured above is installed in a facility in the Netherlands.

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By Matt Pilon

Healthcare investors are prepared to shell out $152 million to bring a pricey high-tech cancer radiation therapy to Connecticut, but getting commercial health insurers to cover the treatments may not be easy.

Proton beam radiation therapy delivers high doses of radiation to targeted areas of the body, sparing healthy tissue and vital organs around a tumor.

Rendering | Contributed

A rendering of the proposed proton therapy facility in Danbury, which could end up being the second such facility in Connecticut, joining a planned Yale-Hartford HealthCare project in Wallingford.

A rare collaboration between Hartford HealthCare and Yale New Haven Health seeks to build a $72-million proton therapy facility in Wallingford, while a physician-owned group with experience developing and administering proton therapy in other states recently announced its own plans for an $80-million facility in Danbury.

As Connecticut regulators review the two proposals, federal judges in multiple other states are presiding over ongoing class action lawsuits against Aetna, UnitedHealthcare and other health insurers, filed by cancer patients who were denied coverage and then chose to pay tens of thousands of dollars out of pocket for proton therapy, which is often much more costly than more conventional radiation regimens.

Stephanie A. Casey, Partner, Colson Hicks Eidson

“Some people have mortgaged their homes [for proton therapy]. We see that regularly,” said Stephanie A. Casey, a partner with Florida-based law firm Colson Hicks Eidson, who is representing plaintiffs in three ongoing proton therapy lawsuits against health insurers in federal court.

The recent complaints come on the heels of a Nov. 2018 verdict against Aetna in Oklahoma state court, where a jury determined the Hartford-based insurer had acted in bad faith in denying proton therapy to a patient with a rare form of head and neck cancer.

Aetna, which was ordered to pay the patient’s widower $25.5 million, is appealing the verdict.

Signs of progress

The legal disputes have raised the profile of proton beam therapy, which has existed for decades but seen an explosion in new investment and facilities since 2004. The lawsuits also put pressure on health plans to pay for greater use of the technology, including for specific types of cancer for which insurers argue there’s a lack of hard evidence showing proton therapy is a superior treatment. However, advocates say research continues to be released painting proton therapy in a positive light, which they predict will turn the tide in favor of further reimbursement.

Last year, a federal judge presiding over a lawsuit filed by a Florida cancer patient lambasted UnitedHealthcare in court, calling the company’s denial of the patient’s prostate cancer treatment “immoral and barbaric.” The judge was in the process of recusing himself, CNN reported at the time, because he had gone through prostate cancer treatment and felt conflicted.

Several months before that suit was filed, there was a sign of progress for treatment advocates. UnitedHealthcare changed its coverage policy, stating that proton therapy was a proven treatment for prostate cancer and considered clinically equal to a more commonly used (and often cheaper) radiation therapy for the disease.

That turned heads in the oncology community, as prostate cancer is the fourth most common cancer, but there are more battles ahead when it comes to reimbursement.

“I think by and large the insurance companies still take the position that proton therapy is experimental or investigational or unproven for the majority of cancers,” said Casey, whose firm represents the plaintiff in the case from which the judge recused himself.

Investors in Connecticut’s proposed proton therapy facilities say they’re well aware that reimbursement can be an uphill battle that leads to claim denials and lengthy appeals.

A consultant working for Yale and Hartford HealthCare, which selected Georgia-based Proton International as the operator of their proposed facility, even mapped out commercial carriers’ coverage policies and handicapped the odds of claim denials and successful appeals.

Even with the threat of denied claims, the overseers of both Connecticut projects predict their operations would be profitable by year two.

In the third year of operation, the two facilities project a combined $9.4 million in profits and $52.6 million in net patient service revenue, with 62 full-time equivalent employees.

The two facilities anticipate treating more than 800 patients annually once fully up and running; just over one-third of patients are projected to have commercial insurance. Medicare, which is generally seen as more lenient about proton therapy coverage, would be the next largest payer, followed by self-pay and Medicaid patients.

A growing sector

Using proton radiation to treat cancer dates back to the 1950s, but the technology has seen much more rapid growth this century.

There are 35 proton therapy centers operating in the U.S., according to the National Association for Proton Therapy (NAPT), and nearly all of them were erected in the last 16 years. At least four more centers were slated for 2020 or 2021 openings. Wallingford and Danbury, if approved, could open in 2022 and 2023, respectively.

Jennifer Maggiore, Executive Director, National Association for Proton Therapy

NAPT Executive Director Jennifer Maggiore said proton therapy has been growing in popularity because medical providers increasingly see the benefit of the technology, particularly for young patients.

“Radiation oncologists want the best for their patients and when they realize this is the technology that is really a standard of care now for pediatrics, that’s really important,” Maggiore said.

Research showing proton therapy’s benefits also continues to trickle out. For example, a recently released study by Stanford University medical researchers found that patients who received proton therapy had lower incidences of new, distinct cancers later on, when compared to other types of radiation treatments. A study published last year found proton therapy patients had lower risk of being unexpectedly hospitalized due to severe adverse health events (such as difficulty breathing) within 90 days after treatment.

“What you’re starting to see, that I think will make a difference with the insurance companies, is the research in the last two to three years that supports the use of proton therapy and advanced technologies,” Maggiore said. “I’m hoping that’s where insurance companies will understand the justification for the use of this.”

Maggiore said it’s unfortunate that patients have felt the need to sue their insurers, but it’s understandable.

“Patients are frustrated when they don’t really have the access to care being recommended by their doctor,” she said.

Drew Crandall, a spokesman for the Danbury proton therapy project, concurs with Maggiore that the treatment’s growth is being driven by its merits, rather than negative headlines about lawsuits.

“What supersedes the legal aspects is the bonafide value of proton therapy,” Crandall said. “Recognition is growing and I think that will win the day.”

Skepticism remains

However, some have pushed back against the public pressure to compel insurers to cover proton therapy. Dr. Ezekiel Emanuel, chair of the Department of Medical Ethics and Health Policy at the University of Pennsylvania and most recently an advisor to Gov. Ned Lamont on the coronavirus, wrote last year that not enough high-quality clinical trials have been completed proving the merits of proton therapy.

HHC and Yale declined comment for this story, citing their pending application with state regulators, who will decide whether there is a public need for proton therapy in Connecticut, and whether the proposed projects are financially feasible and will lead to improved care quality and access.

Cigna and Anthem did not provide comment for this story.

Other commercial insurers said scientific evidence and safety guide their decisions about proton therapy or any other treatments.

UnitedHealthcare spokeswoman Maria Gordon-Shydlo said the insurer covers a variety of oncological therapies, including, for some cancers, proton beam therapy.

“We continually review and update our medical policies and plan coverage provisions based on the most current published clinical and scientific evidence,” she said.

Photo | Contributed

Aetna’s Hartford headquarters.

Aetna spokesman Ethan Slavin said when it comes to treatment coverage decisions, “our guiding principles will continue to be proven effectiveness and member safety, as determined by rigorous scientific studies.”

ConnectiCare spokeswoman Kim Kann said the Farmington-based insurer seeks to ensure new technologies and treatments are safe and effective before including them in its plans.

“We have provided our members with access to proton beam therapies since 2016, including through our cancer center of excellence at Memorial Sloan Kettering in New York,” Kann said. “Over time, we have expanded the list of cancer types approved for [proton beam therapy], when clinically appropriate.”

For now, the closest proton beam therapy facilities for Connecticut cancer patients are in New York and Boston.

State insurance regulators have limited experience with the treatment, since there’s never been a facility in Connecticut.

Jim Carson, a spokesman for the Connecticut Insurance Department, said the agency has made five external review decisions on insurer proton therapy denials in the last four years. The decisions upheld the denials in four of the five instances.