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Oregon lawmakers further ease proton therapy coverage despite lingering debate

Bill tweaks law prohibiting insurers from denying high-cost cancer treatment
Oregon Health & Science University, which a decade ago dropped plans to build a proton therapy center, says it is constantly reevaluating treatments. | SHUTTERSTOCK
May 18, 2023

Oregon lawmakers continue to make it harder for insurers to deny coverage of a costly treatment for cancer that has long been controversial due to conflicting evidence on its benefits. 

The Oregon House on May 8 overwhelmingly approved Senate Bill 463, which prohibits insurers from requiring prior approval for proton beam therapy. The bill earlier passed the Senate unanimously and now awaits Gov. Tina Kotek’s signature.

Proton therapy is a radiation treatment that uses a beam of particles to destroy cancer cells. Advocates say the beam reduces radiation exposure and damage to healthy tissue by targeting cancer cells more precisely than traditional X-rays or gamma-ray treatments.. 

However, research intended to verify its benefits in treating different types of cancer has come to mixed conclusions, and critics have long said proton therapy exemplified a hospital and health system “arms race” that leads to higher health care costs for everyone.

S.B. 463 makes technical fixes to previously enacted legislation legislation intended to prevent insurance companies from using prior authorization to prevent patients from accessing the therapy. 

Prior authorization is an often controversial cost-control process insurers use that requires patients and providers to get approval before proceeding with treatment. Insurers don’t apply the practice to other radiation therapies.

State Sen. Bill Hansell, R-Athena, told The Lund Report he cosponsored the bill out of his experience trying to access proton therapy after being diagnosed with prostate cancer in 2000. 

Hansell acknowledged the limitations of the treatment as well as its cost. But he said the bill is about giving patients the choice to access a non-invasive treatment that carries fewer side effects. He said sometimes doctors don’t take into account how an otherwise effective treatment might affect patients’ quality of life. 

“Let’s say you have surgery, and you end up being incontinent and impotent. For the patient, that is pretty important,” said Hansell. “But the medical world says, ‘Hey, we got the cancer. They’re alive. Get on with your life.’”

Hansell acknowledged that the bill won’t shield patients from higher out-of-pocket costs associated with the costly treatment.

For example, he said proton therapy may cost $70,000 and a more conventional treatment might cost $50,000. The bill would mean a patient opting for proton therapy would have to cover the $20,000 difference, he said.

Scant opposition

State Rep. Maxine Dexter, a Portland Democrat and pulmonary and critical care physician, was the sole “no” vote on the legislation. She told The Lund Report that the Legislature should not be mandating coverage “unless access to care is limited by politics as is the case with abortion and gender-affirming care.”

“In general, coverage mandates prioritize certain groups above others and should be avoided by the legislature,” she wrote. “Our job is to make sure all Oregonians have access to high-quality, affordable care and we should be focusing on systemic changes that make that aspirational goal a reality.”

The new bill drew no formal opposition from the health insurance lobby, unlike with previous bills on the subject. 

Mary Anne Cooper, of Cambia Health Solutions, expressed concerns about the bill to the Senate Health Committee in March, though her employer didn’t formally oppose it. She said that the evidence shows that intensity-modulated radiation therapy, or IMRT, is less expensive and therefore results in lower out-of-pocket costs to patients. Prior authorization, she said, ensures the patient has a heads-up on the additional costs.

“By removing prior authorization, we are concerned that patients can end up being surprised by a significant out-of-pocket bill for proton beam therapy when they could have gotten equally as good an outcome from the much less-expensive IMRT therapy,” she said.

Though the health insurance trade group AHIP has expressed concerns about proton therapy in the past, its lobbyist, Elise Brown, told The Lund Report in a short email that neither her organization nor its members had a position on the bill. 

Is it worth the money?

The long controversy over access to proton therapy stems from the expense of the  large and complex facilities it requires. These include particle accelerators, technology developed for nuclear physics research and can weigh up to 200 tons and be 25 feet in diameter

The size and complexity of the facilities mean proton therapy is twice as costly as other radiation treatments and can cost about $60,000 per course of treatment, according to an article last year in the Philadelphia Inquirer newspaper. 

Medical centers have paid hundreds of millions of dollars to offer proton therapy. But there is nowhere for patients to receive the treatment in Oregon. In 2012, Oregon Health & Science University halted plans to build a proton therapy facility, calling the therapy’s benefits “not clear.”

It’s unclear whether the university’s assessment has changed in the intervening years. 

“Proton therapy is one of the many radiation therapy technologies that have unique advantages and some distinct disadvantages,” university spokesperson Amanda Gibbs told The Lund Report in an email. “OHSU continually assesses new technologies and whether investing in them will ultimately benefit Oregonians. There are no specific plans to offer proton therapy treatment at this time.”

Now Medicare approved, demand for the treatment is growing and the proton therapy market is expected to grow to $1.8 billion by 2028. Payments for the treatment from the Medicaid-funded Oregon Health Plan soared from $98,000 in 2021 to $771,573 in 2022, according to state records The Lund Report obtained.

Meanwhile, questions remain over how effective the costly treatment is. The answer may depend on the type of cancer and location of the tumor targeted.

Oregon’s Health Evidence Review Commission, which determines what treatments are cost-effective enough qualify for coverage under the Oregon Health Plan, in 2016 found evidence that supports a “superior” health benefit for ocular tumors and an “incremental net health benefit for adult brain/spinal tumors and pediatric cancers.” But when it came to liver, lung and prostate cancer, it also found that proton therapy’s benefit was “comparable” to less costly alternatives.

“Importantly, however, the strength of evidence was low for all of these conditions,” reads the commission’s recommendation. “The evidence base for all other condition types was insufficient to determine net health benefit, including two of the four most prevalent cancers in the U.S.: breast and gastrointestinal.”

A 2019 study for the Washington State Health Care Authority found that proton therapy “may be most promising” for treating tumors that are near organs at risk. It cited studies that found patients who received proton therapy for ocular cancer had less recurrence than those who received a different radiation treatment called brachytherapy.

The study notes that the use of proton therapy has expanded to include cancerous and noncancerous brain tumors as well as cancers afflicting the central nervous system, eyes, lungs, liver, prostate, spine and pelvis.

But the study concluded that the overall quality of evidence on proton therapy’s effectiveness was “poor.” One clinical trial the study reviewed found “there were no statistically significant differences” in the overall likelihood of prostate cancer survival between those receiving proton therapy and conventional radiation therapy.

One 2020 study published in JAMA Oncology found that patients with proton therapy were significantly less likely to have side effects than those who received more conventional radiation therapy. But Drs. Henry Park and James Yu, the Yale School of Medicine researchers who authored the study, wrote in an accompanying editorial that the study suffered from significant limitations and more evidence from randomized clinical trials is needed “to truly justify the expenses of proton therapy.”

Patient perspectives drive bill

State Rep. Hai Pham, a pediatric dentist and leukemia survivor who co-sponsored the bill, told The Lund Report there often isn’t one “silver bullet” to treat cancer. But the Hillsboro Democrat said that proton therapy is useful for certain types of brain and pediatric cancer.

“At the end of the day, it’s up to the physician and the patient to help decide what the best course of action is,” Pham said. “And every second counts when you have cancer, especially ones that are diagnosed late, like pancreatic cancer or prostate cancer.”

Pham said that the bill is about ensuring that insurance companies don’t dictate what kind of treatment patients can access.

Hansell said he became  interested in receiving proton therapy after receiving his prostate cancer diagnosis in 2000.

“The thing that was attractive to me was that prostate surgery was known for some potential negative quality of life side effects: impotence and incontinence, neither of which I was very interested in pursuing,” he said. 

But Hansell said his insurance company initially denied his application for the therapy and he had to go through multiple appeals. Finally, he said his insurance company called in an outside medical expert who confirmed that proton therapy is no longer considered an investigational or experimental treatment. 

Because Oregon has no proton therapy facilities, Hansell said he temporarily relocated to Loma Linda in southern California to undergo 42 treatments that lasted about three minutes a day. 

“And I’ve been cancer free since that time,” he said. 

Hansell said about six years ago a friend told him he was unable to get proton therapy after running into barriers with his insurance company. He said that set him on a “quest” to ensure other patients could access the treatment.