Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas; Proton Therapy Center, The University of Texas MD Anderson Cancer Center, Houston, Texas.
Int J Radiat Oncol Biol Phys. 2019 Jul 15;104(4):724-733. doi: 10.1016/j.ijrobp.2018.12.019. Epub 2018 Dec 14.
Proton therapy is increasingly prescribed for cancer treatment, given its potential for improvements in clinical outcomes and toxicity reduction; however, insurance coverage continues to be a barrier to patient access. This study examined insurance approval and appeal outcomes at a large-volume proton therapy center to clarify the process and identify areas for improvement.
In 2013 to 2016, 1753 patients with thoracic or head and neck cancer were considered for proton therapy; 903 (553 thoracic, 350 head and neck) entered the insurance process. Rates of and times to approval and successful appeal after initial denial were calculated. Clinical factors were evaluated for association with insurance outcomes via logistic regression.
Approval rates by Medicare (n = 538) and private insurance (n = 365) were 91% and 30% on initial request, at a median 3 days and 14 days from inquiry to determination. Of the 306 patients initially denied coverage, 276 appealed the decision, and denial was overturned for 189 patients (68%; median time, 21 days from initial inquiry). On multivariable analysis, Medicare (odds ratio [OR], 14.20; P < .001) was the strongest predictor of initial approval. Approval rates decreased from 2013 to 2014 versus 2015 to 2016 (OR 0.54; P = .001). For patients who appealed denial, multivariable analysis found no associations between approval and trial enrollment or tumor type. Submission of a comparison treatment plan (proton vs photon) indicating dosimetric advantage to normal tissues was associated with decreased likelihood of approval (OR 0.43; P = .006), as was a prescribed dose of ≥66 Gy (OR 0.48; P = .019).
Despite an 87% ultimate approval rate for proton therapy, the insurance process is a resource-intensive barrier to patient access associated with significant time delays to cancer treatment. These findings, plus the lack of clinical correlates with insurance outcomes, highlight a need for increased efficiency, transparency, and collaboration among stakeholders to promote timely patient care and research.
鉴于质子治疗在改善临床结果和降低毒性方面的潜力，越来越多的癌症治疗采用质子治疗，然而，保险覆盖仍然是患者获得治疗的障碍。本研究旨在通过考察一家大型质子治疗中心的保险审批和上诉结果，阐明该过程并确定需要改进的领域。
在 2013 年至 2016 年期间，1753 例胸部或头颈部癌症患者被认为适合质子治疗；903 例（538 例胸部，350 例头颈部）进入保险流程。计算初始拒绝后批准和成功上诉的比例和时间。通过逻辑回归评估临床因素与保险结果的关系。
医疗保险（n=538）和私人保险（n=365）的批准率分别为初始申请时的 91%和 30%，中位数分别为从询问到决定的 3 天和 14 天。在最初被拒绝保险的 306 例患者中，276 例提出上诉，189 例（68%；中位数时间为从初始询问起 21 天）推翻了最初的决定。多变量分析显示，医疗保险（优势比[OR]，14.20；P<.001）是初始批准的最强预测因素。2013 年至 2014 年的批准率低于 2015 年至 2016 年（OR，0.54；P=.001）。对于提出拒绝上诉的患者，多变量分析发现，批准与试验入组或肿瘤类型之间无关联。提交表明质子治疗相对于光子治疗在正常组织的剂量学方面具有优势的比较治疗计划（质子治疗与光子治疗的比较）与降低批准可能性相关（OR，0.43；P=.006），处方剂量≥66Gy（OR，0.48；P=.019）也与降低批准可能性相关。
尽管质子治疗的最终批准率达到 87%，但保险流程是患者获得治疗的资源密集型障碍，会导致癌症治疗的显著延迟。这些发现，加上保险结果与临床因素之间缺乏关联，突显了提高利益相关者的效率、透明度和协作的必要性，以促进及时的患者护理和研究。
