Mendenhall William M, Brooks Eric D, Smith Stephanie, Morris Christopher G, Bryant Curtis B, Henderson Randal H, Nichols Romaine C, McIntyre Kathy, Klein Stuart L, Mendenhall Nancy P
Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA.
University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA.
Int J Part Ther. 2021 Jul 27;8(3):36-42. doi: 10.14338/IJPT-21-00002.1. eCollection 2022 Winter.
To determine factors that influence insurance approval for definitive proton therapy (PT) for prostate cancer.
Between 2014 and 2018, 1592 insured patients with localized prostate cancer were evaluated and recommended to undergo definitive PT; 547 patients (34.4%) had commercial insurance, whereas 1045 patients (65.6%) had Medicare/Medicaid. Of those with Medicare, 164 patients (15.7%) had Medicare alone; 677 (64.8%) had supplemental plans; and 204 (19.5%) had secondary commercial insurance. Insurance that "covered" PT for prostate cancer implied that it was an indication designated in the coverage policy. "Not covered" means that the insurance policy did not list prostate cancer as an indication for PT. Of all 1592 patients, 1263 (79.3%) belonged to plans that covered PT per policy. However, approval for PT was still required via medical review for 619 patients (38.9%), comparative dosimetry for 56 patients (3.5%), peer-to-peer discussion for 234 patients (14.7%), and administrative law judge hearings for 3 patients (<0.1%). Multivariate analyses of factors affecting approval were conducted, including risk group (low/intermediate versus high), insurance type (commercial versus Medicare/Medicaid), whether PT was included as a covered benefit under the plan (covered versus not covered), and time period (2014-16 versus 2017 versus 2018).
On multivariate analysis, factors affecting PT approval for prostate treatment included coverage of PT per policy (97.1% had approval with insurance that covered PT versus 48.6% whose insurance did not cover PT; < .001); insurance type (32.5% had approval with commercial insurance versus 97.4% with Medicare; < .001); and time, with 877/987 patients (88.9%) approved between 2014 and 2016, 255/312 patients (81.7%) approved during 2017, and 255/293 patients (87.0%) approved thereafter ( = .02). Clinical factors, including risk group, had no bearing on insurance approval ( = .44).
Proton insurance approval for prostate cancer has decreased, is most influenced by the type of insurance a patient belongs to, and is unrelated to clinical factors (risk group) in this study. More work is needed to help navigate appropriate access to care and to assist patients seeking definitive PT for prostate cancer treatment.
确定影响前列腺癌确定性质子治疗（PT）保险批准的因素。
2014年至2018年期间，对1592名投保的局限性前列腺癌患者进行了评估，并建议他们接受确定性PT；547名患者（34.4%）拥有商业保险，而1045名患者（65.6%）拥有医疗保险/医疗补助。在拥有医疗保险的患者中，164名患者（15.7%）仅拥有医疗保险；677名（64.8%）拥有补充保险计划；204名（19.5%）拥有二级商业保险。“涵盖”前列腺癌PT的保险意味着这是保险范围内指定的适应症。“未涵盖”意味着保险政策未将前列腺癌列为PT的适应症。在所有1592名患者中，1263名（79.3%）属于每份保险单涵盖PT的计划。然而，仍有619名患者（38.9%）需要通过医学审查批准PT，56名患者（3.5%）需要进行剂量学对比，234名患者（14.7%）需要进行同行讨论，3名患者（<0.1%）需要进行行政法法官听证。对影响批准的因素进行了多变量分析，包括风险组（低/中危与高危）、保险类型（商业保险与医疗保险/医疗补助）、PT是否作为计划涵盖的福利（涵盖与未涵盖）以及时间段（2014 - 2016年与2017年与2018年）。
多变量分析显示，影响前列腺癌PT批准的因素包括每份保险单对PT的涵盖情况（保险涵盖PT的患者中97.1%获得批准，而保险未涵盖PT的患者中48.6%获得批准；<0.001）；保险类型（商业保险患者中32.5%获得批准，医疗保险患者中97.4%获得批准；<0.001）；以及时间，2014年至2016年期间987名患者中有877名（88.9%）获得批准，2017年312名患者中有255名（81.7%）获得批准，此后293名患者中有255名（87.0%）获得批准（P = 0.02）。包括风险组在内的临床因素与保险批准无关（P = 0.44）。
本研究中，前列腺癌质子保险批准率有所下降，受患者所属保险类型影响最大，且与临床因素（风险组）无关。需要开展更多工作以帮助患者获得适当的医疗服务，并协助寻求前列腺癌确定性PT治疗的患者。
