Frustrated with insurance delays, Scripps Health recently increased the number of patients it treats without prior health-plan approval at the $225 million proton therapy center it manages in Mira Mesa.
The shift is already driving more business to the underused facility even as it raises risks some hefty bills will go unpaid.
Scripps said the new approach, resulting from a 3-month-old policy change supported by the center’s locally based owner, California Proton Treatment Center LLC, has led to a 15 percent to 20 percent increase in the volume of patients treated at the facility.
Previously, Scripps was more reluctant to forgo insurance pre-authorization of treatment regimens that can cost $60,000 or more. But with physicians expressing concern their patients were running out of time, the company says it decided to move forward with treatments and try harder to win reimbursement afterward.
“The patients that have brain tumors get caught between the insurance companies and the physicians,” Scripps Corporate Vice President Tim Collins said. He emphasized insured patients will not be held financially responsible if their health plan ultimately won’t pay for the services.
Gaining Acceptance
Proton therapy is a form of radiation first used on cancer patients in the 1950s. Proponents say its main benefit is the ability to aim radiation precisely at tumors rather than risk long-term damage to surrounding tissue during conventional X-ray radiation therapy.
Scripps says proton therapy can be particularly effective for children with brain tumors, people with head or neck tumors and women with cancer in their left breast, where X-rays might incidentally harm their heart.
The National Association for Proton Therapy counts two dozen proton therapy centers in operation around the country, including the Scripps facility, one in Loma Linda and a third California center in San Francisco. An additional 11 are under construction or development nationally.
State Arbitration
While the treatment is covered under Medicare, and studies have shown its effectiveness, private insurers often question the need for proton therapy, which costs about $20,000 on the low end for treatment regimens lasting weeks.
In California, disputes between insurers and operators of proton therapy centers can be resolved in an independent medical review process overseen by the state Department of Managed Health Care.
The agency reported that, since 2014, 27 insurer denials of coverage (75 percent) were upheld on appeal, seven (19 percent) were overturned and two cases (6 percent) – both from 2016 — were “reversed,” meaning the insurance company agreed to cover treatments prior to completion of the review process. The department would not specify how many of the review outcomes or reversals were associated with the Scripps facility.
A lack of randomized clinical trials contributes to disagreement between physicians and insurers. A spokeswoman for trade group America’s Health Insurance Plans said by email insurers make authorization decisions “based on empirical research and data on the effectiveness of treatment.” She declined to address proton therapy directly.
Collins said part of the reason there aren’t more randomized trials supporting proton therapy is patients can’t afford to take the chance they won’t get treated.
Not Living Up to Expectations
Since the five-room, 102,000-square-foot Scripps Proton Therapy Center opened in February 2014 as a standalone facility along Summers Ridge Road, it has not lived up to financial expectations.
Scripps and California Proton Treatment Center declined to provide patient totals. But Collins acknowledged a shortfall, saying “it’s fair to say we haven’t reached the capacity we had hoped for with the center” because in many cases insurers have withheld treatment authorization.
CPTC, which leases the center to the San Diego-based health care system, said in a written statement it hopes the approach of providing treatment without prior insurance authorization will help clinically appropriate patients and lead to dialogue with insurers. It said patient access to the facility has “steadily increased, and our outlook is positive.”
Access has not been uniform, however. Collins said HMO patients are the least likely to receive approval for proton therapy. Half to 55 percent of patients treated at the Scripps facility during the last fiscal year were covered by Medicare, 26 percent had PPO insurance and 13 percent belonged to HMOs, he said, adding the remainder had other arrangements.
Meanwhile, only 35 percent of people with HMO coverage who asked to come in for a consultation at the center were granted insurance authorization to do so, he said.
“We’re getting barriers to patients even being able to explore” their options, he said.
Making Its Case
As part of its push for more patient treatments, Scripps has engaged with local and state officials and hired additional staff to pursue reimbursement from insurance companies, Collins said. The company is also reaching out to insurers, as well as working more closely with lawyers at the state level appeals stage, he added.
Scripps is monitoring how well the new reimbursement strategy performs. Although the company previously treated some patients without receiving insurers’ pre-approval, never was this done on such a large scale, Collins said.
“We’re evaluating it as we go,” he said. “There are some (insurer denials) that have been overturned. … We’re optimistic, but at the same time we need to support the patients.”
Lost Leverage
A nationally recognized proton therapy billing specialist, Joy Godby, associate director of radiation oncology at the University of Texas MD Anderson Cancer Center in Houston, was skeptical of Scripps’ new approach.
She said when proton therapy centers go ahead with treatment before winning insurance authorization, health plans lose the incentive to work with patients or medical service providers. In such cases, insurers are more likely to drag out the process as long as possible.
“It’s very difficult after you’ve already rendered the service to get the insurance company to cooperate,” she said. “Unfortunately, (Scripps) has left all the leverage on the table,” she said.
Collins responded to such criticisms by saying Scripps does not take pre-authorization treatment lightly.
“When we pursue this path, we’re pretty confident we will reach a resolution with the insurance company,” he said. “This is all about doing what is best for the patient.”
In related initiatives, Scripps said it is working to lower proton therapy costs in some cases by delivering higher doses of radiation in fewer treatments, and doing more to attract international patients by offering concierge and translation services and placing overseas visitors with local groups. Treatments for such patients are generally paid upfront.
Patient Gamble
When Poway resident Kathleen Hill, 65, was diagnosed with breast cancer one year ago, her doctor told her she would need to have radiation treatment within 12 weeks after surgery, which took place Dec. 31. But because of insurance hassles, she said, it didn’t fall within that time frame – and almost didn’t happen at all.
She felt proton therapy was appropriate because she had suffered a minor heart attack about five years earlier, and feared X-ray treatment might further weaken her heart. In late January, however, the insurer denied coverage.
Scripps filed an appeal, telling the insurance company it wanted to proceed with a peer-to-peer review that could overturn the denial. But she said the health plan never returned the company’s calls.
Not until her case entered the independent medical review stage under the Department of Managed Health Care did the insurer change its mind and authorize payment, Hill said. On the 13th week following surgery she started the first of nearly 30 daily treatments she was told would have cost more than $50,000 if she had to pay for them out of pocket.
She accused the insurance company of denying her proton therapy treatment because it didn’t know whether she would be its customer within a year and was willing to “gamble” she wouldn’t be.
The experience instilled her respect for Scripps’ medical and billing team.
“They are such patient advocates,” she said.