Industry Voices—Medicare patients could lose access to advanced cancer treatment. Congress must intervene

Proton beam treatment
Congress must step in by calling on CMS Administrator Seema Verma to remove proton therapy treatment from the proposed Radiation Oncology Alternative Payment Model (RO Model), argues the executive director of the Alliance for Proton Therapy Access. (Chiaki Kawajiri for KHN)

Three of the scariest words in the English language are “you have cancer.”

It was not long ago that these three words were a death sentence. But today, many new treatments are helping cancer patients not only survive but thrive and live long and healthy lives.

Unfortunately, the Centers for Medicare and Medicaid Services (CMS) is proposing a new rule that will make it much harder for cancer patients to receive one of these amazing life-saving treatments. At risk is a highly precise form of radiation treatment known as proton therapy. 

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Unlike traditional radiation, proton therapy allows doctors to target the bulk of the cancer-fighting energy on the cancerous cells while minimizing radiation exposure to healthy tissue, reducing risks to surrounding vital areas, such as organs and bones. Recognizing these benefits, top cancer centers around the country have invested in this cutting-edge technology.

Now, the government is relying on outdated studies in a proposed rule that will severely limit access to this life-saving treatment.

In its proposed rule, CMS not only fails to include the well-established guidelines from the American Society of Radiation Oncology and the National Comprehensive Cancer Network, it cites an outdated (2014) report from the Institute for Clinical and Economic Review and a flawed Medicare Patient Advisory Commission report, in which authors cited old data and ignored clinical expert opinions.

RELATED: Oncology centers say CMS payment model would discourage use of new technology

If implemented as written, many cancer institutions would be in the difficult position of not being able to offer their patients proton therapy because the reimbursement rate would not adequately cover the costs for delivering this sophisticated technology. As a result, many proton centers may have to shut their doors, and new ones won’t open as planned. Access to proton therapy would decrease for all patients—especially in rural and underserved areas—not just those covered by Medicare. 

It appears that CMS’ rationale for undercutting physicians’ ability to prescribe proton therapy is based solely on short-term cost-saving objectives rather than what is the best treatment option for cancer patients. The proposed rule is penny-wise and pound-foolish. Rather than saving money, this rule will increase costs to the Medicare Trust Fund over the long term.

Without proton therapy as a viable option, more patients receiving traditional radiation will need treatment for long-term side-effects and secondary cancers later in life. This rule would deny cancer care that could lessen their suffering and improve quality of life, all in the name of short-term cost savings.

RELATED: CMS eyes expanding Medicare coverage of DNA tests for breast, ovarian cancer

We believe the most prudent option is for CMS to remove proton therapy from the RO Model. If CMS insists on including proton therapy, the only sensible way forward is to require taking into account current medical guidelines and considerations for the resource-intensive nature of the treatment and reimburse accordingly. 

Congress needs to stand up for cancer patients and make sure that CMS does not implement the RO Model as written. Cancer patients deserve the right to work directly with their medical teams to determine the best care plan for them.

Letting a government agency undercut patients’ and physicians’ options—based on outdated and flawed information, no less—should not be tolerated.

Daniel E. Smith is the executive director of the Alliance for Proton Therapy Access.

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