Disincentives plague the U.S. health care system, driving costs higher and the quality of care lower. Improving health outcomes requires reforms that remove these disincentives. With respect to health insurers, this means returning payers to their proper role of providing effective risk management services to patients.
In contrast to other insurance markets, health insurers degrade their ability to cover medical emergencies because they cover the costs of routine expenditures that are not risks in the true sense of the word.
If other insurance industries worked like health insurance, then automobile insurers would be paying for the costs of routine oil changes, and disability insurers would be reimbursing people for missing work due to everyday illnesses such as the common cold. The consequence would be that automobile insurers and disability insurers would become financially strapped and would likely create greater and greater coverage restrictions to maintain their financial viability.
This is, of course, what is happening in the health insurance market.
Payers attempt to maintain their financial viability by continually imposing more coverage restrictions that appear arbitrary to many doctors and patients. Worse, these policies are impacting the medical treatments that are available to patients, even restricting access to life-saving treatments that a patient’s doctor may have deemed necessary.
The restricted coverage patients face with respect to proton therapy exemplifies these problems. Proton therapy has been viable for over a half century, however recent technological innovations and published scientific advancements have enabled more effective use of proton therapy to treat cancer. These innovations enable oncologists to more effectively target the cancer treatment and kill the cancer cells without damaging the surrounding healthy tissue.
Due to these advances, proton therapy can now be used to fight more types of cancers, such as cancer of the head and neck, with fewer side effects and reduced chances of the development of secondary cancers. There is also growing evidence that these improved medical outcomes reduce hospital stays ultimately reducing total health care expenditures.
However, proton therapy may be more expensive than alternative radiation therapy on a direct comparison basis, which is where the problem with payers arise.
If you are 18 or younger, proton therapy is recognized as a medically necessary treatment (i.e. non-experimental and non-investigational), and the therapy is generally covered by insurance companies. The same is true if you are 65 and older as CMS also recognizes proton therapy as medically necessary. The problem can arise if you are between the ages of 18 and 65 and diagnosed with these cancers.
For these people, insurance companies will have varying definitions of medical necessity. Some insurers will consider proton therapy as an experimental or investigational treatment, and therefore the treatment will not be covered, while other insurers will consider proton therapy medically necessary, and therefore the treatment will be covered.
If you are unlucky enough to have signed up for the wrong insurance, or your employer signed up for the wrong insurance on your behalf, then a treatment universally recognized as effective for people under 18 and over 65, and a treatment that your oncologist recommends, could be deemed experimental and investigational (i.e. not medically necessary) and therefore uncovered by your insurance.
This is as ridiculous as it sounds; yet, it is all too real for too many patients. For instance, in a study published in the International Journal of Particle Therapy, doctors from the University of Texas MD Anderson Cancer Center and the Boston University School of Medicine found that “insurance coverage of proton beam therapy in the state of Texas varied not only among payers, but also for the type of cancer.”
This variance in coverage arises due to inconsistent and vague definitions regarding when a therapy is considered experimental and when it is considered medically necessary. In the near-term, reforms should promote greater transparency regarding how (and why) an insurance company defines a procedure as medically necessary, such as the reforms being promoted by the newly formed Alliance for Proton Therapy Access.
More broadly, this coverage problem illustrates the ineffectiveness of the current insurance markets. Structural reforms are necessary. These reforms should return health insurance to its primary purpose: cover the unexpected, and large, costs from health risks (such as cancer treatments) without having insurance professionals playing the role of practicing physician.
In other words, health insurance should become actual insurance.