It’s an extremely common and reasonable question: How much does proton therapy cost? The answer is as complex as the health care industry itself, but this article will try to explain a few of the factors that come into play. In general, the cost of proton therapy varies depending on the treating facility, the payer, and the prescribed course of treatment.
Payers can be divided into two categories: government payers and non-government payers.
The largest government payer is Medicare. About half the patients at a typical proton center will have Medicare or some type of Medicare product. Proton centers can fall under one of two categories with Medicare: hospital-based or free-standing. The Centers for Medicare and Medicaid Services (CMS), a government agency, releases a national fee schedule each year that applies to all hospital-based proton centers.
For free-standing proton centers the local Medicare Administrative Contractor (MAC) sets the payment fee schedule. Each state has a MAC that administers coverage and payment on behalf of CMS. These rates vary depending upon MAC and location. The MACs use Geographic Cost Pricing Index (GPCI) adjustments to help determine appropriate payment levels.
The easiest way to think about this is that it is a “Cost of Doing Business” adjustment. For example, a center in New Jersey would likely get paid more by their Medicare MAC than a center in Tennessee because it costs more to do business in New Jersey.
Other government payers include TriCare, Medicaid, and the VA.
This category includes commercial insurance companies, as well as patients paying cash out-of-pocket.
There are hundreds of commercial insurance companies. Some of the largest in the United States are UnitedHealth Group, Wellpoint, Kaiser Foundation Group, Aetna, and Humana. The largest insurance network is Blue Cross and Blue Shield. Each of these payers will make an individual determination on what types of cancer they will pay to have treated with proton therapy. They will also negotiate rates with individual centers for these treatments.
Commercial insurance companies will pay based on one of four methods:
- “Case rate” – This is a flat rate for treatment of a disease site, regardless of how many daily treatments are delivered
- “Percent of charges” – This is a percentage of the charges billed out by the proton center
- “Percent of Medicare” – This is a percentage of the Medicare fee schedule
- “Fee schedule” – This is a schedule assigning a payment rate for each type of service
The bottom line
Unfortunately, there really is no one answer to the question, “How much does proton therapy cost?” It is sometimes more expensive than traditional radiation therapy, but there are times when it is equal to or less than traditional radiation therapy.
It’s our goal at Provision to continue working to bring down the cost of treatment and to expand the types of disease sites that are covered by insurance companies.