Hartford Business Journal

8 Hartford Business Journal • June 1, 2020 • www.HartfordBusiness.com By Matt Pilon mpilon@hartfordbusiness.com H ealthcare investors are prepared to shell out $152 million to bring a pricey high-tech cancer radiation therapy to Connecticut, but getting commercial health insurers to cover the treatments may not be easy. Proton beam radiation therapy deliv- ers high doses of radiation to targeted areas of the body, sparing healthy tis- sue and vital organs around a tumor. A rare collaboration between Hartford HealthCare and Yale New Haven Health seeks to build a $72-million proton therapy facility in Wallingford, while a physician- owned group with experience de- veloping and administering proton therapy in other states recently announced its own plans for an $80-million facility in Danbury. As Connecticut regulators review the two proposals, federal judges in multiple other states are presiding over ongoing class action lawsuits against Aetna, UnitedHealthcare and other health insurers, filed by cancer patients who were denied coverage and then chose to pay tens of thousands of dollars out of pocket for proton therapy, which is often much more costly than more con- ventional radiation regimens. "Some people have mortgaged their homes [for proton therapy]. We see that regularly," said Stephanie A. Casey, a partner with Florida-based law firm Colson Hicks Eidson, who is representing plaintiffs in three ongo- ing proton therapy lawsuits against health insurers in federal court. The recent complaints come on the heels of a Nov. 2018 verdict against Aetna in Oklahoma state court, where a jury determined the Hartford-based insurer had acted in bad faith in deny- ing proton therapy to a patient with a rare form of head and neck cancer. Aetna, which was ordered to pay the patient's widower $25.5 million, is appealing the verdict. Signs of progress The legal disputes have raised the profile of proton beam therapy, which has existed for decades but seen an explosion in new investment and facilities since 2004. The lawsuits also put pressure on health plans to pay for greater use of the technology, including for specific types of cancer for which insurers argue there's a lack of hard evidence showing proton therapy is a superior treatment. However, advocates say research continues to be released painting proton therapy in a positive light, which they predict will turn the tide in favor of further reimbursement. Last year, a federal judge presid- ing over a lawsuit filed by a Florida cancer patient lambasted Unit- edHealthcare in court, calling the company's denial of the patient's prostate cancer treatment "immoral and barbaric." The judge was in the process of recusing himself, CNN reported at the time, because he had gone through prostate cancer treat- ment and felt conflicted. Several months before that suit was filed, there was a sign of progress for treatment advocates. UnitedHealth- care changed its coverage policy, stat- ing that proton therapy was a proven treatment for prostate cancer and considered clinically equal to a more commonly used (and often cheaper) radiation therapy for the disease. That turned heads in the oncology community, as prostate cancer is the fourth most common cancer, but there are more battles ahead when it comes to reimbursement. "I think by and large the insurance companies still take the position that proton therapy is experimental or investigational or unproven for the majority of cancers," said Casey, whose firm represents the plaintiff in the case from which the judge recused himself. Investors in Connecticut's proposed proton therapy facilities say they're well aware that reimbursement can be an uphill battle that leads to claim denials and lengthy appeals. A consultant working for Yale and Hartford HealthCare, which selected Georgia-based Proton International as the operator of their proposed facility, even mapped out commer- cial carriers' coverage policies and handicapped the odds of claim deni- als and successful appeals. Even with the threat of denied claims, the overseers of both Connect- icut projects predict their operations would be profitable by year two. In the third year of operation, the two facilities project a combined $9.4 million in profits and $52.6 million in net patient service revenue, with 62 full-time equivalent employees. The two facilities anticipate treat- ing more than 800 patients annually once fully up and running; just over one-third of patients are projected to have commercial insurance. Medicare, which is generally seen as more lenient about proton therapy coverage, would be the next largest payer, followed by self-pay and Medicaid patients. Proton Therapy Pushback As costly high-tech cancer facilities eye CT market, insurance coverage a hurdle A physician-owned group proposing to build an $80-million cancer facility in Danbury would use a proton therapy system made by Mevion Medical Systems, based in Littleton, Mass. The Mevion system pictured above is installed in a facility in the Netherlands. FOCUS: HEALTH CARE Annual average cost* of radiation therapies Proton beam therapy is significantly more expensive than other forms of cancer radiation, such as IMRT, which uses photons instead of protons. 2015 2016 2017 2018 Proton beam therapy $79,384 $78,592 $70,875 $73,003 Intensity-modulated radiation $28,754 $30,322 $31,622 $34,248 Brachytherapy $1,499 $5,363 $5,521 $5,330 Image-guided radiation $2,828 $3,283 $3,200 $3,413 3D conformal radiation $1,827 $2,272 $2,318 $2,219 *Cost data do not include patient out-of-pocket costs. Source: IFT Consulting 2020 report for HHC, Yale using data from MarketScan PHOTO | MEVION MEDICAL SYSTEMS

• Cover