Knoxville, Tennessee (May 7, 2018) — Governor Haslam’s veto statement of the Proton Therapy Access Act states that it “circumvents the established process for determining state employee insurance program coverage based on medical evidence and effectiveness.” According to Don Denton, President, Tennessee Cancer Patient Coalition, “This implies the State has a rigorous process to determine benefits coverage for its health benefit plans; when, Executive Director of Benefits Administration, Laurie Lee, testified multiple times that her team lacks the resources and expertise to recommend or review coverage guidelines which is why they outsourced those decisions to their insurance company and their insurer’s utilization manager, eviCore. So, the established process the Governor refers to is simply outsourcing the decision to a third-party which has a vested interest in rationing healthcare.”
eviCore Healthcare Management, contracted with the State’s insurance companies, claims it updates its coverage guidelines “to be consistent with the most current evidence-based guidelines and recommendations for the provision of radiation therapy from national medical societies and evidence-based medicine research centers”, such as American Society for Radiation Oncology (ASTRO) and the National Comprehensive Cancer Network (NCCN) which have established coverage guidelines for proton therapy; however eviCore’s guidelines are dramatically narrower. Recently, the National Association of Proton Therapy, sent letters to eviCore’s clients noting that eviCore’s “conclusions drawn in the Clinical Guidelines are based on older evidence, misinterpretation of evidence, and omission of recent evidence”. To quantify this problem for cancer patients, eviCore’s proton therapy guidelines cover less than 5% of cancer incidence while Medicare covers proton therapy for over 70% of cancer incidence. Scott Warwick, Executive Director, National Association of Proton Therapy says, “The State’s reliance on a for-profit benefit management company, eviCore, of which it has been demonstrated is detrimental for cancer patients and their families across the state. We hope that the Tennessee Legislature, who in an overwhelmingly majority voted in favor of this bill, will reconvene for a special session to override the Governor’s veto in support of cancer patients across the state.” According to Tom Welch, President, Provision CARES Proton Therapy, “the only plan presented to The Provision CARES Proton Therapy Center was the Administration’s plan to rely on the eviCore guidelines which did not expand coverage, and in fact restricted coverage. We take exception to defining this as a ‘medically appropriate’ plan.”
The Governor says the State is committed to care that is “medically appropriate and fiscally responsible.” However, the bill specifically provides that the treatment must be prescribed by Board Certified Radiation Oncologists. Therefore, the Governor’s veto is a rejection of the treating physician’s clinical judgment as to what is medically appropriate in favor of the guidelines selectively created by a third party that serves the insurance industry.
With respect to “fiscal responsibility” the Governor disregards language in the bill explicitly providing that the state insurance plan will not have to pay any more for hypo-fractionated proton therapy than it would otherwise pay for the alternative conventional treatment.
The Governor also states that the bill “puts cancer patients at risk of excessive charges” while the language in the bill clearly states, “the amount chargeable to or payable by an eligible patient for a covered course of hypo-fractionated proton therapy shall not exceed the amount that would otherwise be chargeable to or payable by the eligible patient for a course of IMRT” which is traditional radiation therapy. The bill presents no increased financial risk to the State, the insurers or the patient.
The State of Tennessee Health Plan is a self-funded plan, which means it provides health or disability benefits to members of the plan with its own funds, assuming the direct risk for claims and controlling choice of benefits.
Many companies in Tennessee have added proton therapy to their health plans outside of their insurance company’s standard policies. Tom Welch, President, Provision CARES Proton Therapy, says “It is inconceivable why the largest employer in Tennessee, the State of Tennessee, would allow the insurance lobby to mandate treatment options for the State’s plan Members, effectively denying the patient choice that would have been secured by passing the Proton Therapy Access Act.”