The two freestanding proton therapy centers in Jacksonville face the loss of millions of dollars in revenue and possible cutbacks in research, patient support service and operating hours if a proposed Medicare pricing change is finalized.
Under the proposal, the UF Health Proton Therapy Institute, the Ackerman Cancer Center and 51 others across the country would be paid nearly 30% less in 2027 than hospitals delivering the same treatment on the same equipment. In addition to the impact on existing centers, the change could deter development of similar facilities nationwide, limiting patient access to a lifesaving cancer treatment.
"We don't understand what's going on … We can't replicate the math," said Bradley Robbert, director operations at the UF
institute, which opened in 2006 as the first proton center in the Southeast and the fifth in the United States. "We're very concerned if this thing goes through."
Proton therapy treatment accounts for less than 2% of radiation claims submitted to the U.S. Centers for Medicare & Medicaid Services, or CMS, according to Jennifer Maggiore, executive director of the National Association for Proton Therapy.
"It's like a speck of dust, but that speck has a huge impact," she said.
Dr. Scot Ackerman is medical director of the Ackerman center, which was founded in 1997 and added proton therapy in 2015.
"Most people don't want to go to a big hospital, it's very intimidating," he said.
The proposal "puts us completely [financially] underwater with Medicare patients," he said. "As Medicare does these things, doctors retire early. It's very frustrating."
The association and its members, as well as U.S. Rep. John Rutherford, R-Jacksonville, and other members of Congress, have asked CMS to remove the proposed proton therapy payment rate from its 2027 national pricing plan and study the issue further. A CMS decision is due Nov. 1.
"We have consistently maintained that reimbursement for proton therapy — regardless of site of service — must appropriately reflect the unique costs of delivering this highly specialized treatment," according to the association. "The proposed national pricing methodology significantly undervalues the specialized equipment, highly complex case mix, increased staffing requirements and extensive clinical resources required to deliver proton therapy and support ongoing clinical research.
"This proposal raises concerns for the entire proton therapy community because undervaluing this technology in any setting ultimately threatens long-term patient access and continued innovation," the association said.
What is proton therapy?
Proton therapy is a non-invasive form of radiation therapy that directs a precise dose of positively charged particles, or protons, at cancer cells. This targets and destroys cancer cells' genetic material while minimizing the impact on surrounding, healthy cells and is especially beneficial for treating tumors near vital organs and cancer in children.
Patients have reported reduced short- and long-term side effects, including fewer complications, fewer hospitalizations and less need for supportive medications, according to the association.
About 13,000 patients from across the U.S. and 34 other countries have received treatment at the UF Institute since it opened. About 35% or 40% of its patients are on Medicare. The Ackerman center, which offers other radiation therapies and says it was the first physician-owned proton therapy center in the world, has treated about 3,500 patients with proton therapy. About 60% of them are Medicare patients.
Mark Kahrs, 63, received proton therapy treatment at Ackerman after being diagnosed with head and neck cancer in 2023. Now cancer-free without suffering, he is an advocate of proton therapy.
"You will not find a more cost-effective treatment. I did not have to go under the knife, no chemotherapy," he said.
He is concerned for future patients who might be unable to get treatment if the proposed pricing change hampers further development of proton therapy centers.
"I was blessed. I had local access," Kahrs said.
"To restrict funding here but not there doesn't make a lot of sense," he said of the substantial proposed pricing difference between hospitals and standalone center.
A U.S. Centers for Medicare & Medicaid Services spokesperson said the goal of the proposal is to establish national payment rates for proton beam treatment delivery services that are currently priced under different payment systems across the country. Those systems are managed by individual Medicare administrative contractors, which in the Jacksonville area is First Coast Service Options. "Under the current system, payment for these services can vary significantly across geographic areas," the spokesperson said. "CMS proposed a national methodology in response to concerns raised by interested parties about these variations, while recognizing the unique, capital-intensive and specialized resources associated with proton beam therapy."
Historically, Medicare has given hospitals higher proton therapy payments to reflect their higher overhead, infrastructure and round-the-clock emergency support costs. That pattern is heightened in the 2027 proposal.
"CMS recognizes the important role that proton beam therapy can play in treating Medicare beneficiaries," the spokesperson said. "The agency also recognizes stakeholder concerns regarding the potential effects of payment policy on beneficiary access and the ability of providers to furnish these highly specialized services."
In a Sept. 28 letter, Rutherford and 29 other members of Congress asked CMS Administrator Mehmet Oz to "exclude this flawed national pricing proposal" from its 2027 rule making.
They asked the agency to "continue further dialogue with stakeholders to develop a national payment approach that accurately reflects the cost of providing this highly specialized treatment," the letter said. "The proposal, as written, would be catastrophic to patients reliant on this life-saving therapy and to the advancement of cancer treatment in the United States."
Proton therapy has been shown to improve survival compared to other forms of radiation, but fewer than 9% of eligible patients receive proton therapy, the letter said. Proton therapy centers require significant capital investment, specialized equipment and a highly trained multidisciplinary workforce.
"The proposed methodology would reimburse freestanding centers at a rate of approximately 30% less than hospital outpatient departments … even though proton therapy has the same resource intensity and costs across both settings," according to Congress members. "Freestanding cancer centers with proton therapy already face rising costs and inadequate reimbursement. If these reductions are implemented, nearly one-third of the nation's cancer centers offering proton therapy across 11 states could face immediate financial jeopardy."
The loss of even a few centers would leave many patients without reasonable access to this highly specialized treatment, they said.
"This proposal would accelerate the loss of access to one of the nation's most advanced cancer treatments," according to their letter. "Reimbursement cuts to this extent would set back America’s progress while access to proton therapy grows in Europe and Asia."
Building a standalone proton therapy center can cost up to $250 million.
New pricing could be devastating, 'stifle' momentum
Both Ackerman and UF's Robbert said the financial impact could be in the millions.
Ackerman said the loss could force him to cut back or eliminate patient support services, such as support groups and social workers, that are not reimbursed by Medicare.
"That's gravy we provide … to help patients recover," he said.
Ackerman said he also might have to eliminate night and Saturday operating hours, which he offers as a convenience to patients.
Robbert said there were "a lot of options" on the table, such as reducing patient support programs. But providing such assistance to patients is "a good thing to do, the right thing to do," he said. "A cancer diagnosis can be scary."
The CMS proposal could also lead to a weakened local proton therapy industry.
"Jacksonville was the ignition of proton therapy. We [UF] were the first in the Southeast, Ackerman was the first physician-owned," Robbert said.
Mayo Clinic Jacksonville plans to add proton therapy treatment at its Comprehensive Cancer Center in 2027, followed by the first carbon ion therapy program in the Western Hemisphere in 2028.
"We'd like CMS to … not stifle momentum," Robbert said.
The national association's Maggiore agreed.
"We can't go back," she said. "Once we've lost [patient access], it's too difficult to rebuild."
Beth Reese Cravey has been a reporter for The Florida Times-Union for 45 years, currently specializing in nonprofits and health. She can be reached at bcravey@jacksonville.com.
This article originally appeared on Florida Times-Union: Medicare change could cost standalone proton therapy centers millions
