As someone who can use either protons or Xrays for any given individual, I am really fortunate. My income, luckily, does not depend on the use of just protons or just the Linac. How many rad oncs can say that? In a way, I'm living the dream.
Interestingly, on a per hour basis, I get paid about half as much for the proton cases I do, because the complexity is that much higher in planning (and also the management of higher patient expectations). It's still kind of like how a good IMRT plan used to take 2 weeks and multiple trips to dosimetry back in the day, and you had to be careful to tell the computer to not treat through the lips and stuff like that.
I think that it's worth mentioning that patient expectations are all over the map in regard to what protons can offer. Some people will travel internationally and pay out of pocket for a small chance at reducing a life-long risk of side effects. Others won't drive to the next town over, even if I insist that it's much safer for their particular cancer, and that they are doing themselves a disservice if they don't. Neither of these patients are wrong, by the way, but it just reflects their social and economic conditions at the moment - they are all just trying to do the best they can with what they've got, just like you and me.
The Propublica article is short on nuance, just like all news articles. Most patients who come in seeking protons have generally been exposed to biased information or at least a one-sided marketing approach (just like all marketing - have you ever seen a Ford F150 commercial praise the merits of a Chevy Silverado?).
As a result, I sometimes have to tell people that another modality is simply better for their specific situation, just like you would do if someone came in requesting 5 fractions of Cyberknife brand for their H&N cancer involving both necks, "and no chemo either, because chemo has side effects - I don't want any side effects." It can be a long discussion to tell someone who came in specifically for protons that they simply won't qualify and I cannot make a convincing case for their insurance company, because I'm not convinced myself, at least, in that specific patient's case.
It should matter though, when a doctor who can choose any modality, does request one that is quantifiably safer. It should matter, when he or she takes half an hour of uncompensated time to compose a signed letter or have a live hearing with a judge to back it up. It should matter when we do produce the patient-specific comparison plans (hours of uncompensated work), where the proton plan does meet multiple published constraints that no IMRT plan can ever meet. It should matter when I submit professional society guidelines and published articles showing reduced need for expensive and risky procedures like feeding tubes or hospital stays for relevant proton-treated patients.
But no matter what their disease site, or how heavily they were pre-treated, or how superior their proton comparison plan; way too many of my patients who truly NEED protons still get denied due to the arbitrary and capricious rules written years ago by financially biased people. These generally are people who have never prescribed protons or created a proton plan, who lump all proton requests into the same box, who don't have a career-safe mechanism to override the health plan on a regular basis, who aren't up to date on the literature in the particle field, and who have no incentive to do so.
I get the same immediate rubber stamp denial that you and I would get if I tried to prescribe 180 fractions of IMRT+IGRT for a bone met patient on hospice.
To me, that is why we need a legal outlet for these patients (and their doctors), to seek recourse against the insurance companies who turn a blind eye and deaf ear on those that we all have an obligation to protect.