One of the mysteries of the medical arms race is why the CMS administrators who have served in the Obama Administration (Don Berwick and Marilyn Taverner) never took action to eliminate the unjustified Medicare subsidy of high cost proton beam machines.
So, bravo to Blue Shield of California for doing just that, even in the face of inaction at the federal level. Here's the story from the Los Angeles Times. Excerpts:
As hospitals race to offer the latest in high-tech care, a major California health insurer is pushing back and refusing to pay for some of the more expensive and controversial cancer treatments.
Blue Shield of California is taking on this high-cost radiation treatment just as Scripps Health in San Diego prepares to open a gleaming, $230-million proton beam therapy center this fall, only the second one in California and the 12th nationwide.
This week, Blue Shield began notifying doctors statewide of its new policy for early-stage prostate cancer patients, effective in October. The San Francisco insurer says there's no scientific evidence to justify spending $30,000 more for proton beam treatment compared with the price it pays for other forms of radiation that deliver similar results.
"Proton beam is really the perfect example of all that is wrong with our healthcare system," said Cary Gross, a researcher at the Yale School of Medicine who recently compared outcomes for 30,000 Medicare patients who received proton beam or standard radiation. "The rush to adopt proton beam is far outpacing the amount of evidence to support its use."
In December, Gross and other Yale researchers published a study that analyzed 30,000 Medicare patients who received proton beam therapy or standard radiation for prostate cancer. Supporters of proton therapy say it helps those patients avoid common side effects from radiation such as incontinence and erectile dysfunction.
But the Yale researchers found that there was no difference in terms of side effects a year after treatment. Yet Medicare paid more than $32,000 for a course of proton beam treatment, compared with less than $19,000 for conventional radiation.
So, bravo to Blue Shield of California for doing just that, even in the face of inaction at the federal level. Here's the story from the Los Angeles Times. Excerpts:
As hospitals race to offer the latest in high-tech care, a major California health insurer is pushing back and refusing to pay for some of the more expensive and controversial cancer treatments.
Blue Shield of California is taking on this high-cost radiation treatment just as Scripps Health in San Diego prepares to open a gleaming, $230-million proton beam therapy center this fall, only the second one in California and the 12th nationwide.
This week, Blue Shield began notifying doctors statewide of its new policy for early-stage prostate cancer patients, effective in October. The San Francisco insurer says there's no scientific evidence to justify spending $30,000 more for proton beam treatment compared with the price it pays for other forms of radiation that deliver similar results.
"Proton beam is really the perfect example of all that is wrong with our healthcare system," said Cary Gross, a researcher at the Yale School of Medicine who recently compared outcomes for 30,000 Medicare patients who received proton beam or standard radiation. "The rush to adopt proton beam is far outpacing the amount of evidence to support its use."
In December, Gross and other Yale researchers published a study that analyzed 30,000 Medicare patients who received proton beam therapy or standard radiation for prostate cancer. Supporters of proton therapy say it helps those patients avoid common side effects from radiation such as incontinence and erectile dysfunction.
But the Yale researchers found that there was no difference in terms of side effects a year after treatment. Yet Medicare paid more than $32,000 for a course of proton beam treatment, compared with less than $19,000 for conventional radiation.
I know that you think this payment decision is well within CMS' purview, but I have read elsewhere vague statements that imply that it is not.
ReplyDeleteI wish, once and for all, someone would explain this in plain English. Can CMS just decide what they will pay by fiat, or not????? And if not, why not??
nonlocal MD
The question remains in either case. If it is within CMS jurisdiction, why no action? If it is without, why no advocacy from the leaders for the change?
ReplyDeleteBut I'd like to hear the answers to your questions, too.
I applaud Blue Shield of CA’s action as well. As an alternative, though, for patients and their doctors who are convinced that proton beam therapy is better than IMRT, Blue Shield of CA could offer to pay the IMRT reimbursement rate of $19,000 and let the patient and family cover the difference if they can. I know that many if not most of the elderly wouldn’t be able to afford to but there is probably a significant number who can. The insurer could offer patients that choice through reference pricing, at least as long as CMS continues to pay for the procedure.
ReplyDeleteAs for why CMS doesn’t just refuse to cover proton beam therapy, I think the answer is that the ability of special interests and their money to influence congressmen and senators too often trumps rational decision making by CMS.
Barry, I too suspect that politics plays a role, although I wasn't saying CMS should refuse to cover it, just that it should not be given a premium based on the manufacturer's hype rather than data.
ReplyDeleteOn another of your excellent and oft-made points, Barry, I read that North Carolina recently passed legislation requiring its hospitals to publicly disclose the prices they negotiate with insurers. It's a start, although I suspect gaming will occur.
Paul, I think your comment raises a larger question - what is, after all, the mandate of CMS? Is it supposed to advocate for cost containment or just follow the advice of the RUC, as it seems to have been doing? Its leaders seem to believe the latter.
nonlocal
Since CMS isnt allowed (by Congressional mandate) to consider cost-effectiveness in deciding upon coverage, what would their basis for rejecting a therapy preferred by provider and patient in the absence of any evidence proving that it leads to worse outcomes? Agree with you completely on the waste, but is this in CMS' purview, or isn't this the kind of move that the death panel talk succeeded in preventing CMS from making?
ReplyDeleteakhan13, I too would like a clear statement on the cost-effectiveness issue. I've heard something of the sort repeatedly but I don't know what the exact rule is. Anyone?
ReplyDeleteWhile I commend BCBS for taking action to reduce healthcare spending I can't help but think this was for their own good and not the greater good. BCBS is focused on their bottom line and nothing more, so let's not give them more credit than they deserve.
ReplyDeleteBCBS limits coverage for metabolic formula and medical foods to $5000/year for children and adults greater than 6 years of age with phenylketonuria (PKU), despite strong evidence that people with PKU must consume the medical formula and be on a low protein "diet for life." I believe in the instance you mentioned they acted on literature that was not as strong as the PKU literature. My assumption is because providing essential medical formula for patients to be normal, high functioning adults decreases their bottom line instead of increasing it.
It is my understanding that CMS cannot consider cost in deciding WHETHER to cover something. What is not clear to me is how they decide on the $$ number that they will pay, and whether/how they can change that number as more evidence comes in. As Barry says, why not cover it at the same price as IMRT? Who decides if it deserves more?
ReplyDeletenonlocal
CMS doesn't just decide on a price. There is a something called the Outpatient Prospective Payment System (OPPS), sort of similar to the DRG system for inpatient.
ReplyDeleteAll the possible outpatient procedures that are paid under this system are divided into payment classification groups (APC's). Similar procedures (similar in clinical type, cost, etc) are bundled into the same APC.
Different APC's are weighted as to their cost and payment levels are assigned based on those weightings.
There is a technical advisory panel that meets twice a year to give CMS input about the APC groupings. I was on that panel for about a year, but had to leave it due to a change in my job.
At those meetings, industry groups come in and lobby CMS about why their technology, device, or procedure should go into a higher weighted group (more payment).
Here's the kicker though. The total amount available for the OPPS is a fixed pie each year. So if one APC group gets a higher payment, it has to come out of somewhere else in the OPPS.
Hospitals turn in cost data and CMS uses those self-reported costs in adjusting or assigning the payment rates (amongst many other factors).
-Neville
Also, I should note, that Proton therapy payments have been cut significantly.
ReplyDeleteSee here:
https://www.astro.org/Web-Exclusives/Practice-Management/2013-proposed-OPPS-regulations--proton-beam-services-experience-significant-decreases.aspx
-Neville
Neville,
ReplyDeleteAre the rates now the same as IMRT for prostate cancer?
Historically, the Medicare Payment Advisory Commission (MedPAC) offered suggestions for how the Medicare program could save money. While it did much good work, most of its recommendations gathered dust because they required congressional approval to take effect which was rarely if ever forthcoming.
ReplyDeleteUnder the Affordable Care Act, the Independent Payment Advisory Board (IPAB) is supposed to fill this role. However, the legislation doesn’t allow the IPAB to offer any ideas that would ration care, reduce benefits or increase beneficiary premiums, deductibles or co-payments. That leaves mainly tinkering with provider payments, especially for services, tests and procedures that are deemed to be overused and offer only marginal medical benefits at best.
At the same time, CMS is not allowed to take costs into account in deciding what to pay for and not pay for. So, anything that wins FDA approval because it’s better than a placebo gets covered even if they’re no more effective than older therapies that cost much less. We can thank the power of special interests and their money for this. To hear single payer advocates argue that we would all be much better off if we extended Medicare to the entire population leaves me incredulous.
Read the book "Confidence Men". It explains how the ACA evolved from health CARE reform to health INSURANCE reform, with the only feature being more coverage. Nobody in government is pursuing outcome-based health care even as the costs of the present mess are clearly unsustainable.
ReplyDeletePaul,
ReplyDeleteI doubt it has come down that far, but I do not know for sure.
Keep in mind that IMRT itself is no better than the even cheaper "Conformal" therapy for prostate cancer.
See here:
http://www.healthnewsreview.org/2013/05/imrt/
Supposedly the reduced rates are in part due to a mistake one center made in their cost reports, so the rate might go up again...
http://www.dotmed.com/news/story/20140
-NS
See this as well. These are the folks advising Proton therapy centers on how to get their reimbursements increased again...
ReplyDeletehttp://www.advisory.com/Research/Technology-Insights/The-Pipeline/2013/08/Achieving-financial-success-in-proton-therapy-in-2013
I'm glad I received my proton therapy before Blue Shield of Ca. Made this decision. I am also glad that I am up for open enrollment in a few weeks, time to change!
ReplyDeleteAll you need to do is attend a local prostate cancer support group. You will find men who have either had their prostate removed, IMRT or some procedure other than Proton Beam Therapy. The PBR patients are out living life as normal, no need for a support group. Side effects during and after radiation are minimal, if any at all.
I do believe these decisions are supported by special interest groups. Let's think, who has more money to push their agenda? The many thousands of IMRT centers and the many thousands of surgeons that will lose patients to PBT centers as more are built.
If you think that new technology and better procedures are what's wrong with our health care system, you are what is wrong.
Don't trust all the studies, go to a support group and listen to the men that didn't have the knowledge or access to Proton Beam Therapy. Then find men that have had PBT, different stories.
My grandfather died from prostate cancer. My father and uncle are living with the side effects. They are continually costing their insurance carriers more money with follow up procedures and medications.
I am living life like it never happened.
Forget the special interest groups and negative propaganda towards Proton Beam Therapy. Talk to real people.
ReplyDeleteThis is the best real person explanation I have found.
http://laurieandodel.blogspot.com/2008/12/big-words-impressive-statistics-on.html
As "Lisa" commented on the article link above, 40-60% IMRT patients have complications compared to 2% of Proton Beam patients.
They both kill the cancer. One like a shotgun blast, the other with precise accuracy.
Sorry, anecdotes do not amount to science. It is not uncommon for people who have had successful treatment to feel loyalty to the modality chosen. That's not the way clinical choices should be made for society.
ReplyDeleteSorry, it is not anecdotes, it is science at its best.
ReplyDeletePlease read about the differences of IMRT and Proton Beam Therapy. Try and use your "scientific mind". Scientific fact, PBT patients receive much less radiation to non-cancerous tissue than IMRT patients. Hence less side effects with PBT.
Negative comments to someone's experiences are not appreciated. Also, why would you assume that a person who has gone through a fight with cancer, didn't spend many hours researching the best treatment possible?
Just hoping that someday our decision makers will have a little common sence and actually do what is best for the people and not their bank accounts.
My comment was not negative about your experience. I was just suggesting that such experience is not the basis for how society should choose to spend scarce dollars among the various types of medical treatments available. To date, there is not scientific evidence that suggests that proton beam machine produce appreciably better results for prostate treatment. If we choose to spend billions of dollars on this, there are likely other priority areas that will not be funded.
ReplyDelete