Sunday, September 21, 2014

How fast can a proton go down a drain?

I've had a number of people write to me upon seeing Jaimy Lee's story in Modern Healthcare:

The Indiana University Proton Therapy Center will close in December, marking the first time a proton-beam therapy center in the U.S. has shut its doors since the rapid proliferation of the costly treatment centers began about a decade ago.

University executives and an independent review committee attributed the center's financial losses to a range of issues, including the cost of maintaining its aging cyclotron, but the committee also suggested the industry may be on the verge of a “proton bubble” as the centers struggle to serve a sufficiently large patient population.  

"Is this a trend?" they ask me.  The UI had a special committee to help them in this matter:

In the committee's report, the reviewers highlight many of the issues affecting the proton industry as a whole, including the lack of completed randomized clinical trials, improvements in alternative treatments, changing care patterns for patients with prostate cancer, and the rise in new payment models, such as bundled payments that may remove incentives to use the therapy.

“It is, therefore, quite possible that we are on the verge of a 'proton bubble' with the more indebted centers or those without a strong patient supply line closing,” the committee said in the report. 

Well maybe and maybe not.  Maybe there were local conditions at work: 

The losses and challenges were clearly outlined in the report. The IU center requires 63 people to staff the cyclotron, spelling high labor costs. The technology, which was adapted from a research cyclotron, needed a $30 million upgrade. The Bloomington site, which is an hour's drive from Indianapolis, is not ideal for clinical-trial participation because it requires most patients to travel.

The center reported a $3.5 million operating loss in fiscal 2013. Another challenge it faced: newer centers are expected to be opened by University Hospitals in Cleveland, Ohio, and by the Mayo Clinic in Rochester, Minn., key referral markets.

But one thing is for sure.  The investment in this machine represents a huge opportunity cost for the University and the patients served by it and, indeed, for other clinical departments.  That tax on the University will persist, as the bonds must still be paid off.  Millions of dollars have and will go down the drain in support of a technology with limited clinical applicability--all part of the edifice complex supported by selected physicians and hospital administrators.  (See the pride with which it is described on the website above and in this 2010 press release announcing a renaming: "We will be proud to be known as IU Health Proton Therapy Center," stated Dr. Peter Johnstone, president and CEO, who shared this important information with staff via executive email.)

And all of this is aided and abetted by perverse Medicare payments that CMS persists in maintaining--even as private insurers declare the treatment ineligible for payment.


e-Patient Dave said...

I think we got ourselves a HBR case study in the making ...

And I wonder: in climate change I see an amazing dearth of "Oops, we were wrong" from the scientists who said for decades it wasn't happening; what are the executive saying who didn't foresee the factors that were cited in this announcement?

To me there's no shame (in science or business) in saying you blew it - didn't correctly assess what was happening. I know there are pressures for people not to assess mistakes candidly, but I wonder what those people say now.

nonlocal MD said...

While I was still reading the part of your post in italics, my mind said 'what a waste'. And then you articulated exactly that. As Dave says, I hope at the very least the same sort of root cause analysis will be applied to this poor use of patient care dollars that is used for clinical errors.

Unfortunately, my diagnosis, fair or not, is: greed.