Some Insurers Stop Paying for Proton Beam Therapy

What the insurers were paying is a multiple of what Medicare was paying. Someone without insurance was charged an arm and a leg.
Some organizations have been building proton facilities, that cost a mint, in order to create a new cash cow or profit from a new technology.
Recent studies have shown no significant benefit over some cheaper kinds of radiation, I have read.
The concern of the insurance organizations seems reasonable to me.
realestate.dmagazine.com/wp-content/uploads/2012/12/DHCD-ProtonBeam.pdf

Post Edited (robertC) : 8/29/2013 7:40:15 AM (GMT-6)

Hey Tud,
Here's the Infolink article for more information:

prostatecancerinfolink.net/2013/08/29/payers-tell-pbrt-centers-that-they-need-better-data-to-justify-high-prices/#more-18518

Just my own comment,
I saw this coming years ago. PBT is still at over 100k in many cases though we have seen a drop as new centers have opened up. But unless a therapy can prove it is better, with less side effects, then I think the carriers are acting responsibly. I know many PBT patients and they are indeed very passionate about it. I respect that. But if a patient is thinking that their low risk case in best handled with the most expensive of local therapies I think there's room for improvement. I do think that these carriers should consider limited coverage as opposed to total denial. If a man insists he wants it, he should have that option. And if other forms of radiation would be covered to say 30k? Then they should pay up to 30k and let the patient make their own call on whether to pay the rest.

But all of this changes if the PBT centers finally do what they have been requested to do for over a decade ~ provide unbiased proof it's better other than patient comment.

Tony

The headlights on this train have been visible for a long time… In 2007, Anthony Zeitman wrote an article titled “The Titanic and the Iceberg:   Prostate Proton Therapy and Health Care Economics” which foretold of today’s “ collision of two colossi ,” as described in his very articulate words.   (Having read several of his publications, he is one of the best writers in the field of prostate cancer care.) Dr. Zeitman writes on this topic from a highly respected position.   He is a radiation oncologist who not only teaches Radiation Oncology at Harvard Medical School, he also treats prostate cancer patients with both IMRT and proton beam therapy—so his perspective is uniquely (and refreshingly) free from a single-treatment mode/financial bias.   Furthermore, as chairman of the 10,000-member ASTRO (American Society of Radiation Oncology), a part of his mission is to promote excellence in patient care while simultaneously recognizing the (business) realities of his organization. When Dr. Zeitman published “The Titanic and the Iceberg,” many of today’s proton beam therapy (PBT) treatment centers had yet-to-be-built, yet the writing was on the wall.   The business models for the emerging centers were based on continuation of more-and-more, younger-and-younger prostate cancer diagnoses taking place.   PBT had already been in use for decades for rare cases of ocular and skull-base tumors, but these cases are far too infrequent to financially support the millions of dollars it takes to build a facility.   PBT was basically a high-priced solution looking for something to treat…and prostate cancer emerged as the leading money-making opportunity to support a business case.   Six years ago, Zeitman described in detail how the cancer control benefit of PBT in intermediate-risk patients was slight and speculative.   (High-risk and low-risk cases are not discussed because the narrow beam of PBT makes high-risk treatment inadequate, and frankly most low-risk men should not be seeking aggressive treatments.)   So in his conclusion, he challenged his own industry to not waste scarce resources (in this case, “beam time” and physics expertise) in an endeavor which offered essentially no advantage—as he wrote, “rearranging the deck chairs…[rather than] redirecting the ship.” His final sentence:   “If we fail to give this issue our attention, then we may have a 21-st century collision between technology and the iceberg, with the same sorry end.” Very insightful.   A good read.   Zeitman’s article LINK

Perhaps anecdotal however when I read the proton experiences on YANA vs the IMRT experiences, the men in the proton group always seem to have less side effects. Coincidence?

Tony, the part regarding no papers on the effectiveness I find strange too...that one has baffled me. However as you said it works, however how good or how much better, I guess is up to debate (if that is possible without trial data).

I've always been interested in is what seems to be the very few side effects for proton. I've ruminated through YANA for years and again and again it seems as proton always comes out as the therapy with the least side effects.

Perhaps with some insurance carriers pulling out of proton coverage it will force some of the proton centers to rethink their pricing.

Jim,
Yes, I read the same thing with one carrier that renegotiated their rates. Frankly I was surprised Medicare even covered proton, given that Medicare seems to have a tougher set of rules/terms for coverage.

Good discussion...

My insurance BCBS of Alabama will not cover PBT but it will cover CyberKnife RT as the cost for that is in line with traditional IBRT. Here in Birmingham the new CK facility charges less than $20,000  to the insurance company. When I looked into PBT after my diagnosis BCBS told me they still considered it experimental and would not cover the cost. Strange how CK is not considered experimental.

I just want insurance to cover Cialis and Viagra for prostate surgery and radiation guys. :-\

I also know my comment is not directly related to the topic at hand, but the carriers refusal to pay is.
It P*&^%$ me off.

John T said...

You also have to wonder why for some intermediate patients and high risk patients IMRT is added to Proton in order to give it a boost. If it was so effective then why the need for additional radiation from IMRT?

I wouldn't call it a boost with IMRT, but an increase in coverage area for cancers that are thought to have spread beyond the prostate, the IMRT treats more of the prostate bed and lymph nodes which does not need a full dose of radiation. And I believe it true that most proton patients have less side effects, hence less representation on these message boards. I have yet to meet a proton patient that has ED or incontinence that they did not have prior to treatment. I have met at least a hundred patients in BOB meetings and the significant side effects just aren't there. JMHO. I think most treatments have about the same success rates, to me it boiled down to possible side effects and quality of life. My BCBS of Florida paid all but $35/visit deductibles.

Regards,
Kris

Tony,
Are you referring to "pencil beam" PBRT?

In regard to Medicare, my understanding was that Medicare A and B, by law, can not deny coverage based on price alone. If the FDA approves the treatment, it should eventually be covered by Medicare.
Then again, Medicare can set its own reimbursement levels for the treatment.

Kris great paper on the Pros of PBRT.

The issues that carriers have are just before the conclusion:

A Randomized Study Comparing Photons and Protons?
There has already been a great deal of discussion in the literature regarding the feasibility of a randomized study comparing PT and IMRT for prostate cancer, which is an issue beyond the scope of this review.It is unclear how much dose escalation and dose intensification the improved dose distri-bution from PT will permit. Thus, at this point in time, the degree of benefit achievable with PT is unknown, so it seems premature to commit significant resources to a randomized trial testing a mature technology against an immature technology. Funds and research resources would be better spent at this point in developing PT and in determining how best to maximize its benefits.

I italicized the problem carriers are having. This statement does not help the pro-PBRT groups at all. If after 20+ years of charging 100k to treat PCa and not fund trials to prove it's efficacy statements then why fund the procedure at all is what we are seeing today by denial of service for PBRT.

It really does not follow logic to acknowledge the lack of trials comparing technologies by saying it's too costly when you are charging the highest dollars to perform such treatment.

Tony

Post Edited (TC-LasVegas) : 8/30/2013 6:58:03 PM (GMT-6)