Austin Frakt links to an interesting study on the comparative effectiveness of proton beam therapy (PBT) for a variety of cancers:
ICER’s review found that PBT was superior to surgical treatment of tumors of the eye, and appears to be a safer alternative to conventional radiation in brain and spinal tumors as well as pediatric cancers, although most of the evidence in the latter two conditions has been based on simulation modeling rather than actual clinical study. There was insufficient evidence to determine whether PBT offers any improvement over alternative treatments for many other conditions, including bone, breast, gastrointestinal, head and neck cancers, lymphomas, and benign arteriovenous malformations. For many other conditions, including prostate, liver and lung cancer, PBT provides comparable outcomes but at greatly increased cost. Payments for PBT are typically 2-3 times higher than for other forms of radiation treatment and may approach $50,000 per course of treatment in some situations.
There are three categories of outcomes in that paragraph. Better results than current best practice, about the same results as best practice alternatives at signficiantly higher costs, and potentially worse than alternative results. How does our health system(s) deal with this information and how should our health system deal with this information.
First, let’s deal with the should instead of is. As a value and moral judgement that informs the technocratic equation, I think the idea should be we do and pay for things that work well. And if there is equal effectiveness between various alternatives, the least expensive alternative should be tried first. We should not, as a society, pay for less effective and more expensive treatments while allowing individuals to pay for those courses of treatment themselves. These are moral statements in the garb of technocratic language.
How does these values get expressed in insurance industry plumbing?
There are a couple of ways. For cancers of the eye, as well as brain/spinal cancers, PBT would be quickly and routinely approved as it is better/safer than the alternatives even if it more expensive.
For the cancers where effectiveness is roughly equal but the costs are significantly higher, there are a couple of ways to deal with this scenario. The first is to engage in bundle payments for those particular diagnosises where the average bundle is pegged to the cost of the just as effective but significantly less expensive treatment modality. Clinicians could appeal for PBT bundle uppers if there were unique markers/indicators that lead to a statistical argument that PBT would be the superior course of action, but the default standard of care would be the previous less whizbangy treatment. An alternative modification would be a reference priced bundle where the reference price for the bundle would be the current standard of care plus a little bit while allowing the individual to buy up to PBT if they wanted to.
And for the cancers such as bone and breast where PBT is both more expensive and less effective than the current standard of care, PBT should either be denied as a paid for service pending appeal or the individual can have the choice of either the standard of care at full coverage or paying for the entire expense of PBT. The goal here is to move doctors to a closer to uniform standard of care and treatment modalities while making medicine closer to science than a craft.
How is Proton Beam Therapy treated today?
Medicare Fee For Service is currently forbidden from taking cost into consideration when it receives a claim. As long as a billing code is valid and not deemed experimental and the bill comes from an authorized Medicare provider, Medicare pays. Medicare pays even if there are superior modalities availabile in terms of both outcomes and costs. Medicare will pay its full rate for PBT for breast cancer, it will pay a full rate for PBT to treat prostate cancer, and it will pay full rate for PBT treatments for brain cancer. Only the last offers high value for the money spent. Slowly Medicare is changing as it is experimenting with bundled payments, but those bundles are not cancer related yet.
CHIP and Medicaid payment policies vary by state. Some states’ CHIP programs will not cover PBT in any circumstance. Others will pay for PBT depending on diagnosis and clinical indicators. The same variance applies to Medicaid policies. Managed care states will see PBT vary by managed care organization.
Large commercial insurers will have a variety of responses. Some insurers currently will pay full rates for any prescription by an in-network provider. Others will selectively deny PBT therapy based on effectiveness. For instance, Blue Shield of California won’t pay for PBT for early stage prostate cancer. Even within the same insurance company, policies may vary. An individual covered by a PPO offered by a company may have easier access to PBT for non-cost effective treatments than an individual in that company’s aggressively medically managed HMO. In the HMO, authorization is most likely required for PBT, and it is likely to be denied if the PBT is prescribed as for cancers where there are better and cheaper alternatives. The same situation will apply to on-Exchange policies. The PPOs are more likely to pay than HMOs.
There is some, haphazard cost effectiveness decision making at current. It is not transparent, and it is not easily navigable. Medicare is in the process of reducing their reimbursement rate for PBT so that its costs will equalize with other alternatives that produce similar results. But it is confusing and allowing people to receive less than optimal treamtent at high costs in service of the value of “consumer choice” and “freedom” with the side effect that there are few systemic paths of no that could drive prices down.