Insurance Companies Dictating Medical Decisions – A Bad Precedent

An estimated 240,000 men will be diagnosed with prostate cancer in America this year.  Hospitals and physicians are always searching for the ultimate treatment for a cure, favorable disease-free survival intervals, decreased patient morbidity, and a reduced risk of secondary cancers and other harmful side effects. Innovative changes have included the widespread use of robot-assisted laparoscopic prostatectomy and proton beam radiation treatment. 

Scripps Health in San Diego is about to open a $230 million proton beam therapy center, only the second one in California and the twelfth nationwide. This move has prompted Blue Shield of California to challenge the high cost of this radiation treatment, compared with the cost and effectiveness of standard radiation therapy.

Blue Shield has notified doctors throughout California that effective October 2013, it will not pay for a proton beam treatment because the insurer claims that simple radiation delivers “similar results.”

Hospitals, in their never-ending quest for the latest in high-tech care, are planning to open nearly 20 more of these proton centers in cities such as New York, the Washington DC area, and Phoenix.

Supporters say that the new proton therapy device, a 90-ton cyclotron, delivers a precise proton beam that affects only cancer cells and spares healthy tissues nearby, reducing the risk of secondary cancers. But insurance carriers quote multiple studies that have found that proton therapy doesn’t yield better results than the older, cheaper alternatives and that this quest for the high-tech advantage is one reason US health-care costs have been spiraling out of control.

Cary Gross, a researcher at the Yale School of Medicine, recently compared the results of 30,000 Medicare patients who received proton beam or standard radiation. He noted that “the rush to adopt proton beam is far outpacing the amount of evidence to support its use” and that “proton beam is really the perfect example of all that is wrong with our healthcare system.” He points out that Medicare has paid more than $32,000 for a course of proton beam treatment, compared with less than $19,000 for conventional radiation.

In defense of the company’s plan to move ahead with the high-tech cyclotron and proton beam therapy, officials at Scripps say that “the benefits of proton beam therapy are well established” and that “some of the research cited by critics is seriously flawed.”

What I find most troubling is that Blue Shield has apparently failed to recognize the long-term benefits of proton beam therapy and the savings that can be achieved over time. For example, proton beam therapy can cut treatment time for breast cancer patients in half compared with using traditional treatment modalities.

The scientific basis for proton beam therapy appears to be well established. The cyclotron speeds protons at nearly the speed of light to form a pencil-thin beam that attacks malignant cells with extreme precision. Traditional radiation bombards a tumor with more of a shotgun approach. The proton beam’s accuracy can be particularly helpful in tumors near a patient’s eyes, brain, or other critical organs.

Roughly 40 percent of patients treated at centers utilizing the cyclotron receive care for prostate cancer, even though the treatment is available for a wide range of tumors in the brain, breasts, and lungs.

Cigna, another large health insurer in California, is also getting into the act. The organization said that it considers proton beam “to be clinically equivalent, but not clinically superior” to standard radiation. As a result, Cigna has concluded that proton therapy isn’t considered “medically necessary” in most cases given its high cost.

Allowing insurance companies to dictate a doctor’s choice of treatment modality for a patient sets a very dangerous precedent. The point of proton beam therapy is to spare normal tissue. If there is an assumption that the therapy costs more, is such a cost justified in terms of the patient’s outcome? The jury is still out, but health plan restrictions based on cost alone is a dangerous practice.

Supporters of proton beam therapy say it helps patients with prostate cancer avoid common side effects from standard radiation, such as incontinence and erectile dysfunction.

Proton beam therapy probably does offer distinct advantages, but Scripps, like other centers acquiring the cyclotron, will have to make every effort to reduce costs so that the cost-effect argument is off the table. Moving forward across all areas of medicine, high-tech, expensive—and perhaps superior—treatment modalities will be coming on line, and the ultimate challenge for the entire health-care industry is to bring costs to an affordable level so patients can avail themselves of these new and better treatments.

Dudley S. Danoff, MD, FACS is the attending urologic surgeon and founder/president of the Cedars-Sinai Medical Center Tower Urology Group in Los Angeles, California. He is the author of Penis Power: The Ultimate Guide To Male Sexual Health (Del Monaco Press, 2011) and Superpotency (Warner Books).

Read discreetly with the Kindle™ edition of Penis Power™ now available for purchase from Amazon. The Nook Books™ edition from Barnes & Noble and the Sony eReader™ edition from Sony’s Reader Store. Available for under $7.00!

About the Author:

Dudley S. Danoff, MD, FACS is the attending urologic surgeon and founder/president of the Cedars-Sinai Medical Center Tower Urology Group in Los Angeles, California. To view his complete medical bio, please click here.

Leave A Comment

css.php