Blue Shield of California to curb coverage of pricey cancer therapy
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.
This fight, pitting expensive new technology against the pressure to hold down costs, is flaring up nationwide as elite hospitals and medical-device makers look to build nearly 20 more of these proton centers in cities such as Phoenix, New York and the Washington area.
Existing proton beam facilities, such as the one at Loma Linda University Medical Center near San Bernardino, also stand to be affected by changes in insurance coverage. Loma Linda’s center has treated nearly 20,000 patients since opening in 1990.
Backers say the latest proton therapy enables doctors to zap cancer cells with precise beams and spare healthy tissue nearby, reducing the risk of secondary cancers and other harmful side effects. Hospitals aggressively tout those benefits to the 240,000 men diagnosed with prostate cancer each year.
But a slew of studies have found that proton therapy doesn’t yield better results than older, cheaper alternatives. Some health-policy experts say hospitals’ constant pursuit of the fanciest gear and luxury amenities is one reason U.S. healthcare costs have been spiraling out of control.
“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.”
Officials at Scripps say the benefits of proton beam therapy are well established and that some of the research cited by critics is seriously flawed. Scripps says the limits imposed by insurers such as Blue Shield are troubling because they fail to recognize the long-term benefits from proton beam therapy and the savings that can be achieved over time.
For instance, they say, proton beam therapy can cut the treatment time for some breast cancer patients in half compared with using traditional X-rays.
“An insurance company looks at the short term,” said Chris Van Gorder, chief executive at Scripps Health. “They are not concerned with the long-term cost impact because the patient may be with a different insurance company later.”
The Scripps Proton Therapy Center is expected to open in late October, capping a three-year construction process. The centerpiece of the facility is a 90-ton cyclotron that was built in Germany and shipped through the Panama Canal to reach San Diego. The machine weighs about as much as a fully loaded 737 airplane, yet it’s only 6 feet tall and 9 feet wide.
The cyclotron speeds protons to 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 for tumors near a patient’s eyes, brain or other crucial organs.
The Scripps center will have five treatment rooms connected to the cyclotron, and it expects to treat about 2,400 patients a year. The bulk of those patients, perhaps 40%, will be getting care for prostate cancer, but there will also be treatment for a wide range of tumors in the brain, breast and lungs as well as pediatric cases.
“The point of this exercise is to spare normal tissue,” said Carl Rossi, medical director of the Scripps Proton Therapy Center. “There is an assumption it costs more, but that’s not always the case. The criticism frustrates me to some degree.”
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.
Marcus Thygeson, a physician and chief health officer at Blue Shield, said the company had already been reviewing the medical literature on this issue and that the latest study was the final straw.
“The real issue here is the growth of these expensive new technologies that drive up the cost of healthcare when there is no evidence of improved outcomes,” Thygeson said. “It’s important we set limits on their use so we can achieve a high-quality healthcare system but also an affordable one.”
Blue Shield said it would continue to pay for patients’ proton treatment in cases when clinical evidence supports its use, such as certain tumors in children.
Some other health insurers have started to take a harder look at proton therapy. Cigna Corp. said it considers proton beam “to be clinically equivalent, but not clinically superior,” to standard radiation. As a result, proton therapy isn’t considered “medically necessary” in most cases given its high cost.
Daniel Fontoura, a senior vice president at Loma Linda University Medical Center, said these health plan restrictions put the onus on proton centers to be more competitive on price and to conduct more rigorous clinical studies. “Ultimately, there will be vindication for us scientifically. It just hasn’t come yet,” Fontoura said.
Van Gorder, the Scripps CEO, said the overall cost was prohibitive for his hospital system to tackle this project on its own. It partnered with an outside developer based in San Diego, Advanced Particle Therapy, that purchased the equipment from Palo Alto device maker Varian Medical Systems Inc.
Advanced Particle Therapy will own the proton center and Scripps will run it with a team of 140 doctors, nurses and other staff.
In addition to Scripps, Varian and Advanced Particle Therapy are working on two other proton therapy centers with Emory University in Atlanta and the University of Maryland in Baltimore.
Dow Wilson, Varian’s chief executive, said his company is working on lowering the cost of these massive machines in order to draw interest from more hospitals.
“We have to get the core cost of the technology down,” Wilson said. “It’s just too expensive.”
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