Payers tell PBRT centers that they need better data to justify high prices


According to media reports this morning, a number of payer organizations in the USA are initiating new policies regarding the coverage of proton beam radiation therapy (PBRT) for the treatment of localized prostate cancer.

According to a report in the Wall Street Journal (which we have not seen since we do not subscribe to this publication) some major insurance companies have already decided not to cover PBRT for early stage prostate cancer; others are reviewing their policies. In addition, according to a story in the Los Angeles Times, Blue Shield of California recently “began notifying doctors statewide of its new policy for early-stage prostate cancer patients,” stating that “there’s no scientific evidence to justify” the extra cost compared to “other forms of radiation that deliver similar results.” However, “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.”

The Wall Street Journal and the Los Angeles Times both apparently indicate that Medicare is currently paying more than $32,000 for PBRT, but other forms of radiation therapy may cost more like $19,000 for treatment of localized prostate cancer.

In the story in the Los Angeles Times, a senior vice president at Loma Linda University Medical Center — where PBRT has been used to treat localized prostate cancer for some 20 years — is reported to have said that  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,” he states.

The “New” Prostate Cancer InfoLink has long been critical of what we consider to have been the over-use of PBRT in the treatment of localized prostate cancer at very high cost and based on very few good data. As long ago as the mid-1990s we were given a promise by a leading specialist at Loma Linda that they would be collecting and reporting detailed data on the efficacy and safety of PBRT in the treatment of prostate cancer. To date, more than 15 years later, there have been minimal published data from this center.

In the meantime, multiple centers around the USA have invested many, many millions of dollars in PBRT centers in the hope that they would be able to “cash in” on the high revenue that has (theoretically) been available from the use of PBRT in the treatment of common cancers like prostate cancer (as opposed to the few much rarer cancers like pediatric mengiomas for which there are good, supportive data regarding the benefits of PBRT).

The “New” Prostate Cancer InfoLink wishes to be very clear that we are not “against” the use of PBRT in the management of prostate cancer. What we are “against” is profiteering on the basis of dubious data and unsubstantiated marketing claims. No drug company would have been able to make the sorts of claims about their products that have been made routinely by manufacturers and hospitals for PBRT or for a host of other medical technologies (including the da Vinci robot and CyberKnife radiation therapy, among others). Furthermore, the idea that these technologies can justify “premium pricing” without data to demonstrate a very real set of clinical and cost benefits is economically unsustainable, which is why we are finally seeing this backlash from the insurance industry.

Unfortunately, of course, the payers are now going overboard. There was a much simpler solution to the problem, which was to simply tell patients and healthcare provider institutions that there was a fixed, standard reimbursement for any type of radiation therapy for localized prostate cancer, and that it was up to the institutions and the patients to determine between them what the necessary co-pay might be for things like PBRT.

We had already heard rumors that some PBRT centers had been having a hard time covering their overhead. The situation will get worse unless these centers accept financial reality and work with the rest of the radiation oncology community to implement some really good multi-center trials comparing outcomes from differing types of radiation therapy in the treatment of men who really do need treatment for localized prostate cancer (and not in men who are excellent candidates for active monitoring as opposed to treatment).

13 Responses

  1. Health insurers are always looking for ways to deny expensive care to patients in need. Death is always a more cost-effective alternative. Those with means will always be able to pay for treatment options that may have less side effects and work for some patients, even though there are no formal double-blind studies to show that one is better than the other. In fact there are very few double-blind studies comparing the different treatment options.

    Ironically, the few studies that have been done indicate that the 10-year survival for different treatment options for localized, low grade prostate cancer are greater than 90%, including those that do nothing.

  2. Another option taken away by the insurance companies. Wouldn’t it be better if they just try to negotiate the price down, or allow for a certain amount and the patient covers the rest? Perhaps PBRT is just as effective as other treatments with fewer side effects?

    Last year I was told by my insurance company that color Doppler ultrasound was experimental and not covered. This year I was told that MRI is not part of an AS program, no coverage.

  3. Dear AKAI:

    Actually, at least one study has suggested that the side effects associated with PBRT may actually be worse that those associated with other forms of treatment … but none of the available data are really detailed enough to “hang one’s hat on” because most of them are based on administrative data. The truth is that the PBRT industry has done a very poor job of justifying the value of this type of radiation therapy in the management of prostate cancer … but many centers depend on prostate cancer patients to meet their revenue goals.

  4. The study I think you are referring to is a retrospective study, and retrospective studies have issues.

    There was a recent retrospective study from the Fred Hutchinson Cancer Research Center which made a link between omega-3 fatty acids and prostate cancer. They concluded this based on 834 men with prostate cancer and it turned out these men had higher levels of omega-3 The problem with this study and others like it is they did not account for when the people started the omega-3. Was it after or before diagnosis? Were other factors also overlooked?

    I do agree that the PBRT has done a very poor job of justifying their therapy, but I would also suggest that the other treatment options, except for active surveillance, have also done a poor job of justifying themselves.

  5. Dear John:

    I am not holding a candle for other therapies either … I am an equal opportunity skeptic! However, if you want to charge a premium price (and PBRT certainly has been doing that), you’d better provide some clear clinical evidence of a premium service (which PBRT has, to date, not done — at least in my eyes).

  6. Sitemaster,

    As much as I genuinely respect you and what you do with this site, I also must observe that you have been a consistent detractor of PBRT, at least since I began perusing your site about 3 years ago. You’re quick to make comments like, “Actually, at least one study has suggested that the side effects associated with PBRT may actually be worse that those associated with other forms of treatment …” However, you’ve spent less time highlighting the published results that have been made public by PBRT centers like UFPTI.

    I concede that institutions like Loma Linda should by now have released fuller data on the PBRT experience and outcomes. As you note, they’ve been at PBRT for a relatively long time. Nevertheless, Bob Markini has been an “unofficial” chronicler of PBRT results for years and has reported impressive findings on the safety and efficacy fronts, including quality of life. I might venture to say that since Loma Linda prides itself more on caring for patients than being a high-brow academic institution, it doesn’t surprise me that they may be focusing their resources accordingly, versus writing papers and appearing at conferences.

    I can attest that PBRT worked for me in every way, including quality of life. Like many, many men before me, I can vouch for the safety, efficacy and lack of any side effects of the treatment. One more thing: Aside from denying reasonable choice, I very much believe these insurers are being short-sighted in their decision and in their cost-benefit calculus. With the weight of published evidence showing fewer side effects and a lower chance of secondary malignancies versus IMRT, PBRT — while more costly up front — may indeed be the total cost “winner” over the lifetime of the patient. Wouldn’t that be ironic?

    Bottom line: Definitely bring on more comparative data, but in the meantime, do not deny men this valuable option in the case of prostate cancer. I’m even fine with your interim compromise for the insurer to declare a set dollar amount allowed for EBRT (indexed annually, of course), which the patient could then apply as he sees fit for his RT. That would likely speed the publication of further supporting data as well as encourage the market to bring down the price of PBRT as its technology shrinks and improves in time.

  7. Saw this coming a long time ago….

  8. Excellent perspective and valid points you make Sitemaster. Two things might result:

    (1) The cost of proton therapy could come down, in which case I would think they would have a tough time denying it, since the few studies available indicate it is at least as effective as IMRT, or,

    (2) One might be able to expect the insurer to at least cover up to the cost of IMRT, and the patient covers the excess. The problem with that is different clinics charge different amounts for the exact same procedure, whether it be radiation therapy or surgery.

  9. SOME INSURERS COVER EXPENSIVE WORK-UP AND RADIATION

    I believe the accounts here of insurers who are likely using reasonable approaches to controlling cost to enhance real bang for the buck, as is likely for proton beam for low-risk prostate cancer, and also the accounts of some insurers who deny likely important and sound care such as color Doppler ultrasound, perhaps for business centered reasons at the expense of patient care.

    I have been grateful that my insurer — a very large, nationally very well-known group, has so willingly covered the work-up and TomoTherapy radiation for my own case over the past 2 years, supporting my shot at a cure at the 13.5-year point since diagnosis with a challenging case. The work-up included the Na18F PET/CT bone scan, the investigational Feraheme USPIO MRI scan, ancillary tests and ultrasound, and 39 sessions of TomoTherapy, including the prostate and pelvis, as well as supportive triple androgen deprivation therapy, and drugs to counter side effects; I started the drugs well before the therapy and will remain on them well beyond. In all, the expense dwarfs that figure of “more than $32,000” that was mentioned for Medicare coverage of proton beam for prostate cancer in the context of low-risk disease.

    The only time my insurer refused to cover intended care was their refusal to cover Celebrex at 200 mg b.i.d., prescribed “off label” as part of my prostate cancer program. I had been on the drug, but they stated they would not cover a new prescription. The issue apparently was primarily safety related; this was back in the days when sister COX 2 inhibitor drugs Bexxtra and Vioxx had been withdrawn from the market. Years later, about 2011 as I recall, they again covered the drug for my off-label use against prostate cancer; I’m thinking that’s because the safety questions had been resolved favorably.

    I’m writing all this to make the point that there are good guys out there in the insurance industry. I’m sure many of us would agree and are most grateful.

  10. One clarification to my post of 10:00 PM last night … I knew up front I would have to pay about $1,000 for the contrast agent — Feraheme — for the USPIO 3 T MRI study. Feraheme, though approved by the FDA, is being used off label for such imaging.

  11. SECONDARY MALIGNANCY CLAIM FOR PBRT

    Hi R. Scott,

    I looked into this when I was choosing the type of radiation for my therapy, and all I could find for the claim that PBRT has “a lower chance of secondary malignancies versus IMRT, PBRT” was data based on children’s cancer, where it’s easy to understand how PBRT could have an advantage, considering that children are growing rapidly and their growing healthy cells are more prone to damage.

    Is there any study supporting the claim for adults, especially regarding prostate cancer?

  12. ADDENDUM

    A new report on the Medscape Oncology web site today has added some additional information related to this story about coverage of PBRT.

  13. More discussion on health insurers who have decided not to cover payment for proton beam therapy with prostate cancer. [As already noted immediately above (Ed.).] Subscription to Medscape is free and you need to subscribe by picking a user name and password. Excellent information site.

    Vicki Mann

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

This site uses Akismet to reduce spam. Learn how your comment data is processed.

%d bloggers like this: