Because new and expensive treatments for medical conditions have substantial implications for cost, outcomes, and access, the extent to which insurers can and will resist covering such therapies is a perennially important question. Last month brought some interesting news on this front:
As hospitals race to offer the latest in high-tech care, a major health insurer, Blue Shield of California, is pushing back and refusing to pay for some of the more expensive and controversial cancer treatments….
… 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.
Blue Shield of California is not alone, according to a story in the Wall Street Journal (pay wall). Aetna has also stopped covering proton beam therapy for prostate cancer, and Cigna will review its policy for such coverage later this year, the story notes.
Indeed, recent studies have failed to find evidence of benefit from proton beam therapy relative to other, cheaper ways to treat prostate cancer. For instance, a retrospective study of more than 50 000 Medicare beneficiaries published early this year in the Journal of the National Cancer Institute found that 1 year after treatment with either proton beam or intensity-modulated radiation therapy (IMRT), there was no difference in the radiation toxicity experienced by patients. A study in JAMA last year by Sheets et al found that proton therapy was associated with more gastrointestinal morbidity than IMRT. However, IMRT costs slightly more than half the cost of proton beam therapy.
Not surprisingly, some dispute the allegation that proton beam therapy for prostate cancer provides no incremental benefit over other treatments for the condition. According to the Los Angeles Times, officials at Scripps Health in San Diego, which would be directly affected by Blue Shield’s new coverage policy, say that
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.
Therefore, expect a vigorous fight over whether Blue Shield’s coverage policy should stand. Who will win, the insurer or those who offer proton beam therapy for treating prostate cancer?
The historical record provides some clues. In general, there is a strong bias in the United States in favor of covering new technology. This is among the reasons why technology is one of the leading drivers of health care spending growth. We pay for it—a lot.
One reason why new technologies are often covered is that insurers face a lot of pressure from clinicians, health care organizations, and patients when they try to limit coverage. Don Taylor, PhD, an associate professor of public policy at Duke University, reminds us of an attempt by Blue Cross Blue Shield of North Carolina to limit spinal fusion surgery. Facing resistance from the American Association of Neurological Surgeons and the North Carolina Spine Society, the coverage limitations were lifted in January 2011, just 6 weeks after Blue Cross Blue Shield tried to implement them.
Another reason new technologies are covered is that support for coverage is enshrined in law. Health economists Katherine Baicker, PhD, and Amitabh Chandra, PhD, wrote,
US corporate laws also make it difficult for individual insurers and hospitals to reduce the use of technologies with variable payments: insurers and hospitals are not permitted to interfere with the medical judgment of physicians. State laws also require insurers to pay for any service deemed medically necessary by a physician.
Health legal scholar Einer Elhauge, JD, concurs, writing in a Virginia Law Review article that “studies find, not just legally but in actual practice, that ‘hospitals must cater to physicians’ desire for new technology.’” But it’s not just hospitals that are pressured to do so; insurers are, too.
Take the story of bone marrow transplantation for breast cancer, as told by Gilbert Welch, MD, MPH, and Juliana Mogielnicki. Although the costly therapy was later found to be no better than alternatives, courts ruled in favor of plaintiffs who sued for damages when coverage was denied. One reason, among others, that courts rule against insurers who deny coverage for a new therapy or physicians who don’t provide it is that it is often possible to find evidence that the new and questionable technology is the accepted standard of care. If physicians provide it and if other insurers cover it, it’s harder to argue it’s reasonable not to.
And guess what? The biggest insurer of them all, Medicare, covers proton beam therapy for prostate cancer. As Katharine Cooper Wulff, MPH; Franklin Miller, PhD; and Steven Pearson, MD, MSc, wrote about vertebroplasty in Health Affairs,
Some private payers thought that if Medicare moved first to use the new evidence as the basis for different coverage policies, then private payers could follow. But without action from Medicare, many private payers believed that they lacked the legitimacy to lead in adjusting coverage; “their hands were tied,” as one put it.
Perhaps Blue Shield’s proton beam coverage policy will stand, but its action is an unusual one. As Pearson commented, it is uncommon for an insurer to stop covering a procedure without overwhelming evidence of harm. Instead, Blue Shield is resisting proton beam coverage largely because of its price. Noble or not, given the historical record and Medicare’s stance, do not be surprised if it succumbs to pressure and reverses course.
About the author: Austin B. Frakt, PhD, is a health economist and an associate professor at Boston University’s School of Medicine and School of Public Health. He blogs about health economics and policy at The Incidental Economist and tweets at @afrakt. The views expressed in this post are that of the author and do not necessarily reflect the position of Boston University.
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