Insurers Nix Payment for Prostate Cancer Proton Therapy

Medscape Medical News > Oncology

Roxanne Nelson

Aug 30, 2013

Proton-beam therapy, which is used primarily in the United States, is a controversial alternative to conventional radiotherapy for cancer patients. Proponents argue that it is safer and results in fewer complications and less damage to healthy tissue, but opponents say that, in most cases, the supporting evidence just isn't there, especially considering the exorbitant cost.

The controversy has now reached another level. According toa report in the Wall Street Journal, insurers are now balking at the cost. Two major insurance companies have announced that they no will longer pick up the tab for proton-beam therapy to treat early-stage prostate cancer. A third has joined the fray, saying it will be reviewing its policy later this year.

Blue Shield of California has notified 300 radiation oncology and urology practices in the state that, as of the end of October, it will no longer cover proton-beam therapy for prostate cancer. Ironically, this decision comes just as Scripps Health in San Diego is preparing to open its new proton-beam therapy center, which will be the second in California and the twelfth in the country.

Aetna Inc., the nation's third-largest insurer, stopped covering the procedure for prostate cancer on August 1, and Cigna Corp. says it is planning to review its policy on the therapy later this year.

These are not the first insurers to discontinue coverage. Three years ago, Regence, a BlueCross Blue Shield insurer that operates in 4 states, stopped its coverage for this indication, and Highmark Inc., Pittsburgh, and Blue Cross and Blue Shield of Kansas City do not cover it.

Cost and Lack of Evidence

The major issue with proton therapy is the cost of the treatment and of the treatment facility.

The cost to equip and construct a suitable proton center can range from $25 to $150 million. The acquisition cost for intensity-modulated radiation therapy (IMRT) systems is far less pricey, ranging from $1.8 to $5.4 million, according to a 2009 report by the Institute for Clinical and Economic Review on management options for low-risk prostate cancer.

The treatment also has a much higher price tag. Some data show that for prostate cancer, the median Medicare reimbursement for proton therapy is $32,428 and for IMRT is $18,575.

Although many experts agree that some patients are good candidates for proton therapy — most notably children with central nervous system tumors — its use in prostate cancer is highly controversial.

One expert at the 2013 Annual Meeting of the American Society of Clinical Oncology went so far as to say that "proton radiotherapy sells hope, but there is no clear measurable benefit that we can actually translate and explain to a patient."

"I think you've been spending money on something that, at the moment, doesn't deliver. It may deliver in the future, but that will probably be after my retirement," Frank H. Saran, MD, from the Royal Marsden NHS Foundation Trust in the United Kingdom, told the mainly American audience at the meeting.

Even though proton therapy is supposed to focus the beams more tightly and thereby reduce complication rates, there is no real evidence for this, explained Gerald Chodak, MD, director of the Midwest Prostate and Urology Health Center in Michiana Shores, Indiana, in a Medscape videoblog posted earlier this year.

Proton therapy "is a technology that is at least 30% more costly than IMRT, with no clear evidence that it does reduce long-term side effects and absolutely no data to show that it provides better outcomes," he said.

And, although some centers have been using this technology for a substantial period of time, "we have yet to see a single report talking about long-term mortality," Dr. Chodak added.

Hanging in There

But not all insurers are throwing in the towel. Notably, the federally funded Medicare program is continuing to pay for proton therapy for patients with prostate cancer, and they have not announced any changes in that coverage. However, according to the Hospital Outpatient Prospective Payment System rule for 2013, Medicare did reduce its reimbursementrate for proton therapy.

The mean payment for proton therapy was reduced from $1549 in 2012 to $682 in 2013. This means a 32% drop in revenue, from an average of $35,917 per patient to a projected average of $24,565 per patient, according to the Advisory Board Company, a research and consulting firm.

WellPoint Inc., the second-largest insurance company in the United States, will also continue to cover the procedure, but is negotiating the cost down. Kristin Binns, a spokesperson for WellPoint quoted in the Wall Street Journal report, said that the cost of proton therapy is now comparable to other forms of radiation therapy, at least in some parts of the country. She also said that WellPoint considers proton therapy to be "medically necessary" in certain situations.

Blue Shield is also not throwing in the towel completely. Like WellPoint, it believes that proton therapy has advantages for certain patients, and it will continue to cover the treatment when clinical evidence supports its use, such as in children with certain tumors.