Insurers Hesitant To Cover Many Proton Beam Therapy Treatments
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Everyone seems to agree that proton beam therapy–a type of radiation that can attack cancerous tumors while generally sparing the surrounding tissue–is an exciting technology with a lot of potential. But some insurers and disease experts say that, until there鈥檚 better evidence that proton therapy is more effective at treating various cancers than traditional听types of less expensive radiation, coverage shouldn鈥檛 be routine.
That approach doesn鈥檛 sit well with听proponents, some of whom say that insurance coverage is critical for necessary research of the controversial therapy鈥檚 uses.
Meanwhile, the number of proton therapy centers — huge structures that can cost more than $200 million — continues to increase. Fourteen are in operation in the United States and a dozen more under development, according to Leonard Arzt, executive director of the .
Critics assert that the rush to build the centers is putting a very large cart before the horse.听
In general, 鈥渢he evidence has failed to demonstrate that there is a significant improvement in outcomes with proton beams,鈥 says J. Leonard Lichtenfeld, deputy chief medical officer at the American Cancer Society. 鈥淚t鈥檚 fair to question whether the number of facilities that are being constructed really reflect the proven value of proton beam therapy.鈥
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A published in the journal Radiotherapy and Oncology, for example,听found proton beam therapy听to be superior to traditional photon therapy for some childhood cancers affecting the central nervous system as well as large cancers of the eye and tumors at the base of the skull. In the case of prostate and liver cancers, there was evidence that the therapy worked, but not that it was superior to photon-based treatment, according to the study. It found that there wasn鈥檛 enough evidence to recommend the proton beam therapy for lung cancer, head and neck cancer, gastrointestinal malignancies and other pediatric cancers.
In addition, a of Medicare patients published in the Journal of the National Cancer Institute found听the cost of proton beam therapy to treat prostate cancer was roughly 70 percent more than photon therapy. Experts say costs are often even higher, with a course of proton beam treatment running three to six times the cost of conventional radiation.
The use of proton beam therapy has accelerated rapidly in recent years as medical centers have raced to capitalize on its clinical and financial potential. At the same time, those efforts have drawn increasing criticism from some consumer and health care advocates who suggest听that the therapy is a clear illustration of how new technology can drive costs higher for consumers and insurers without necessarily improving care.
Last month, the proton beam center at the University of Indiana, one of the country鈥檚 first, . Among the reasons were the center鈥檚 aging equipment, the large number of newly designed听 facilities and falling insurance reimbursements.听
Prostate cancer has become a particularly controversial coverage area. The most common cancer among men, it听accounts for roughly a third of patients at proton centers, and even more at some centers, says Arzt. But research has generally failed to show that proton therapy results in better outcomes or fewer side effects than traditional radiation despite its higher cost, and some insurers have for prostate cancer.听听
Insurance coverage for proton beam therapy varies widely and changes as research emerges. Some insurers, such as Cigna,听cover proton therapy only for cancer of the eye. Others, , cover the therapy for additional conditions, including skull-based tumors and arteriovenous malformations in the brain as well as some pediatric illnesses.听Although Medicare doesn鈥檛 have a national coverage policy for proton therapy, the therapy is generally covered with few limitations, according to a spokesman for the Centers for Medicare & Medicaid Services.
Some advocates for proton beam therapy say insurers need to provide more support for the clinical trials that they believe will show the treatment is superior.
Steven Frank, the medical director of the proton therapy center at the MD Anderson Cancer Center in Houston, is trying for a randomized clinical trial to test proton therapy against photon therapy in head and neck cancer.
鈥淭he biggest struggle we鈥檙e coming up against is that the insurers don鈥檛 want to pay for it,鈥 he says.
Under the health law, most insurers are associated with participating in approved clinical trials for cancer or other life-threatening conditions. So if a patient suffers side effects or other medical problems during the trial, insurers are responsible for covering those costs, among others. But they don鈥檛 have to pay for costs related to the investigational part of the trial, in this case the pricey proton beam therapy.
Some say this situation is no different than testing a cancer drug: The insurer covers the routine costs, but the drug manufacturer is often responsible for providing the drug and testing it.
“Drugs should prove whether they are equal or superior to an existing treatment,” says Lichtenfeld. “Why should proton beam be any different?”
Proton beam therapy proponents counter that it is different because they already know the therapy works.听
How the standoff will be resolved is unclear, but as long as it continues and research isn’t conducted to evaluate which type of therapy works best, there鈥檚 one clear loser: the patient.
This story was updated at 9:50 a.m.听to add information in the final graph.
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