Don Taylor recently noted the likely resistance to Blue Cross Blue Shield’s refusal to cover the ineffective, costly procedure known as proton beam therapy. Austin Frakt has a terrific post up at JAMA Forum that presents more reasons why the decision will probably not stick:
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.
Austin mentions autologous bone marrow transplantation for breast cancer as another example of an ineffective medical technology that became political impossible not to fund. As related in the must read book False Hope, scientific evidence that a technology doesn’t work has little chance of being influential once compelling advocates with emotional stories capture the limelight. No Members of Congress want to preside over a panel of grieving families blaming them for denying care to a deceased love one (yes, even ineffective care) and in a media battle with a “plucky patient who is taking on the insurance industry fat cats” on one side and a bespectacled nerd with randomized clinical trial results on the other, the patient will carry the day almost all the time.
In the case of autologous bone marrow transplantation for breast cancer, that meant that a number of breast cancer patients “won” access to a needless, ineffective and absolutely excruciating medical procedure. Proton beam therapy advocates will probably “win” a similar victory, sustaining another center of high-cost, ineffective medical technology in the U.S. health care system
Are there legal reasons why a company cannot offer a “proven methods only” policy which would cost substantially less, but would only pay for treatments that are proven?
Yes, yes, there are the usual technical questions of who defines proven, etc. Let’s assume those are solved (eg “we’ll do whatever the British NHS is willing to do, and nothing they are not willing to do”), I’m not interested in that. I’m interested in whether there are LEGAL issues that prevent such a policy, some sort of language somewhere that says something like “an insurer MAY NOT offer cheaper policies by denying ‘commonly used treatments’ regardless of the efficacy or otherwise of such treatments”.
One of the (many) reasons I’m opposed to the current neither-fish-nor-fowl public-private abomination that is the ACA is that it does not seem to allow for plans that are willing to put a serious dent in medical costs in return for the sort of minor inconvenience I am quite willing to accept. The plan I want
- doesn’t consider my doctor to be my best friend, and so has no qualms about assigning me to a doctor, not giving me open-ended choice in this matter
- is quite happy to schedule my heart surgery in Thailand if American doctors insist on charging 5x what Thai doctors charge
- refuses to pay for unproven (or even worse, proven ineffective) treatments
- refuses to pay for branded drugs when generic equivalents exist
But as far as I can tell, no-one is willing to offer me such a plan. I’m trying to understand how much of this is legal encumbrances, how much is a belief that there is no demand for such plans (because the rational-when-it-comes-to-their-own-health population of the US is measures in the low thousands?), and how much is simply fear of public complaints (by do-gooders trying to live other people’s live) if they DID offer such a plan?
…which is why Keith’s title is “Siren Song.”
You have to strap yourself to the mast while you’re healthy, so you can’t succumb to the siren’s call later.
…and so your family can’t, either.
Whenever I see these fantasies about how we will all be going to India or Thailand for much cheaper medical care I recall the letter I read in the Thai English language press when I was in Bangkok several years ago.
An American came to Thailand for laser eye surgery because it was much cheaper than in the US. The fancy, hi-society Thai Doc he went to was associated with the most well-known Thai hospital. The Doc botched the operation and left the poor guy blind.
When he looked into remediation or compensation the Doc laughed at him and told him there was no chance at all that a foreigner to win a suit against a connected Thai. So he wrote his letter to warn others.
Personally, it will be a very long time before I go to a foreign land where I don’t speak the language for a crucial operation-even to save some bucks. I have found even going to a hospital half an hour away adds measurable to the problems associated with surgery.
We need to fix the US medical system-not export patients.
But, it does make a good story. Mix exotic vacation with wonderful medical care and save big too.
And the relevance of a single anecdote is, uh, what exactly? Are you claiming that the US medical system NEVER makes mistakes? I assume you are not that stupid.
So what is the concern here? You seem to feel that the right to go through all the pain and hassle of a US trial (with uncertain outcome) is somehow a valuable option? I’d have thought the rather MORE IMPORTANT question is which medical system screws up more often…
Before making your (let’s not mince words here) flat out racist statements about Thailand, how about you actually VISIT a hospital like Bumrungrad? A hospital that has every sign in five languages (including English, Russian and Arabic, because wealthy Russians and Arabs don’t have a problem with the supposed incompetence and non-recourse of Thai doctors), and which treats 400,000 patients a year? A hospital whose organization and efficiency puts every US hospital I’ve ever dealt with to shame.
Or you have to be uber-rational about the whole thing. Such people do exist, although it might be easier with some diagnoses than others.
There should also be an exception written in to cover costs (other than the therapy costs) for experimental treatments. After all, that is how we figure out what works and what doesn’t.
Proton beam therapy is the best available treatment for a number of cancers, just not the ones that seem to bring in the most patients. Take prostate cancer as an exammple. While I was at the UF/Shands Proton Therapy Institute in Jacksonville for treatment (SBRT not Proton Beam) I had a chance to talk to lots of other patients. Most of the Proton patients were there for prostate. Childhood head and neck cancers are where proton therapy really is the best and there was a group of about thirty kids from the UK there for treatment, paid for by the NHS.
Interesting story. The NHS was specifically excluding prostate cancers from the patients it was referring for proton beam radiotherapy, and indeed the 15 or so rare tumors for which its use was being approved would never pay for the cyclotron, much less the other fixed costs. There are not enough pediatric anaplastic ependymomas to warrant the purchase of a dedicated machine, and the treating centers are likely to need a volume of horses sufficient to justify the huge investment needed to treat the zebras.
There were great hopes for neutron therapy (also requiring a cyclotron) in the 1970s and 1980s, with good looking early results but unfortunate late toxicity. No one knows if proton beams will suffer a similar fate.
It is important to recognize the intrinsically difficult problem here, which is a member of a class of difficult problems: an intervention which may be effective for very rare diseases may need to have paying customers whose indications are more questionable in order to cover its huge fixed costs.
Keith may be is missing something. I know nothing about proton beam therapy, and share Keith’s concerns about the politics of expensive therapies. But I do know that insurers have incentives to deny any expensive new therapy: effective or ineffective. BCBS’s refusal to cover proton beam therapy tells me that it is expensive. It doesn’t have much to do with effectiveness.
Come to think of it, there are only two kinds of therapies that insurers have an incentive to accept: effective preventative therapies, and those that the insurance market (largely employers) insist on. Left to their own devices, insurers would provide plenty of statins and not much else.
And bizarrely neglect to accompany them with CoQ-10, too.
Well, it’s probably not “bizarre,” since the information on CoQ-10 is a jumble (at best) right now. Here’s what the Mayo Clinic has on their website about it:
Coenzyme Q10 (CoQ10) is produced by the human body and is necessary for the basic functioning of cells. CoQ10 levels are reported to decrease with age and to be low in patients with some chronic diseases such as heart conditions, muscular dystrophies, Parkinson’s disease, cancer, diabetes, and HIV/AIDS. Some prescription drugs may also lower CoQ10 levels.
Levels of CoQ10 in the body can be increased by taking CoQ10 supplements, although it is not clear that replacing “low CoQ10” is beneficial.
Oh, and also it’s not “bizarre” that insurers do not cover cheap over-the-counter supplements. That’s similar to similar scenarios where a doctor may prescribe a medicine and simultaneously recommend an OTC supplement, such as Coumadin supplemented with aspirin, or simvastatin supplemented with Omega-3 fish oil. The insurance covers the prescription, but not the OTC supplement.