WSJ: Proton beam therapy comes 'under attack' from insurers

Insurers cite dearth of medical evidence on procedure's superiority

Several major health insurers have stopped covering proton beam therapy for early-stage prostate cancer amid growing concerns that it may be less cost-effective than standard radiation, the Wall Street Journal reports.

The decisions reverse health insurers' long-standing support for the therapy, which was introduced more than a decade ago. Currently, there are 11 proton beam facilities operating in the United States, and an additional 15 are in development.

Proponents say that proton beam therapy offers precision targeting of tumors, sparing healthy tissue and reducing the side effects associated with other radiation treatments.

However, critics of the therapy have seized on the cost: A recent study found that Medicare pays more than $32,000 for the procedure, compared with about $19,000 for more conventional options to treat early-stage prostate cancer.

  • The New Proton Therapy Marketplace: Join Technology Insights' Chris Pericak for a webconference detailing how key changes in the proton therapy market—including new market entrants, technology innovation, and reimbursement—affect current and prospective proton providers. Learn more.

The insurers that have decided to stop covering proton beam therapy for early-stage prostate cancer are:

  • Blue Shield of California, which sent a letter this week to 300 radiation oncology and urology practices in the state, advising them that the company will stop covering the procedure at the end of October;
  • Aetna, which stopped covering the procedure on Aug. 1; and
  • Regence—a Blue Cross Blue Shield insurer in the Northwest—which stopped covering the procedure three years ago.

The three insurers join Highmark and Blue Cross Blue Shield of Kansas City, which have long-standing positions against the procedure. Meanwhile, Cigna plans to review its coverage policy later this year.

The insurers cite a dearth of evidence attesting to the treatment's superiority over standard radiation therapy.

A study based on Medicare claims data that was published last year that found proton beam therapy was associated with fewer complications in the first six months after treatment, but that the benefit ceased by 12 months.

James Yu, a Yale University radiation oncologist who led the study, told the Journal, "Because of all the claims that have been made on behalf of proton treatment and the sheer enormity of these facilities, the cost has risen to the level where we need to scrutinize how much better proton beam is."

Experts remain split on the costly therapy

Insurers' growing reluctance to cover proton-beam therapy comes amid ongoing concern about U.S. health care costs and a "land-rush atmosphere" among hospitals to acquire the technology, the Journal reports.

However, some hospital executives question the insurers' rationale. Chris Van Gorder—CEO of Scripps Health, which is opening a proton-beam facility in San Diego later this year—said the decision reflects a "very short-term mind-set" that is overly concerned with the procedure's cost. "This is an example of an insurance company injecting themselves in the middle and making a decision as to what's best for the patient and their physician," he said.

Meanwhile, Harvard's Amitabh Chandra told the Journal that he is "encouraged" by the steps insurers are taking. But as long as Medicare continues to pay for therapy, Chandra thinks it will be difficult for insurers to halt coverage. "It's an important move in the right direction, [but] one would have to be incredibly optimistic to think that this is enough to really put the squeeze on this technology," he said (Winslow/Martin, Journal, 8/28).

Next in the Daily Briefing

ACO roundup: ACOs proceed at their own pace

Read now