Every time you start to dream about progress on slowing runaway healthcare spending, reality bursts the bubble. Industry stakeholders have the talking points on costs down pat, but when action is required, their attitude is that shared sacrifice is for losers.
How else to explain the Medicare bill? In restoring needed payments to physicians (but avoiding any tough decisions on fixing the bloated payment system), Democratic leaders in Congress cut wasteful spending on Medicare Advantage plans, but delayed a plan to subject durable medical equipment, or DME, to a test of competitive bidding. Medicare will continue to pay as much as twice the retail costs for items such as power wheelchairs and home oxygen, because key leaders such as Reps. Pete Stark (D-Calif.), John Dingell (D-Mich.) and John Boehner (R-Ohio) caved in to unrelenting pressure from their buddies in the DME lobby.
Meanwhile, outside the Beltway, the medical arms race continues to accelerate, which brings us to todays case study: proton-beam therapy. Democratic Michigan Gov. Jennifer Granholm wisely vetoed a decision by the states Certificate of Need Commission to grant a consortium of the states largest cancer providers a monopoly on the hideously expensive technology. The question being begged is why the plan was being proposed in the first place.
For those who havent followed this issue, proton-beam accelerators are the mother of all medical devices. They are the size of football fields, with walls 18-feet thick, costing upward of $160 million apiece. Their advantage is that they can accelerate protons to almost the speed of light and then apply them in an incredibly focused beam onto cancerous tissue, sparing surrounding areas excessive doses of radiation. There is some evidence that the technology may provide superior results in rare forms of cancer.
But the wild-eyed medical-industrial complex is focused like a proton beam on using the untested modality for prostate cancer, the second-most common form of cancer in men. What is drawing providers in is Medicare reimbursement per treatment regimen of $50,000, twice that of conventional radiation.
Certainly, having the technology available is a good idea, if for no other reason than we need to develop a base of clinical evidence on its efficacy. But there is as yet simply no clinical case for five existing accelerators in the U.S. and another seven or eight in development, with surely more to follow. Just as with MRIs, we are hellbent on promulgating the technology without first making a solid scientific case for it.
There has been a debate in articles in the Journal of Clinical Oncology this year over the clinical case for the superiority of the modality. James Cox of M.D. Anderson Cancer Center in Houston and Michael Goitein of Harvard Medical School write that based on the properties of proton therapy, any objective person should conclude that it is highly probable that it provides superior therapy to conventional radiation.
In a response published in the same journal in May, British physicians Fergus MacBeth and Michael Williams charged that there is no reliable evidence that proton therapy provides better outcomes and called for randomized clinical trials pitting the new technology against X-rays and brachytherapy to determine the superior treatment.
Meanwhile, a Harvard colleague of Goiteins, radiation oncologist Anthony Zietman, says that while protons are vital in treating certain rare tumors, they are little better than the latest X-ray technology in dealing with prostate cancer. Zietman, whose hospital, Massachusetts General, operates a proton-beam center, calls the rush to develop new proton-beam facilities evidence of the dark side of American medicine.
Those who care about the future of healthcare may be wondering where they can find the light that can lead us out of the mess were in.