Proton beam therapy is rapidly gaining attention as an alternative form of radiation—advocates say it is less damaging to healthy tissue and may improve outcomes for patients. But it's a costly investment for healthcare providers. Proton centers can cost as much as $200 million to build. The more inexpensive and smaller centers still require at least a $30 million investment.
As more centers have been built and more patients have chosen proton therapy, insurers have become increasingly skeptical about paying for a treatment that can cost at least $13,000 more than standard intensity-modulated radiation therapy—at least when treating prostate cancer—and does not have randomized clinical trials to prove its benefits.
“That's putting this technology in a real challenge,” says Dr. Justin Bekelman, assistant professor of radiation oncology at Penn's Perelman School of Medicine. “We can't produce the evidence unless the treatment is covered. Yet we understand that the payers are concerned about developing the evidence in order to cover it.”
Bekelman and another Penn physician published an article this month in the Journal of Clinical Oncology about using reference pricing with evidence development for proton therapy.
“Although some may argue that reference pricing could threaten the ability of proton therapy centers to recoup their investment, delaying wider access to proton therapy, the current and very real alternative—that is, no reimbursement for proton therapy by major payers for most malignancies—is a more imminent challenge,” they wrote.
Before Philadelphia-based Penn opened its proton center in 2010, it established a reference pricing agreement with Independence Blue Cross, the largest insurer in the region. Independence reimburses Penn at the same rate for radiation whether a patient undergoes proton therapy or other forms of radiation. At the same time Penn is enrolling all the patients into a registry to assess outcomes.
“It's clear that there are profound questions as to where this particular technology fits in,” said Dr. Donald Liss, the insurer's senior medical director for clinical programs and policy. “The challenge is coming up with the responsible way to simultaneously answer those questions and allow patients to receive appropriate care. That's the conundrum.”
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