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Insurers Balking On Proton Prostate Therapy

September 5, 2013
Written by: , Filed in: Abdominal Imaging, Practice Management
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Major insurers have begun withdrawing coverage of proton-beam therapy for prostate cancer, balking at the cost—although the second-largest U.S. health insurer has taken a different approach to the same issue.

Aetna has stopped its coverage, according to the Wall Street Journaland Blue Shield of California has announced that it will cease coverage of proton-beam therapy for early-state prostate cancer at the end of October.

Marcus Thygeson, MD, senior vice president and chief health officer at Blue Shield of California, told the Journal:

The preponderance of medical evidence clearly shows that the treatment has about the same clinical outcomes as other forms of radiation, but it’s a lot more expensive. Because it’s not cost effective, we’re not going to cover it.

Cigna has said it plans to assess later this year whether it will continue coverage. Regence, a Blue Cross Blue Shield insurer in four states in the Northwest, stopped covering proton-beam therapy three years ago. Highmark, of the Pittsburgh area, and Blue Cross Blue Shield of Kansas City have not covered it.

Medicare, however, does. On average, it pays more than $32,000 for the procedure, compared to about $19,000 for other types of radiation treatments for prostate cancer.

And WellPoint, the country’s second-largest health insurer, continues to cover proton beam but tries to negotiate the price down. Kristin Binns, a WellPoint spokeswoman, told the Journal that WellPoint considers the therapy to be “medically necessary” in certain cases. “In some locations,” she said, “the cost is now comparable to other forms of radiation therapy.”

Advocates say that because proton-beam therapy can be more precisely focused than other forms of radiation therapy, it causes less damage to healthy tissue. Opponents say there’s no evidence to support that theory—although proton certainly seems to work at least as well as older radiation therapies. A study published late last year found that proton-beam therapy was associated with fewer complications in the first six months after treatment but that its benefit disappeared over the next six months.

Leonard Arzt, executive director of the National Association for Proton Therapy, said, “There would be no debate if costs were the same as conventional X-ray radiation.” Well, yeah. But they’re not. That’s, um, kind of the point, isn’t it?

At any rate, research is ongoing, and further evidence will likely tip the debate one way or the other. Stay tuned.

Related CME seminar (up to 11.5 AMA PRA Category 1 credits™): UCSF Abdominal and Pelvic Imaging: CT/MR/US

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