Will BCBS California’s proton beam therapy decision stick?

Austin Frakt with news of Blue Cross Blue Shield of California deciding not to cover proton beam therapy for prostate cancer because it is no better than other options, but costs more.

Will this stick? By that, I mean that my experience in talking about health care cost control is that most people are all for it in the abstract–while being opposed to just about anything that has a chance to work. And push back seems inevitable.

From my book (ch. 6, pp 55-55) is the story of Blue Cross Blue Shield of North Carolina deciding to limit spinal fusion surgery under certain circumstances due to concerns about appropriateness and cost.

BCBS NC did not say they will never pay for spinal fusion surgery, but instead that they are tightening the criteria for when they will do so to ensure that that the procedure is warranted. In other words, under some circumstances they will say no, we will not pay for spinal fusion surgery.

Who could mind, right? (there is lots of research to back up what BCBS NC proposed)

The American Association of Neurological Surgeons and the North Carolina Spine Society lodged complaints against BCBS NC and their planned change. They professed worry about the welfare of their patients, and also linked this decision to the broader health reform context. “If this intrusion into the physician-patient relationship goes unchallenged, other insurers will follow” Dr. John Wilson a neurosurgeon at Wake Forest University is quoted as saying in the December 25, 2010 Raleigh, N.C. News and Observer.

And, as Austin noted, Medicare has limited ability to do this sort of thing for both legal, but also historical reasons.

The use of this type of spinal surgery in the Medicare program is also controversial, and some say Medicare should review its criteria regarding when the procedure should be covered. The number of procedures paid for by Medicare has quintupled since its approval as a treatment option in 1997, and Medicare routinely covers non-experimental therapies with almost no oversight so long as there is a willing patient and a ready provider.

The change didn’t stick in North Carolina

And right on cue, six weeks after the initial story of BCBS NC’s proposed change there was an announcement late in January 2011 that the policy had been modified after meeting with provider groups.

So, what does that mean?

the largest barrier to reducing health care spending is cultural acceptance that reducing spending means delivering less care. We say we want to save money, but anything that could do this will be met with the retort, “that is not what I meant.” This general story could be told with dozens of examples. It will be able to be told a decade from now for a therapy that has yet to be discovered.

Will this decision stick in California? We shall see.

cross posted at freeforall

Comments

  1. James Wimberley says

    Critics will say this is a ¨slippery slope¨ to something like the NHS´s NICE, forgetting that the current system of ignoring costs is already on a slippery slope – to bankruptcy.

  2. BM says

    … forgetting that the current system of ignoring costs means your wallet is the only member of your “death panel”.

  3. Ed Whitney says

    It is difficult to comment without more information concerning how the BCBS policy was developed. However, there was more to the story than simply a generic objection about “intrusion into the doctor-patient relationship.” The difficulty presented here is one that confronts medical practice guidelines everywhere. Namely, the nuances of clinical practice are more subtle than the nuances of a written policy can hope to capture.

    The version of the BCBS policy that I found online did not cover fusion for initial discectomy for neural structure decompression. The North American Spine Society (NASS) did not categorically disagree with this restriction http://www.spine.org/Documents/BCBSNC_Lumbar_Fusion_Response121510.pdf , but did point out that sometimes a discectomy (as for a foraminal herniation) will entail the removal of a large portion of the facet joint, creating an unstable spinal segment. NASS agreed that the proposed policy is probably appropriate for the more commonly encountered central and lateral recess herniations.

    This raises a second intrinsic difficulty in formulating guidelines, namely, the composition of the guideline panel What should be the balance of specialists and generalists? A back pain guideline panel dominated by internists, physiatrists, chiropractors, osteopaths, neurologists, and anesthesiologists will miss things that will be picked up by spine specialists. A panel dominated by spine surgeons will likely be biased toward more invasive interventions at the expense of less invasive ones.

    There are no easy answers to these twin dilemmas; they have been sought, but not found. Generalists have perspective on things that specialists lack, and specialists appreciate nuances that generalists find it hard to be aware of. Coverage policies need to have some boundaries if they are to be worth drafting, but they cannot cover the fine structure of reality and remain readable.

    • Maynard Handley says

      “Namely, the nuances of clinical practice are more subtle than the nuances of a written policy can hope to capture.”

      That may be so, but given that we live in the real world of imperfect doctors, not some fantasy world of perfect doctors, I’d rather have the stats and the proven treatment on my side than someone’s gut instinct. Exactly how many REAL Dr House’s are there, whose intuition actually IS CONSISTENTLY superior to “impersonal data”? I suspect no more than there are money managers who are capable of consistently beating the market…

      For a timely article on this very point:
      http://www.slate.com/articles/health_and_science/medical_examiner/2013/08/heart_procedures_in_presidents_problems_with_george_w_bush_barack_obama.html

      • Ed Whitney says

        You can still have a manageable guideline that covers the majority of cases, but have provisions like requiring prior authorization for the cases which fall outside the guidelines.

        Dr. House is a fictitious character and a ludicrous one at that. This is not a matter of appeasing doctors who do not exist in any universe. It is a matter of recognizing that evidence-based policies apply to common situations. The less common the situation, the less you have practice based on high level evidence.

        For example, there is a good amount of Level 1 evidence for induction of remission of multiple myeloma, due to the number of large enough randomized trials that have been published. For recurrent myeloma, there are fewer studies and the level of evidence is not as great. For zebras like hairy cell leukemia, the best available evidence is often Level 3.

        Prostate cancer is a horse, not a zebra. Ditto for metastatic breast cancer (see below). A guideline for prostate cancer can be backed up by lots of data and Level 1 evidence. It appears that BCBS has done this for their policy.

        I wonder if anyone in California is going to demand that the big fat gubmint get its big fat hands on their private health insurance in this matter. Or will the Tea Party recognize the sanctity of the rights of a private corporation to act as it damn well pleases when its bottom line is at stake?

  4. Ed Whitney says

    There was the situation in the 1990s concerning high dose chemotherapy with autologous bone marrow transplant for metastatic breast cancer. BCBS and other insurers called it experimental and refused coverage. There was great outrage and several cases of litigation with multi-million dollar jury awards. The treatment was never approved, and it was not until much later that several well-done randomized trials showed that it did not improve survival. One South African study showing that the treatment was effective was shown to have been fraudulent and unable to withstand even a cursory audit of its records.

    The “death panels” in this case condemned women with incurable metastatic disease to die at home, surrounded by loved ones, receiving state of the art palliative care, and denied them the option to die in intensive care units with bright lights and bells going off and severe restrictions on visitation from children and spouses.

    Not a bad kind of death panel in the long run.

    • agorabum says

      You know, with all the constant lying and misrepresentations, I almost forget some of the classics. Like “Death Panels.” I was reminded again how revolting it was that a proposal to provide counseling to people to let them know they could choose to die in comfort rather than with a tube down their throat, was turned into “the (liberal) government will kill you if your conservative.” Disgusting.
      This country could do a lot more thinking and talking about how to have a good death. It might also help them reflect on how to have a good life…to realize that they can’t take it with them.

  5. Josh G. says

    The problem is that private insurance companies don’t have the moral credibility to make the determination about what medical practices constitute the best use of financial resources, because these companies are for-profit operations. Everyone will assume (probably rightly) that the decisions are being made in order to increase corporate profits, not to help patients or to keep insurance rates down.
    Only a single-payer system accountable to the public has the necessary stature to make these kind of calls.

    • J. Michael Neal says

      And as soon as we can get one, that would be great. In the meantime, someone has to decide what treatments should and shouldn’t be covered. I don’t notice anyone else stepping up to do the job and Congress sure as hell isn’t going to authorize the government doing it.

  6. paul says

    “the largest barrier to reducing health care spending is cultural acceptance that reducing spending means delivering less care.”

    No. The barrier is cultural acceptance of the fact that less-expensive care is not “less care” in any meaningful sense. If I go to a mechanic to fix my busted tie rod, and they sell me new tires and replace my shocks, they really haven’t given me more car repair, even though it cost a grand more than replacing the tie rod. But somehow if I go to a doctor who uses a treatment with stats indistinguishable from those of the most-expensive one, I’m getting “less care”.

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