Senate bill on proton

[harro]

House Bill #1515 is going to cut proton in Oklahoma. It says:
A health benefit plan that provides coverage for cancer therapy shall be prohibited from holding proton radiation therapy to a higher standard of clinicial evidence for medical policy benefit coverage decisions than the health plan requires for coverage of any other radiation therapy treatment.

I don't read legalese but I think it might be saying they're cutting proton reimbursement to the same as IMRT?? Is it going to hurt insurance firms, rad oncs, or both? And if it is rad oncs who get hurt, how much is it going to hurt?

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[medgator]

Not how I interpret it at all. Sounds like they are trying to force them to cover it without requiring extra "evidence" for the higher price tag.

They are probably concerned about what happened in California

http://articles.latimes.com/2013/aug/28/business/la-fi-hospital-proton-beam-20130829

 

[Gfunk6]

Honestly, we probably need someone who lives in OK who can comment on this. In CA, there have been similar proposals by the state legislature that have been DOA. The latest was a ban on physician ownership of linear accelerators or some such nonsense.

 

[Gfunk6]

Not how I interpret it at all. Sounds like they are trying to force them to cover it without requiring extra "evidence" for the higher price tag.

Here is the exact wording:

A health benefit plan, as defined in subsection C of Section 6060.4 of Title 36 of the Oklahoma Statutes, that provides coverage for cancer therapy shall be prohibited from holding proton radiation therapy to a higher standard of clinical evidence for medical policy benefit coverage decisions than the health plan requires for coverage of any other radiation therapy treatment.

So it DOES sound like they are trying to protect reimbursement for protons! Given the disproportionate number of proton facilities in OK relative to the low population, there is a justifiable fear that the health sector will go belly up if proton reimbursement gets slashed.

 

[medgator]

Here is the exact wording:

A health benefit plan, as defined in subsection C of Section 6060.4 of Title 36 of the Oklahoma Statutes, that provides coverage for cancer therapy shall be prohibited from holding proton radiation therapy to a higher standard of clinical evidence for medical policy benefit coverage decisions than the health plan requires for coverage of any other radiation therapy treatment.

So it DOES sound like they are trying to protect reimbursement for protons! Given the disproportionate number of proton facilities in OK relative to the low population, there is a justifiable fear that the health sector will go belly up if proton reimbursement gets slashed.

Doesn't say anything about reducing reimbursement to imrt levels as has been suggested by some via reference based pricing

http://www.uphs.upenn.edu/news/News_Releases/2014/04/bekelman/

Could easily see insurers going that route

 

[BobbyHeenan]

I talked with someone involved in similar legislation trying to be passed in another state, but very similar to the OK bill. He was quite familiar with this OK bill.

The party line from the proton folks goes something like this:

Insurance companies rarely denied IMRT when it first came out and we only had "theoretical" dosimetric benefits - before all of the studies were published showing clinical benefit in things like head and neck and prostate cancer. You're still approving IMRT for things like lung or esophagus cancer when there really aren't randomized trials. Thus, why should you use a different standard for proton therapy (ie requiring randomized trials) and not approve our proton therapy on the basis of lack of mature clinical outcomes data when we have dosimetric data showing superiority? That was good enough for IMRT for a number of years, why is it not good enough for protons now?

The linac/insurance folks are saying that the cost is unsustainable and if you have carte-blanch say over treatment modality, of course you'll choose protons. In addition, the clinical proton data for prostate is to some degree conflicting (see SEER study showing worse GI side effects), so until this picture is cleared up you shouldn't pay for protons at a rate higher than IMRT.

In my mind this is just another example of rad onc poorly policing itself (I believe Simul has touched on this before). In a perfect world Mr. Upstanding Rad Onc proton doc would carefully select patients, but unfortunately it's not a perfect world. I have personally seen (as in personally reviewed the consult notes, charts, etc) some VERY questionable clinical decisions made at a non-academic proton center (right sided whole breast, pre-op rectal cancer, for example) when they can get it paid for.