• Blue Shield of California just did something unusual

    Perhaps you’ve heard that Blue Shield of California will stop covering proton beam therapy for prostate cancer. Look here for details.

    By email, Steve Pearson, President of the Institute for Clinical and Economic Review, told me just how unusual a move this is.

    This action by Blue Shield of California is supported by multiple reviews by independent review bodies of the existing (lack of) evidence on proton beam’s comparative effectiveness, but that makes it none the less remarkable.  It is exceedingly rare for health plans to remove coverage for any service that they have previously covered unless there is striking new evidence of safety problems or other unanticipated harms.  And Blue Shield is not saying that they believe proton beam treatment for prostate cancer is ineffective or more harmful than other radiation techniques. Instead, they are saying that proton beam treatment may be just as good as other options, but it will not be covered because it is far more expensive.  Not covering an effective treatment using this “just as good but more expensive” rationale has always been fair game given most private insurers’ contract language, but I’m unaware of any other important example of its having been exercised once a treatment has been covered and used by thousands of patients.  That’s why I’m impressed with the clarity of Blue Shield’s statements today and by what has to be called their courage in drawing a line in the sand over high-cost treatments that lack convincing data of superiority over other options. 

    In principle, one could imagine an alternative policy approach by the insurer: they could have continued covering proton beam therapy but decided to reduce their payments to the same level as the most reasonable competing approach.  It’s not clear whether it was philosophical, strategic, or just practical reasons that led Blue Shield to opt for non-coverage instead.  Medicare is constrained by its statutory language and years of precedent from exercising either policy approach when a treatment turns out to be no better than another less expensive option.  That’s why it’s refreshing to see a health plan willing to look at the available evidence and do something to help control health care costs and, importantly, provide more of an incentive for manufacturers and researchers to do better comparative studies on new treatment options.  Patients, and all of us, will be the ultimate winners.  Maybe proton beam really is better for prostate cancer than other radiation options, but we don’t know.  Patients don’t know; neither do doctors.  The early evidence is not promising.  So why pay more?  Why pay for it at all at this point when there are other state-of-the-art options that seem just as good and are far less expensive?  By their action today, Blue Shield has shown that it is asking the right questions.


    @afrakt (via phone)

    • Right on, Dr Pearson! About time that plans made it clear what they cover and what they don’t and why. Proton beam therapy is extremely expensive and has begun to proliferate without substantial evidence of greater effectiveness than other treatments. How do we stop that proliferation if some entity does not stand up and say “we won’t pay for it”? If patients really had to pay the difference, proton beam therapy would be stopped in its tracks.

    • Good post.

      I am also curious why Blue Shield is not using tiered pricing. Perhaps they fear angry policyholders who would get a huge balance bill, and that this is not worth the hassle.

      Your sentence about Medicare is accurate for now. If we ever want to get Medicare on a budget, that statutory language must change and precedent must be ignored. Nations have done a lot harder things.

    • Seems like a very good thing. My opinion is that now that medical care is 18% of gdp things need to change and will with or without government action.