• JAMA Forum: Covering the proton beam

    As noted last week, Blue Shield of California did something unusual in reversing course and deciding not to cover proton beam therapy for prostate cancer. Will its decision stick or be reversed, the fate of many prior attempts by insurers to control utilization of therapies not clearly superior to cheaper alternatives? I discuss in my new post on the JAMA Forum. Go read it!

    @afrakt

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    • I probably have significant agreement with you in that I have no problem with any insurer that decides not to pay or only pay for a portion of any medical procedure providing the insurer makes it perfectly clear to the common man that that procedure is not covered before the policy is written and in all the advertisements and solicitations. In fact it would be a good thing for competition if there was a so called standard acceptable policy so that each purchaser could more easily see the additions and deletions to a policy. I would also advocate that if there was a lack of clarity to the insurance contract that the burden of proof be placed upon the insurer. This would stimulate the insurer to avoid ways of causing misunderstandings. We may be lumping too many things into the standard insurance contract and need to add additional layers like we do with car and homeowner insurance.

      I do object to BC/BS’s scientific conclusions which as of yet have not been proven one way or the other. There is a good likelihood that substantial benefit will be found in the use of proton beam therapy even if the extension of life is insignificant especially in younger patients. Its mechanism of action tells us this should be so. We have seen history prove that type of logic correct in many high tech areas of medicine. Not only that, but if the price were the same or less we might have seen insurers more than willing to pay for this procedure. Thus if an insurer uses this type of scientific conclusion to push their product or justify exclusion of a procedure it should be held liable should one be able to prove their scientific statement to be incorrect. I don’t think insurers need to justify how they insure as long as they are transparent, accurate and do not attempt to deceive the common man.

      Should Medicare cover it? That is a different story for the Medicare senior is older and I bet will not reap the same advantages as the younger male. Secondly it is covered by pooled funds that are involuntarily paid. I do think Medicare should at least pay a comparable portion of the cost to the acceptable procedures seen today with the patient paying the rest out of pocket. In this fashion the patient makes the final decision not the doctor or the insurer so the patient bears the responsibility of cost and choice (malpractice). The privately insured patient would be bearing the same responsibility as long as he was told the procedure wasn’t a covered service.

      The bone marrow transplant case would never have had to occur if the patient knew in advance that this procedure was not going to be covered.

      • Your arguments are why I think we should ditch insurance altogether and move to single payer. When I evaluate an insurance policy, should I have to research the cost of a prosthetic leg, so that I know if my policy will cover me in the extremely unlikely event I need one? Or the bone marrow transplant?

        The American system is that the doctor or clinic gets approval for the procedure. I’ve sometimes followed up with my insurance, but the help line rarely has anyone who makes an important decision, so I don’t get very far. I usually get something along the lines of “if the doctor . . . then . . .” which is not very useful for answering the question of “based on the documents you have, will this be covered?”

        So, I’ve tried, but getting answers is hard. And I usually spend a few hours on the phone to providers and the insurance company getting the bills straightened out.

    • I do like your idea of the standard policy +/- additions or deletions by individual insurance plans. But I could see this as getting very complicated and long winded. And how am I the consumer/patient going to know what to include/exclude and at what relative cost vs risk for each change?

      As a physician I can barely place a dollar value on a BM transplant vs my age and risk factors. Is it worth another $1, 10 or 100/month in premiums?

      And then I have to move onto exclusion number 2….

      • Hoonose, as a consumer you can choose the standard plan which is probably almost the same as what the government would offer if politics were not involved. The additions and subtractions would generally be to attract certain other groups that might value certain things differently.

        Since you are a physician, how did you know how to evaluate the location of your office or the choice of your specialty? Would it have been better if a third party mandated what specialty you should practice and where? Of course not, so even though you could barely place a dollar value on those questions you made a choice likely better than the choice that would have been made for you.

        Don’t you have to make similar decisions when buying a car? Lease, loan or purchase? A house? How about insurance for your house or car? Uninsured motorist? Replacement value or actual value? Flood insurance? Hurricane insurance? Disability insurance to pay for these loans? Office insurance?

        Let me add one last thing. Insurance companies exist solely for the purpose of selling insurance and spreading the risk. I can virtually guarantee you that they won’t offer the type of list you are thinking of. That is too difficult to sell so they will offer like and different things in packages to spread the risk even further so premiums can fall.

        I think this answers SAO’s concerns as well. However, it sounds as if SAO prefers someone else to make decisions for him.

    • With insurance companies, their business is information and risk management, but THEIR reward has to be very high on their list of purpose. So they already know most all the stuff I and any consumer/patient would sure like to know before constructing and signing on for a custom plan. i.e. the old asymmetrical information paradigm for profit seeking.

      Buying insurance for car or house, and even locating my office is generally much less abstract and potentially complicated than for HC coverage. Far far fewer unknowns, and serious failure limits easily described. Thus the need for regulation (politics) and relatively standard (more politics) plans with HC coverage. Shoot, with the car there’s maybe a 1/2 dozen categories with variations of deductibles. And as a typical consumer I essentially already know the significant possibilities and basic risks with my car and home. With healthcare there are millions of potentials and risks, and even I as a physician would have a hard time weighing the multitudes. I’m not particularly looking forward to Oct. 1 when I and millions of individuals start on our quest for a new plan. Hopefully my trek will be short.

      • Hoonose, where entrance into the insurance company involves a level playing field and is not hindered by political interference there are plenty of companies waiting in the wings to compete if the profit margins exist or if innovation can improve the profit margins. Thus, that an insurer knows the “stuff” does not mean that the insurer can hold his share in the market place if another insurer competes more favorably so I am not sure what your problem is. Without question, buying insurance means the selling of one’s risk and thus one always loses a dollar amount in the process. It is up to you to decide if the dollars are worth it or not to you or if you can better spend those dollars in a different fashion.

        “Buying insurance for car or house, and even locating my office is generally much less abstract and potentially complicated than for HC coverage. ”

        Figuring out a location for your practice is less complicated? Absolutely not. That decision involves a life style and the lives of others such as wives and children. It also involves picking the right demographics for your specialty and a knowledge of the competition, hospital availability and more. Moreover one has to consider their own personalities as to how long a drive they are willing to take to and from both from their home and their offices. One has to integrate those things among others with the cost of space in various areas, how much space, what type etc. I can’t believe you even made that statement.

        When buying health insurance there are a very limited variety that would exist for practical reasons multiplied by the number of insurers where the differences would not be all that great. Standard insurance plus or minus a few different options. You are not buying each type of medical care separately for the administrative costs to the insurer would be astronomical and not profitable. They want to sell more, not less and they want their own risks to be well distributed so it is unlikely that they would provide policies just for bone marrow transplants to breast cancer patients. That would cost too much to the consumer as the risk for the insurer is so high due to the unknown without the ability to spread the risk.

        • “I probably have significant agreement with you in that I have no problem with any insurer that decides not to pay or only pay for a portion of any medical procedure providing the insurer makes it perfectly clear to the common man that that procedure is not covered before the policy is written and in all the advertisements and solicitations.”

          When I read that I envisioned an insurance company writing loads of small print. And what that small print would do, would be to legally remove them from all sorts of responsibility with a multitude of things that the consumers may not be aware of, as far as future risks and possibilities. The insurance company generally knows more about these things than the insured of course. So while each discreet and multiple insurance reduction is written, the consumer might be caught blind sided down the road.
          In fact this very thing just about caught my wife last year when she broke her pelvis skiing. Had we not left the ski area hospital earlier than what would have been considered sensible, she would have missed her oncology appt. That appt. was set up for that specific day because of some arcane rule in our medical plan that requires her to see the doc by or every 90 days, otherwise we have to redo co pays /and/or deductibles, or some such nonsense. Specifics I forget, but there would be a substantial financial hit with our $5K and 20% co pay. Why 90 days, no one could answer.
          I think we agreed on why we need a standard. I just wouldn’t want to see a standard, then 100 pages of disqualifications. Maybe we should agree that degree of complexity is about as likely as getting politics out of the HC insurance business!
          And my opinion on practice location was heavily biased by my own experience 33 years ago. Where I still practice today.

          • Hoonose, I appreciate your concerns, but insurance companies want to sell insurance policies. With adequate competition the things that cause you concern mostly disappear. Though it is OK for government to act as an impartial regulator to keep the playing field level and aid those that might fall through the cracks the mandates and oppressive intervention by government cause a lack of competition and reduced innovation. That leads to higher prices, less access and lower quality. The ACA in particular favors large established insurers that over the years have learned to be quite miserable.

            Unlike you I have been purchasing health insurance all my life without any great difficulty except I can’t find insurance policies that meet my needs or the needs of millions of others because of government regulation. Finding a place to practice medicine or to start a business is something I find far more difficult. I too have significant experience in that area.

            Starting a medical practice 33 years ago was almost instant success without failure. Thus one could believe it is easy because one could throw a dart at a map and likely be successful, however, there are far more things in life that should be considered so I think you underrate the difficulty involved.

            Enjoy your practice. Medicine is a wonderful choice even though one has to continuously fight the bureaucracy and fight for one’s patient.

    • In 1980 we moved to AZ from Chicago for the weather and fishing. I did ER work around the state looking for potentials. Within a year I came to fish Lake Havasu 3 days after their local internist/cardiologist died. I gave the widow $50K and that has been that! So I did have a plan, My daughter’s just a 4th year and will certainly end up staying n the west near skiing. Probably a larger community, critical care, teaching or other such nonsense!

      “Unlike you I have been purchasing health insurance all my life without any great difficulty ”

      LOL, I have had the same high deductible family HC plan through a good friend at St. Farm for +/- 30 years! Being a doc I can of course bury a whole lot of the deductibles and co pays.

      • Hoonose, we have somewhat parallel lives including the use of high deductible insurance. It seems your plan worked out just right. My kids live in different directions but are only a little more than 30 minutes away by car. One is also a physician. It seems you took a year to figure out where to live and the office you wished to buy so you are indeed a contemplative fellow. With such ability I am certain that you can see how private insurance in the market place need not look like pages of fine print that neither of us desire.

        Back on the subject, my concern is the forcing of insurers to cover things like bone marrow transplants for breast cancer and a whole host of other treatments that exist or will exist in the future. However, the insurer has to be able to establish a premium for the risk they take while at the same time keeping the premium reasonable. Therefore in my mind the best thing for the consumer would be to be able to compare a policy to a standard policy which reduces the variables needed for comparison and to place the legal burden of proof that the patient was adequately informed on the insurer. Those wanting the additional coverage options could pay the additional premium.

        The way I see it is to manage risk in such a way that all the desirable things can be accomplished which is best done in the market place. On the other hand when a political agency has control and the people decide that bone marrow transplants are the way to go for treating athletes foot we don’t want our politicians or those they control to suddenly approve the treatment because of political pressure. That is what has happened all over the nation with many states creating rules, regulations and mandates that make little sense because the politicians were bending to the pressures of political groups.