Will BCBS of California’s Proton Beam Therapy Decision Stick?

Austin Frakt with news of Blue Cross Blue Shied 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 with 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.

About Don Taylor
Professor of Public Policy at Duke University (with appointments in Business, Nursing, Community and Family Medicine, and the Duke Clinical Research Institute). I am one of the founding faculty of the Margolis Center for Health Policy, and currently serve as Chair of Duke's University Priorities Committee (UPC). My research focuses on improving care for persons who are dying, and I am co-PI of a CMMI award in Community Based Palliative Care. I teach both undergrads and grad students at Duke. On twitter @donaldhtaylorjr

5 Responses to Will BCBS of California’s Proton Beam Therapy Decision Stick?

  1. Pingback: JAMA Forum: Pushback Against Covering Proton Beam Therapy « news@JAMA

  2. Pingback: Proton Beam Therapy - Cancer Fact or Fiction

  3. Tony Tamer says:

    can my daughter get medicaid for proton therapy. She’s a nc resident. She has an astrocytoma on her back- she had it before- all drs. at Baptist Oncology ctr. agreed it was the best thing for her . That was 4 years ago – it worked then. In the midst of treatment they found that NC was about the only medicaid that wouldn’t pay- so they gave it to us free. The tumor is back and they want to get paid this time. She’s 29 – this is not prostate cancer which could be treated otherwise. She’s doing intravenous chemo now- the chemo dr. said if this doesn’t work she may need the proton radiation. Please let me know soon if NC medicaid will cover this

    • Don Taylor says:

      Hi. I am sorry about your daughter’s illness. I don’t know if Medicaid will cover that or not. If you email me I will try and link you with someone who will better know the answer.

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