Wednesday, May 27, 2015

Dear CMS, price matters

Your government at work.  Here's the pertinent quote from Melinda Beck's Wall Street Journal article on proton beam therapy:

But some insurers are balking at paying premium rates for proton therapy for such common cancers without more evidence that it does improve patient outcomes—ideally from randomized controlled trials. Several are now under way, but it will be years before results are clear.   

Most Medicare regions cover proton therapy for prostate—at about $1,100 per treatment session, compared with $600 for IMRT. But several major insurers stopped after a 2012 study found it has no added long-term benefit. Men with prostate cancer had made up 70% of patients at some proton centers; now they are less than half the facilities’ customers nationwide. 

It's time for the government to have the spine and judgment to change its pricing for this therapy.

As I have noted earlier, where are the Triple Aim advocates on this point?

1 comment:

Barry Carol said...

Unfortunately, CMS has a long history of setting reimbursement rates to approximately cover provider costs, including capital costs. I don’t know what it will take to get them to move toward paying for value for discrete procedures like proton beam therapy. I applaud Aetna and United Healthcare for their decision to stop paying for proton beam therapy for prostate cancer patients without waiting for CMS to do it first in order to provide political cover.

There is a separate article in today’s WSJ about Express Scripts proposing to pay drug manufacturers based on how well certain cancer drugs actually work. That’s another good example of paying for value. I hope we see this approach take hold a lot more broadly over time.