Payer-provider collaborations seek to answer proton beam therapy questions

Reference pricing, effectiveness research go hand in hand

When it comes to high-priced clinical treatments with murky evidence of effectiveness, proton beam therapy takes the cake. As hospitals rake in the profits, payers are left holding bills for a treatment that can cost $30,000 more than other types of radiation therapies

It costs as much as $200 million to build a proton beam therapy program. And that high price is reflected in reimbursement claims. A 2012 study pegged the cost for a 60-year-old man to receive proton therapy at more than $63,500

Meanwhile, payers aren't convinced the costly treatment even works on some types of cancer. Last year, Blue Cross of California, for example, stopped covering proton treatment for prostate cancer. The decision was based on a lack of scientific evidence that the radiation treatment for prostate and other cancers is better than older, less expensive methodsFierceHealthPayer previously reported.

That's led to calls for payers and providers to collaboarate on effectiveness research, notes an article in Healthcare Payer News.

One example: The proton center at the University of Pennsylvania Health System (Penn Medicine) established a reference pricing agreement with Independence Blue Cross, which reimburses the health system at the same rate for radiation therapy, according to the article. In the meantime, Penn is tracking patient outcomes to gauge long-term costs and benefits. 

New Jersey's largest insurer, Horizon Blue Cross Blue Shield, also covers proton treatment for members with prostate cancer who enroll in a randomized trial at Penn Medicine, according to Healthcare Payer News.

"Reference pricing with evidence development is attractive for proton therapy," Penn Medicine oncologists Justin Bekelman, M.D., and Stephen Hahn, M.D., wrote in April in the Journal of Clinical Oncology. "We can conduct the necessary research only if payers pay for proton therapy and its photon-based alternatives. Reference pricing preserves access to proton therapy and reduces financial barriers to evidence development."

For more:
- here's the Healthcare Payer New story
- here's the Journal of Clinical Oncology report

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