New proposal to curb Medicare spending uses prostate cancer as model

Two doctors, formerly with CMS, make a case for comparative effectiveness. Their paper is sure to spark heated debate within the prostate cancer community--as always, never a dull moment in prostate cancer.

A new article by Drs. Steven D. Pearson and Peter B. Bach titled “How Medicare Could Use Comparative Effectiveness Research in Deciding on New Coverage and Reimbursement” looks at treatment options for prostate cancer.

In the article, Pearson and Bach lay out a proposal that would give expensive new treatments 3 years to prove that they were more efficacious than less expensive counterparts, or their reimbursement rates would be cut to that of those less expensive treatments.

Historically, Medicare doesn’t reimburse for good outcomes, the agency pays for any treatment that it deems reasonable and effective. The choice of therapy is made between physician and patient. As in the case of prostate cancer, there are a variety of treatment options; data on which treatment is superior are not fully established.

Moreover, issues of treatment related side-effects; primarily impotence and incontinence, are generally sited by men as primary factors in their decisions. Again, data on side-effect profiles are not conclusive.

Options for treating prostate cancer include three forms of radiation. Three-dimensional radiation, costs Medicare about $10,000; I.M.R.T. costs about $42,000 and proton beam radiotherapy costs roughly $50,000.

Another issue hotly debated is the contention that treatment centers for prostate cancer are in effect, profit centers, driving up revenue for urologists. That sentiment is spelled out in a New York Times article by Stephanie Saul:

Among several widely used treatments for prostate cancer, one stands out for its profit potential. The approach, a radiation therapy known as I.M.R.T., can mean reimbursement of $47,000 or more a patient.

That is many times the fees that urologists make on other accepted treatments for the disease, which include surgery and radioactive seed implants. And it may help explain why urologists have started buying multimillion-dollar I.M.R.T. equipment and software, and why many more are investigating it as a way to increase their incomes.

But the overriding question for the cancer community is whether comparative effectiveness is driven primarily as a cost reduction mechanism or by and effort to achieve best practices.

Testifying at a Senate hearing Dr. Peterson said:
In conclusion, I believe that comparative effectiveness research and efforts to implement “best practices” are mutually supporting and complementary efforts. Using evidence to change practice is often challenging, but it is exactly this challenge that we must address moving forward; and using evidence more effectively is exactly the right way for us to achieve a high quality, affordable health care. Thank you.”

Comparative effectiveness is not going away. It  is an important issue, one that will eventually affect the treatment options offered to cancer patients across the country.