Everyone wants healthcare costs to go down. And everyone wants the development of innovative treatments to improve outcomes, which is a costly endeavor. Are these two concepts diametrically opposed, or can they be brought into alignment?
We have seen time and again in healthcare that providing the right care, versus simply providing the most care, can both improve outcomes and reduce costs by eliminating expensive, redundant tests, or by avoiding costly therapies that have proven no better than current approaches. However, it cannot be denied that technological innovation such as modern imaging and high-precision treatment-delivery techniques, such as robotic surgery, have led to improved outcomes for some patients.
This begs two big questions: How is a patient, a doctor, an insurance company or a society to decide what gets covered and what’s worth investing in? And how do we address the innovation/cost conundrum?
The field of radiation oncology is one area where this dynamic tension between innovation and cost arises. The goal of radiation is to kill the tumor and spare surrounding healthy tissue. In fact, there is no benefit and only potential harm from radiation exposure to healthy tissue. Proton therapy is one such advance that allows physicians to concentrate the radiation dose delivered to the tumor and minimize radiation exposure to surrounding tissue, which is particularly important for younger patients to reduce future side effects and secondary cancers.
If proton therapy reduces future side effects, but hasn’t yet demonstrated an improvement in short-term toxicity or survival, is that enough for insurance companies to cover it at an additional cost? And who will pay for the long-term clinical trials or prospective data-gathering necessary to prove the theory that minimizing radiation exposure to healthy tissues yields a meaningful improvement in clinical outcome?
While we have 30 years of evidence that this is true for pediatric cancers, we don’t have the same clinical trials for adults, so for some, credible data is still unavailable.
We all want innovation and new treatments, especially in cancer care. However, we also must be mindful of the very real cost-containment needs when it comes to healthcare. That’s why questions remain about how much innovation is worthwhile, how it will be paid for and what outcome endpoints are meaningful.
This brings us to the challenge of funding the clinical trials that are required to determine the value of new treatments and technologies, such as protons, in healthcare. For drugs, the pharmaceutical company has to pay for the trial if it wants its drug to come to market. This is not the case with devices and technologies. The federal government provides some clinical trial funding, but this funding is predicated on insurers covering the cost of the treatment itself. Unfortunately, to date, many insurers have been unwilling to pay for treatments until after the clinical trial data demonstrates superiority. We are therefore in a classic “catch 22” of the need for clinical evidence in order to justify coverage, while coverage is required in order to generate clinical evidence.
At Seattle Cancer Care Alliance Proton Therapy Center, we have taken measures to determine the long-term efficacy of our innovative treatment. We enroll most of our patients in clinical trials or data registries that are funded, in part, by our center, because we feel that this is required for responsible stewardship of this new technology. Additionally, we feel that we owe it to our patients to try to identify those who will benefit the most from proton beam radiotherapy, and conversely, those who will not.
But what’s really needed is the entire healthcare system working together with an alignment of interests, so that patients can access the best and most innovative modalities, doctors can practice without worrying about whether the patient can afford it and insurance companies can be encouraged to keep you healthy for the long term. That’s a big prescription, but it will result in a stronger healthcare system and better tomorrows for more patients.
Ramesh Rengan, M.D., Ph.D., is the medical director at Seattle Cancer Care Alliance Proton Therapy Center.