WASHINGTON - "Harder on Cancer, easier on you," proclaims the
banner on
the University of Florida Proton Therapy Institute website, a pitch
to men
scouring the Internet for advice on prostate cancer. This type of
radiation treatment targets tumors more precisely than X-rays, the
site
claims, reducing side effects.
But a study found that though proton beam therapy is at least
five times as
expensive as other forms of radiation, only a few small, brief
studies have
examined its effectiveness. There was no evidence that it was
better at
curing prostate cancer, and insufficient evidence that it was
superior at
preventing side effects.
With US healthcare spending on track to nearly double in the
next 10 years
to $4.4 trillion, the federal government is building a system to
study the
relative benefits of different treatments for diseases.
The economic stimulus package contains $1.1 billion for
"comparative
effectiveness research," a down payment on a project that could
ultimately
cost hundreds of billions of dollars. The legislation also creates
a
council in the Department of Health and Human Services to
coordinate the
work.
But how this research will be used is politically contentious -
and is
likely to grow more so as new studies are conducted, and policy
makers and
insurers decide whether care that is not deemed most effective
should be
covered by Medicare or private insurance. The program has become a
talking
point for Republican critics of the stimulus plan, who argue that
it is a
step toward rationing healthcare.
Cutting costs will probably be one of the major topics at a
White House
summit on healthcare that President Obama plans on Thursday.
Drug and medical device manufacturers, as well as some patient
advocacy
groups, say they support such research so doctors and patients can
make
better decisions about treatment. But they say the research should
not
determine whether procedures or drugs will be paid for by Medicare
or
private insurers. They lobbied vigorously - and successfully - to
keep out
language suggesting that it could be used to cut the cost of
healthcare.
"Medicare denials of coverage could have a devastating effect
in terms of
one-size-fits-all determinations that could make it very, very
difficult
for patients to find alternatives," said Rick Smith, vice
president of
policy for the Pharmaceutical Research and Manufacturers of
America.
Dennis Smith, a senior research fellow in health economics for
the
conservative Heritage Foundation, said restricting treatment
options based
on a government-run board's interpretations of research could
result in a
kind of "cookbook medicine" that ignores individual differences
that make
medicine "an art as well as a science."
"Healthcare is full of stories of doctors trying to do
something better
for their patients because what they had wasn't working," he said.
"My
concern is that comparative effectiveness, in the hands of
government,
starts stifling that kind of innovation."
But unless there are financial incentives to channel patients
toward the
most effective treatments, it is unlikely that the research alone
will cut
health costs significantly, Douglas W. Elmendorf, director of the
Congressional Budget Office, testified last week before the Senate
Finance
Committee.
And proponents of comparative cost effectiveness, including
health
insurance companies and large businesses, say the United States
cannot
afford to ignore the potential for savings.
The nation already spends more on healthcare than every other
industrialized country, and health expenses will account for
one-fifth of
the economy a decade from now, more than twice the proportion in
1980,
according to government estimates.
Rising health costs make it harder for US businesses to compete
globally,
crowd out other government priorities, and consume workers' wages.
A number
of other Western countries, including the United Kingdom, Germany,
and
Australia, have created comparative effectiveness panels.
Massachusetts General Hospital has developed a rating system for
the
clinical and cost effectiveness of various medical treatments.
Dr. Steven Pearson, president of the Institute for Clinical and
Economic
Review at the hospital, said the question "is whether we as a
society are
going to get serious about judging whether something that is a
teeny bit
better but vastly more expensive is a wise way to go."
The institute, which conducted the review of the scientific
literature on
proton beam therapy for prostate cancer, found little evidence
favoring
proton beam over other kinds of radiation, even though payers
typically
paid $50,000 to $80,000 for proton beam therapy, compared with
$10,000 for
the implantation of radioactive seeds, or $20,000 for radiation
therapy
using an X-ray technology.
"Our system is not set up to look at whether the evidence
suggests that
paying so much more for proton beam therapy makes sense for
anybody,"
Pearson said. Instead, hospitals and clinics have the reverse
incentive -
to channel patients to the most expensive treatments, he said.
Karen Ignagni, president of America's Health Insurance Plans, an
association of health insurers, said one way insurers could take
the
results of the research into account may be to offer a tiered
system that
requires patients to pay more for treatments that are seen as less
cost-effective.
The most cost-effective drugs may not work for everyone, though,
said Joff
Masukawa, senior director of government relations and public policy
for
Shire Ltd., which makes specialty biopharmaceuticals. Assigning a
cost-effectiveness grade to a drug or therapy could eventually
discourage
drug companies from pursuing innovative drugs that treat rare
diseases or
help relatively few patients, he said.
Proponents of comparative effectiveness research acknowledge
that studying
the relative value of different therapies does not always yield
straightforward answers.
Thomas Lee, network president of Partners Community HealthCare
Inc. and an
associate editor of the New England Journal of Medicine, points to
a study
in the journal's current issue that compared the effectiveness of
bypass
surgery and angioplasty for patients with advanced coronary
disease.
The researchers found that the rate of complications was lower
for bypass
surgery, but that was not the end of the story. Most of the
complications
with angioplasties were experienced by patients who had returned
for repeat
procedures; meanwhile, the rate of stroke for bypass patients is
much
higher.
"The answers you get may or may not be clean and simple," Lee
said, "but
at least you will get reliable answers to important questions - as
good as
we can get - and patients and insurance companies will be able to
make
better decisions."
The money included in the stimulus package for comparative
effectiveness
research may be just the beginning. Max Baucus, chairman of the
Senate
Finance Committee, filed legislation last year that would create a
nonprofit corporation to oversee a vast research operation,
underwritten by
a small surcharge on private health insurance.
Baucus, who will play a leading role in the healthcare debate in
the coming
months, argued forcefully for robust research in a policy paper he
issued
late last year that was intended to lay the groundwork for a
sweeping
overhaul of the healthcare system this year.
Researchers are already preparing to apply for research grants
funded by
the stimulus money. Anthony Zietman, a radiation oncologist at
Massachusetts General Hospital, is part of a team that wants to
compare two
or three different kinds of radiation therapies for prostate
cancer,
including proton beam. Such work, he said, is urgently needed.
"We've got to help patients sort their way through this morass
of
options," he said. "If these new technologies are better - prove
it. If
it's worth the cost, we should pay the cost. If it's not worth it,
we
should dispense with them or not cover them."
Lisa Wangsness can be reached at lwangsness@globe.com.
c.2009 The Boston Globe