ASK HARD QUESTIONS. MAKE GOOD CHOICES. by Robert Seifert

An article in Wednesday’s New York Times describes a “new nuclear arms race” in medicine – the proliferation of nuclear particle accelerators for use in radiation therapy for cancer. The article encapsulates a significant challenge we face, in Massachusetts and across the country, in trying to bring the growth of health care costs and spending under control without cutting ourselves off from the medical benefits of new technology.

Proton beams created by particle accelerators are more precise than the x-rays typically used in radiation therapy, according to the article, and are therefore particularly valuable in treating tumors in the eye, brain, neck and spine, and for treating children. Ideally, the health care system would supply enough of this advanced technology to treat all cases where there is a clinical advantage in doing so, but not much more. Unfortunately, there are few mechanisms for ensuring optimal supply. The Times article states that much of the use of the five proton centers operating today is for treating prostate cancer, a use which, according to two radiation oncologists interviewed, is no more effective yet much more expensive than the latest X-ray technology.

The article reports that a dozen more proton therapy centers are being developed, spurred by market forces that include profit-seeking firms and local and state governments promoting medical tourism. Proton centers can cost more than $100 million to build, so it is reasonable to think that, once built, there is tremendous pressure to keep them busy. Medicare pays about $50,000 for proton treatment of prostate cancer, about twice what it pays for radiation therapy using X-rays. In short, proton therapy is, according to a companion article, a potentially very lucrative service. But someone’s lucre is someone else’s cost.

I am singularly unqualified to comment on the medical benefits of proton beam therapy and happily accept the view of experts who see it as a great step forward in the treatment of some cancers. As an informed layperson with a responsibility to consider how to slow the growth of health care spending in Massachusetts, however, I have questions and concerns. My main concern is about the overuse of a “supply-sensitive service,” as described by Dr. Elliot Fisher, to whom I referred in a previous post. To guard against costly oversupply, we must ask: in what cases is this treatment effective, relative to alternatives? What is the cost of the incremental effectiveness? How much investment in new proton therapy capacity is clinically worthwhile? When we have this evidence, how can it best be applied to guide the system toward optimal supply?

The example of the proton accelerators is but one of many that cry out for reasoned analysis in order to allocate resources in the public interest. This is especially critical now in Massachusetts, where the future affordability of coverage expansions depends on the adoption of bold strategies – in the public and private sectors – to bring spending increases under control. The Commonwealth Fund’s Commission on a High Performance Health System recommends as one of its 15 “Options for Achieving Savings and Improving Value in U.S. Health Spending” the creation of a “Center for Medical Effectiveness and Health Care Decision-Making,” which seems to me one logical approach.

Whatever the approach, though, as citizens and representatives of institutions with a stake in the continued availability and affordability of our health care, we must ask these questions and begin to answer them with more rigor than ever before. And we must commit to acting on the answers.

Robert Seifert is a Senior Associate in the Center for Health Law and Economics at UMass Medical School’s Commonwealth Medicine, and is a member of the Massachusetts Health Care Quality and Cost Council.