How Mayo drives up the cost of health care

  • Article by: EZEKIEL J. EMANUEL and STEVEN D. PEARSON , New York Times Syndicate
  • Updated: January 3, 2012 - 11:43 PM
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If you want to know what is wrong with American health care today, exhibit A might be the two new proton beam treatment facilities the Mayo Clinic has begun building, one in Minnesota, the other in Arizona, at a cost of more than $180 million dollars each.

They are part of a medical arms race for proton beam machines, which could cost taxpayers billions of dollars for a treatment that, in many cases, appears to be no better than cheaper alternatives.

Proton beam therapy is a kind of radiation used to treat cancers. The particles are made of atomic nuclei rather than the usual X-rays, and theoretically can be focused more precisely on cancerous tissue, minimizing the danger to healthy tissue surrounding it.

But the machines are tremendously expensive, requiring a particle accelerator encased in a football-field-size building with concrete walls.

As a result, Medicare will pay around $50,000 for proton beam therapy for a patient with prostate cancer, roughly twice as much as it would if the patient received another type of radiation.

The higher price would be worth it if proton beam therapy cured more people or significantly reduced side effects. But there is no evidence showing that this is true, except for a handful of rare pediatric cancers, like brain and spinal cord cancer.

For children, the treatment does a better job of limiting damage to normal brain cells and reducing the risk of cognitive impairment and hearing loss.

But — fortunately — fewer than 3,500 American children get these cancers each year. It is impossible to keep all nine existing proton beam centers in full use, much less the approximately 20 others in planning or construction, with so few patients.

To generate sufficient revenue, proton beam facilities need to treat patients with other types of cancer. Consequently, they have been promoted for patients with lung, esophageal, breast, head and neck cancers.

But the biggest target by far has been prostate cancer, diagnosed in nearly a quarter of a million men each year.

There is no convincing evidence that proton beam therapy is as good as — much less better than — cheaper types of radiation for any one of these cancers. There has not been a single randomized trial, only small, short-term studies.

Such trials cannot evaluate the therapy's long-term outcomes, nor resolve the concerns that some experts have raised regarding a potentially increased risk of hip fractures, bowel problems or other delayed effects associated with the therapy's treatment for prostate cancer.

So why is the venerable Mayo Clinic building two proton beam facilities? Because it's competing against Massachusetts General Hospital, M.D. Anderson in Texas, the University of Pennsylvania, Loma Linda in California — all of which have one.

With Medicare reimbursement so generous, and patients and doctors eager for the latest technology, building new machines is sane, profitable business for hospitals like Mayo.

But it is crazy medicine and unsustainable public policy.

One solution is for Medicare to simply refuse to pay for proton beam treatment except for diseases where there is valid evidence that it is clinically superior, as many private insurers do.

This would certainly help keep costs down, and it would also encourage manufacturers and researchers to actually conduct studies comparing proton beam therapy to other treatments.

However, it is often difficult to begin clinical trials without some reimbursement for the treatment that is being studied. So a second option is "coverage with evidence development."

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