Cancer care sparks latest feud between UPMC, Highmark
By Luis Fábregas
Published: Saturday, August 25, 2012, 10:42 p.m.
Updated: Tuesday, September 18, 2012
UPMC oncologists are questioning Highmark Inc.'s denial of radiation treatment for dozens of cancer patients, but the insurer contends the region's largest health care system is overusing a specialized technique as a way to make money.
The feud between the region's two health care titans developed when Highmark, the state's largest insurer, noticed an abnormal number of claims from UPMC for intensity-modulated radiation therapy, or IMRT.
Doctors nationwide embraced IMRT during the past decade because the intensity of radiation beams can be adjusted to spare healthy tissue and adjoining organs. The technology comes with a steep price tag — sometimes more than double the cost of conventional radiation.
“Doctors are generally incentivized to do more because they get paid more to do more,” said Dr. Benjamin Smith, assistant professor of radiation oncology at MD Anderson Cancer Center in Houston. “IMRT is one of those instances where, if you can do it, there are financial incentives to prompt you to use it.”
From January through May, Highmark denied IMRT claims to 134 patients with breast, prostate and head and neck cancers. After appeals, 72 of those patients eventually received the treatment. UPMC doctors say the insurer provided no substantial reasons for its denials.
“This is just wrong,” said Dr. Dwight Heron, vice chairman of radiation oncology at UPMC Shadyside, a partner of the renowned Hillman Cancer Center. “If you're asking us to deny care for cancer patients, tell me what the criteria is. If we're doing something wrong, tell me.”
Highmark officials said they are troubled by a dramatic variation in IMRT use in the region. For example, some hospitals use that therapy in more than 70 percent of breast cancer patients, while others use it in about 2 percent of patients. The insurer would not specify providers.
Dr. Donald Fischer, Highmark's chief medical officer, said UPMC benefits financially from high usage of IMRT, which he said might not be clinically beneficial to everyone.
“Anyone who is doing this test is making more money from this test,” Fischer said.
Cost estimates vary. A study by Smith of the MD Anderson Cancer Center last year reported that the average cost of radiation for breast cancer patients in the first year was $7,179. It jumped to $15,230 with IMRT. The study, published in the Journal of the National Cancer Institute, found that Medicare billing for IMRT increased more than tenfold from 2001 through 2005.
“Our culture is very enamored with the latest and greatest and most complex technology,” said Smith, who generally treats women with breast cancer. He has used IMRT in only three of about 350 cases in the past 21⁄2 years.
“It's not uncommon for IMRT to be chosen, but a simpler technique would be just as good,” he said.
Authors of another study published in the April issue of Health Affairs raised concerns. The study of about 37,000 men diagnosed with prostate cancer found the use of IMRT more than tripled to 83 percent in 2007 from 24 percent in 2001. The study said IMRT can cost $15,000 to $20,000 more than standard radiation treatment.
IMRT is more expensive because of equipment cost and preparation time to administer the treatment, experts said.
The American Society for Radiation Oncology supports IMRT treatment because it can protect some patients from potentially harmful side effects that come with traditional radiation. The society, with more than 10,000 members, opposes a proposed rule by the Centers for Medicare & Medicaid Services that would cut by $300 million payments for some radiation oncology services.
The cuts, announced on July 6, would take effect on Jan. 1 and reduce reimbursement for IMRT by about 40 percent. Private insurers regularly follow Medicare's payment policies.
More targeted beams
Heron of UPMC said initial savings achieved by using traditional radiation instead of IMRT could disappear if patients suffer side effects.
A breast cancer patient, for example, could be harmed by other forms of radiation, depending on the tumor's location and breast size, he said. Some radiation can cause pain, scarring on the lungs or injury to the heart.
Breast cancer patients who received chemotherapy benefit from IMRT because some chemotherapy drugs can damage the heart, Heron said. The more targeted beams of IMRT could help avoid additional injury, he said.
In the end, the cost of treating side effects adds up, especially if patients require hospitalization or cannot return to work, Heron said.
“They look at the cost as the primary driver, and that's the wrong approach,” Heron said. “Some of the treatments they want us to do are treatments we were doing six to eight years ago.”
UPMC doctors said Highmark is putting patients such as Michelle Amodei through unnecessary stress. Amodei, 44, diagnosed last year with a type of breast cancer called ductal carcinoma in situ, underwent a bilateral mastectomy, followed by breast reconstruction surgery. Afterward, doctors recommended IMRT because traditional radiation could be more harmful and cause cosmetic problems.
Highmark refused to pay for the IMRT. Amodei would not take no for an answer and, after several appeals, received her treatment. The experience caused an enormous amount of stress for the mother of three.
“We trust our doctors, so for our insurance to tell us, ‘Well, your doctor might think one way, but we think differently,' it's very hard to understand,” said Amodei of Grove City, an education professor at Slippery Rock University. “It's all about the money.”
Fischer said Highmark's primary concern is patient safety. In January, it hired CareCore National to examine radiation oncology treatment requests.
On its website, the company says it provides clients with “the highest reduction in unnecessary utilization, significant financial outcomes and improved quality.” When it comes to radiology benefits, CareCore, with offices in South Carolina and Colorado, says it has “the industry's most extensive and current set of evidence-based criteria.”
Officials at CareCore did not return calls or emails for comment.
“We have concrete evidence that there is broad variation and that some people were getting radiation unnecessarily,” Fischer said.
A Highmark spokesman later clarified that Fischer was referring to cases of unnecessary treatment elsewhere and not in Western Pennsylvania.
Fischer characterized some denials as “repackaging” treatments that could be given over fewer visits.
“Why make the patient come for treatment 20 times when they could have it done in five visits?” he asked.
Dr. Sushil Beriwal, a radiation oncologist at Magee-Womens Hospital of UPMC, said his staff must fill out extra paperwork for every patient prescribed IMRT.
“It adds to the patient's anxiety and apprehension,” he said. “The approval process can delay the care.”
UPMC doctors said they are frustrated by what they say is CareCore's refusal to outline reasons for denials. Heron said he recently spent an hour and a half talking with CareCore officials.
“I don't think we made progress,” he said.
Highmark spokesman Aaron Billger said all of the insurer's criteria are publicly available on its website.
Smith said doctors will continue to face challenges because there is no framework in medicine instructing physicians to consider cost when treating patients.
“You're trying to think about what's best for my patient and what do they want,” Smith said.
Luis Fabregas is a staff writer for Trib Total Media. He can be reached at 412-320-7998 or firstname.lastname@example.org.
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