One Harvard researcher called proton beam units unaffordable “Death Stars.” A Harvard-linked hospital has one.

It’s not unusual for health policy researchers to hold opinions that differ from parent institutions. Here’s one case.

A Kaiser Health News story says “the facilities zap cancer with beams of subatomic proton particles instead of conventional radiation. The treatment, which can cost $48,000 or more, affects surrounding tissue less than traditional radiation does because its beams stop at a tumor rather than passing through. But evidence is sparse that this matters.”

So, some insurers are refusing to pay, the story says:

The rebellion by private insurers “is very, very good” and may signal the health system “is finally figuring out how to say no to low-value procedures,” said Amitabh Chandra, a Harvard health policy professor who has called proton facilities unaffordable “Death Stars.”

Here’s what they say at MGH:

The MGH Department of Radiation Oncology is an established leading institution treating with protons. In the 1960s and 1970s, pioneering MGH neurosurgeons and radiation oncologists, working with Harvard’s Cyclotron Laboratory, became the first in the world to discover how to harness the extraordinary behavior exhibited by high energy protons, a phenomenon known as the Bragg peak, for medical care. By using protons rather than conventional x-rays (photons), physicians could deliver radiation energy directly and precisely to tumors and cancerous cells, causing less damage to nearby healthy tissue.

See full story below

As Proton Centers Struggle, A Sign Of A Health Care Bubble?

The Maryland Proton Treatment Center chose “Survivor” as the theme for its grand opening in 2016, invoking the reality-TV show’s tropical sets with its own Tiki torches, palm trees and thatched booths piled with pineapples and bananas.

It was the perfect motif for a facility dedicated to fighting cancer. Jeff Probst, host of CBS’ “Survivor,” greeted guests via video from a Fiji beach.

NIH image

But behind the scenes, the $200 million center’s own survival was less than certain. Insurers were hesitating to cover procedures at the Baltimore facility, affiliated with the University of Maryland Medical Center. The private investors who developed the machine had badly overestimated the number of patients it could attract. Bankers would soon be owed repayment of a $170 million loan.

Only two years after it opened, the center is enduring a painful restructuring with investors poised for huge losses. It has never made money, although it has ample cash to finance operations, said Jason Pappas, its acting CEO since November. Last year it lost more than $1 million, he said.

Volume projections were “north” of the current rate of about 85 patients per day, Pappas said. How far north? “Upper Canada,” he said.

For years, health systems rushed enthusiastically into expensive medical technologies such as proton beam centers, robotic surgery devices and laser scalpels — potential cash cows in the one economic sector that was reliably growing. Developers got easy financing to purchase the latest multimillion-dollar machine, confident of generous reimbursement.

There are now 27 proton beam units in the U.S., up from about half a dozen a decade ago. More than 20 more are either under construction or in development.

But now that employers, insurers and government seem determined to curb growth in health care spending and to combat overcharges and wasteful procedures, such bets are less of a sure thing.

The problem is that the rollicking business of new medical machines often ignored or outpaced the science: Little research has shown that proton beam therapy reduces side effects or improves survival for common cancers compared with much cheaper, traditional treatment.

(Story continues below.)

If the dot-com bubble and the housing bubble marked previous decades, something of a medical-equipment bubble may be showing itself now. And proton beam machines could become the first casualty.

“The biggest problem these guys have is extra capacity. They don’t have enough patients to fill the rooms” at many proton centers, said Dr. Peter Johnstone, who was CEO of a proton facility at Indiana University before it closed in 2014 and has published research on the industry. At that operation, he said, “we began to see that simply having a proton center didn’t mean people would come.”

Sometimes occupying as much space as a Walmart store and costing enough money to build a dozen elementary schools, the facilities zap cancer with beams of subatomic proton particles instead of conventional radiation. The treatment, which can cost $48,000 or more, affects surrounding tissue less than traditional radiation does because its beams stop at a tumor rather than passing through. But evidence is sparse that this matters.

And so, except in cases of childhood cancer or tumors near sensitive organs such as eyes, commercial insurers have largely balked at paying for proton therapy.

“Something that gets you the same clinical outcomes at a higher price is called inefficient,” said Dr. Ezekiel Emanuel, a health policy professor at the University of Pennsylvania and a longtime critic of the proton-center boom. “If investors have tried to make money off the inefficiency, I don’t think we should be upset that they’re losing money on it.”

Investors backing a surge of new facilities starting in 2009 counted on insurers approving proton therapy not just for children, but also for common adult tumors, especially prostate cancer. In many cases, nonprofit health systems such as Maryland’s partnered with for-profit investors seeking high returns.

Companies marketed proton machines under the assumption that advertising, doctors and insurers would ensure steady business involving patients with a wide variety of cancers. But the dollars haven’t flowed in as expected.

Indiana University’s center became the first proton-therapy facility to close following the investment boom, in 2014. An abandoned proton project in Dallas is in bankruptcy court.

California Protons, formerly associated with Scripps Health in San Diego, landed in bankruptcy last year.

A number of others, including Maryland’s, have missed financial targets or are hemorrhaging money, according to industry analysts, financial documents and interviews with executives.

The Hampton University Proton Therapy Institute in Virginia has lost money for at least five years in a row, recording an operating loss of $3 million in its most recent fiscal year, financial statements show.
The Provision CARES Proton Therapy Center in Knoxville, Tenn., lost $1.7 million last year on revenue of $23 million — $5 million below its revenue target. The center is meeting its debt obligations, said Tom Welch, its president.
Centers operated by privately held ProCure in Somerset, N.J., and Oklahoma City have defaulted on debt, according to Loop Capital, an investment bank working on deals for new proton facilities.
A facility associated with the Seattle Cancer Care Alliance, a consortium of hospitals, lost $19 million in fiscal 2015 before restructuring its debt, documents show. Patient volume is growing but executives “continue to be disappointed in the slower-than-expected acceptance of proton therapy treatment” by insurers, said Annika Andrews, CEO of SCCA Proton Therapy.
A center near Chicago lost tens of millions of dollars before restructuring its finances in a 2013 sale to hospitals now affiliated with Northwestern Medicine, documents filed with state regulators show. The facility is “meeting our budget expectations,” said a Northwestern spokesman.

Representatives from ProCure and the facilities in San Diego and Hampton did not respond to repeated requests for interviews.

“In any industry that’s really an emerging industry, you often have people who enter the business with over-exuberant expectations,” said Scott Warwick, executive director of the National Association for Proton Therapy. “I think maybe that’s what went on with some of the centers. They thought the technology would grow faster than it has.”

In the absence of evidence showing protons produce better outcomes for prostate, lung or breast cancer, “commercial insurers are just not reimbursing” for these more common tumors, said Brandon Henry, a medical device analyst for RBC Capital Markets.

The most expensive type of traditional, cancer-fighting radiation — intensity modulated radiation therapy — costs around $20,000 per treatment, while others cost far less. The government’s Medicare program for seniors covers proton treatment more often than private insurers but is insufficient by itself to recoup the massive investment, analysts said.

The rebellion by private insurers “is very, very good” and may signal the health system “is finally figuring out how to say no to low-value procedures,” said Amitabh Chandra, a Harvard health policy professor who has called proton facilities unaffordable “Death Stars.”

Proton centers are fighting back, enlisting patients, legislators and nonprofits to push for reimbursement. Oklahoma has passed and Virginia has considered legislation to effectively require insurers to cover proton therapy in more cases.

An entire day at the 2017 National Proton Conference in Orlando was dedicated to tips on getting paid, including a session titled “Strategies for Engaging Health Insurance on Proton Therapy Coverage.”

Proton facilities tell patients the therapy is appropriate for many kinds of cancer, never mentioning the cost and guiding them through complicated appeals to reverse coverage denials. The Alliance for Proton Therapy Access, an industry group, has online software for generating letters to the editor demanding coverage.

In hopes of navigating a difficult market, many new centers are smaller — with one or two treatment rooms — and not as expensive as the previous generation of units, which typically have four or five rooms, like the Baltimore facility, and cost $200 million or more.

Location is also critical. Treatment requires near-daily visits for more than a month, which may explain why larger centers such as Maryland’s never attracted the out-of-town business they needed.

To make the finances work, hospitals are combining forces. The first proton beam center in New York City is under construction, a joint project of Memorial Sloan Kettering, Mount Sinai and Montefiore Health System.

Smaller facilities, which can cost less than $50 million, should be able to keep their rooms full in many major metro areas, said Prakash Ramani, a senior vice president at Loop Capital, which is helping develop such projects in Alabama, Florida and elsewhere.

Maryland’s center hopes to break even by year’s end, executives said. That will involve refinancing, converting to nonprofit, inflicting losses on investors and issuing municipal bonds.

But plans call for four centers soon to be open in the D.C. area.

“It’s a real arms race,” said Johnstone, the former proton-center CEO, who has co-authored papers on proton-therapy economics. He is now vice chair of radiation oncology at Moffitt Cancer Center in Tampa, which doesn’t have a proton center. “What places need now are patients — a huge supply of patients.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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A Harvard panel makes prediction for the the future of the Affordable Care Act #HCR

The Panel

Robert Blendon
Professor of Health Policy and Political Analysis, Harvard T.H. Chan School of Public Health and Harvard Kennedy School

Sheila Burke
Chair, Government Relations and Public Policy Group, Baker Donelson, and Adjunct Lecturer in Public Policy, Harvard Kennedy School

Lanhee Chen
Research Fellow, Hoover Institution, and Director of Domestic Policy Studies and Lecturer in the Public Policy Program, Stanford University

John McDonough
Professor of the Practice of Public Health, Harvard T.H. Chan School of Public Health

Robert Moffit
Senior Fellow, The Heritage Foundation’s Center for Health Policy Studies

 

How to predict suicide risk: A Harvard researcher proposes a test

nyt-ss

 

The New York Times Magazine profiles the work of Harvard psychologist Matthew K. Nock, the director of Harvard University’s Laboratory for Clinical and Developmental Research. Word association begins to describe, but probably oversimplifies, his approach.

The story calls 39-year-old Nock, as “one of the most original and influential suicide researchers in the world.”

The inscrutability of suicide has not kept most psychologists who study it from theorizing about why people kill themselves. Nock, however, tends to approach theories from a different angle. “I think it’s easy to generate explanations,” he said recently. “It’s much harder to test out these different explanations and see whether the data support them or not.”

In 2003,  Nock approached his colleague about the Implicit Association Test, “famous for its ability to measure biases that subjects either don’t care to acknowledge or don’t realize they have on topics like race, sexuality, gender and age. Nock wondered if the I.A.T. could be configured to measure people’s bias for and against being alive and being dead, and Banaji thought it was worth a try. They experimented with several versions in Nock’s lab and at the psychiatric-emergency department at Mass General. Then they put their best one on a laptop and offered it to Mass General patients, many of whom had recently threatened or attempted suicide; 157 agreed to take it. Hunched in plastic waiting-room chairs or propped up in cots as they waited for a clinician to admit or discharge them, they were often grateful for a distraction…The I.A.T., it seemed, was picking up a heightened signal of suicidal tendencies that the most commonly used method for assessing risk — a clinical interview — had been powerless to detect.

More from The Washington Post.

Update 7/10: Knight Science Tracker knocks this as a single source story.

 

 

Harvard health policy event: The year in health law and a look to the future #HCR

globe aca from

More Boston health events here.

Health Law in P/Review

When:Fri, February 1, 1pm – 5pm WhereWasserstein Hall 2036,
Milstein East C, Harvard Law School (map)

 1:00-5:00pm (reception to follow)
Wasserstein Hall 2036, Milstein East CHarvard Law School

The past year was an historic one for health law, with the SupremeCourt issuing the final word on the constitutionality of the Affordable Care Act alongside a host of other critical developments. 2013 promises to continue the trend, with a number of other important topics on the horizon, from employer coverage of contraceptives to gene patenting and more.Please join us for the first annual Health Law Year in P/Review event, bringing together leading experts to review some of the most important changes in the health law landscape over the past year, their implications for the future, and a preview of what is to come.Our inaugural session will feature the following topics and presenters:The ACA and Health Care Reform

Personhood Amendments and Contraceptives Coverage

Immigrants’ Access to Health Care

Affirmative Action and Medical School Admissions

Gene Patenting

Tobacco and Obesity Policy and the First Amendment

Summary and Wrap-up
A wine and cheese reception will follow at 5:00pm.

For questions, please contact petrie-flom@law.harvard.edu, 617-496-4662.
Co-sponsored by the Petrie-Flom Center at Harvard Law School and the New England Journal of Medicine.

What are #Harvard docs and #medical school students reading? Countway tweets tell all #library

The Countway Library at Harvard Medical School has a twitter account listing the books Harvard students, docs and profs return. Here are a few samples.  “Cooper:Therapy dog” seems popular, as do books by Paul Farmer of Partners in Health. For more see @HMSreturns.

History, memoir and colons

Medieval technology and social change by  Lynn Townsend White http://bit.ly/cuu1A8

Alfalfa to ivy : Memoir of a Harvard Medical School dean by  Joseph B. Martin http://bit.ly/wh12DD

Alice Hamilton: Pioneer doctor in industrial medicine by  Madeleine P. (Madeleine Parker) Grant http://bit.ly/IorK5q

The puzzle people : Memoirs of a transplant surgeon by  Thomas E. (Thomas Earl) Starzl http://bit.ly/v7zyjw

The mentally ill in America : A history of their care and treatment from colonial times by  Albert Deutsch http://bit.ly/IpxTlb

Power, sex, suicide : Mitochondria and the meaning of life by  Nick Lane http://bit.ly/iMoUZh

On the pill : A social history of oral contraceptives, 1950-1970 by  Elizabeth Siegel Watkins http://bit.ly/mJgZpX

Subjected to science : Human experimentation in America before the Second World War by  Susan E Lederer http://bit.ly/GWc9jq

Secrets?

Ophthalmology secrets in color http://bit.ly/ioWQHk

Trauma secrets http://bit.ly/Iqm91S

Dental secrets http://bit.ly/qlDxjJ

Med School

Assessment measures in medical school, residency, and practice : the connections http://bit.ly/Iqaikk

So you want to be a brain surgeon? http://bit.ly/ItC6oo

The Washington manual internship survival guide by  Grace A Lin http://bit.ly/A2JnkM

Iserson’s getting into a residency : a guide for medical students by  Kenneth V Iserson http://bit.ly/z47UNY

Diversity

Shattering culture : American medicine responds to cultural diversity http://bit.ly/GDhmrq

Health issues in Latino males : a social and structural approach http://bit.ly/zBRdWe

Race, ethnicity, and health : a public health reader http://bit.ly/dbx8jT

Not too medical

Gold: recovery, properties, and applications by  Edmund M. (Edmund Merriman) Wise http://bit.ly/JeDPM7

Hair transplantation http://bit.ly/JdZoiA

Etc

[Cooper : therapy dog] http://bit.ly/k7raF1

Better than well : American medicine meets the American dream by  Carl Elliott http://bit.ly/rGjxBK

How to

Electroconvulsive therapy : a guide for professionals and their patients by  Max Fink http://bit.ly/IofP7E

Schmidek & Sweet operative neurosurgical techniques : indications, methods, and results http://bit.ly/Io6L2C

Fundamentals of clinical trials by  Lawrence M. Friedman http://bit.ly/xGnSoF

Pocket medicine http://bit.ly/Io5DMl

Introduction to anesthesia; the principles of safe practice by  Robert Dunning Dripps http://bit.ly/HZwUXf

Janeway’s immunobiology by  Kenneth (Kenneth M.) Murphy http://bit.ly/rumf5h

Good general practice http://bit.ly/z56Nuq

Next generation microarray bioinformatics : methods and protocols http://bit.ly/HtuRsP

Bethesda handbook of clinical oncology http://bit.ly/qjBZ8M

The breath, and the diseases which give it a fetid odor : with directions for treatment by  Joseph W. (Joseph William)  http://bit.ly/ItDmrD

Sapira’s art & science of bedside diagnosis by  Jane M Orient http://bit.ly/tMxL9g

Outdated?

Callous disregard : autism and vaccines — the truth behind a tragedy by  Andrew J Wakefield http://bit.ly/HWH0vw

Understanding science news: Infectious disease edition

 

A Harvard student group holds monthly seminars to explain complex scientific topics to the public. They usually fill an auditorium and they always videotape their presentations. Check out “Science in the News” here. The session on dog science didn’t have much of a news hook, but their current “Flash” newsletter does. As a nod to World AIDS Day, they put together a special edition on infectious disease. Check it out.

 

 

FlashSpecial Edition Contents: 

Evolutionary biology wins Nobel for Harvard’s Szostak, et al.

Mass Life Sciences Center photo
Mass Life Sciences Center photo
From the AP Wire

The trio (Szostak, Elizabeth Blackburn, Carol Greider) solved a big problem in biology: how chromosomes can be “copied in a complete way during cell divisions and how they are protected against degradation,” the citation said.

It said the laureates have shown that the solution is to be found in the ends of the chromosomes — the telomeres — and in an enzyme that forms them. Telomeres are often compared to the plastic tips at the end of shoe laces that keep those laces from unraveling.

“The discoveries by Blackburn, Greider and Szostak have added a new dimension to our understanding of the cell, shed light on disease mechanisms, and stimulated the development of potential new therapies,” the prize committee said in its citation.

This from Szostak’s 2008 podcast from Scientific American.

 Sci Am : What exactly does somebody who is studying origins of life do that a regular old evolutionary biologist does not do when they are doing their research?

Szostak: Well, what we’re really trying to understand his how molecules can get together and start to act in a Darwinian fashion, so we’re talking about the origin of cellular systems that can evolve, which is completely different from the way the chemicals interact with each other.

Steve: How is it different?

Szostak: Well, chemical reactions are, you know, controlled by the thermodynamics of chemistry by kinetic considerations, but Darwinian evolution is completely different because in our case we are talking about populations with variation and the selection of variants that are more fit, and it’s that[‘s] it’s repeated and repeated; then better variants come to dominate the population. We just don’t have that kind of cyclic feedback system in a simple chemical reaction.