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Summary of 2019 NAPT Conference, Part II

April 11, 2019

The 2019 conference of the National Association for Proton Therapy was held March 24-27 at the historic and recently renovated Biltmore Hotel in Coral Gables, Florida. See the first part of my Summary.

KEYNOTE SPEAKER
Barbara L. McAneny, MD, president of the American Medical Association.

I was interested in what the AMA had to say about proton therapy. In my experience, traditional mainstream organizations such as this have been overly cautious in embracing new technologies, proton therapy being a good example. I looked at the AMA website and was pleasantly surprised that in their coverage of external radiation cancer treatments, after describing three or four types of x-ray modalities, they included proton therapy. However, they still qualify it more than I would like, for example this statement in the section on prostate cancer.

Although in theory proton beam therapy might be more effective than using x-rays, so far studies have not shown if this is true. Right now, proton beam therapy is not widely available. The machines needed to make protons are very expensive, and they aren’t available in many centers in the United States. Proton beam radiation might not be covered by all insurance companies at this time.

Actually there are numerous studies showing the superiority of proton therapy for prostate cancer. Dr. McAneny spoke about a topic related peripherally to proton therapy, which was Prior Authorization (PA) issues. Some 91% of doctors have experienced delay or denial of needed medical services because of the requirement to first get authorization. Many doctor’s offices have an employee who works full time only with PA. Insurance companies use PA requirements to delay services, thereby making a profit by postponing expenditures. For example, it is common to go to get a refill for a prescription, only to be rejected because the pharmacist says the insurance company must reissue their acceptance, even though you have long taken the drug and may take it for the rest of your life. People have to wait as long as five days for approval. During the interim, 28% suffer adverse effects and one third of the patients never return to fill their prescriptions. Many doctors deal with as many as thirty-one PAs per week. The website fixpriorauth.org makes these points:
1. PA prevents you from receiving the care you need.
2. Your physician’s opinion is undermined.
3. Insurers delay your treatment.
4. When time is wasted, you health suffers.
This is their call to action:
It's time for Congress to demand insurance companies work together with physicians to improve the prior authorization process, ensuring patients have timely access to the care they need.

State insurance commissions may be the best place to start. Once a procedure or drug is approved, it should be gold listed and not require re-approval over and over. It seems that the situation is actually getting worse rather than improving.

HEALTH POLICY UPDATE FROM ASTRO
Anne Hubbard, Director of Heath Policy for ASTRO

I was skeptical about this speaker, too, in that ASTRO has been no friend of proton therapy. But again, the topic was broader than proton therapy, covering legislative (lobbying) efforts regarding important issues such as the opioid crisis, insurance cost and coverage, drug pricing, and changing from a fee-based to a value based system with incentives.

One bit of recent progress started on January 1st when hospitals were required to post the prices for their services. I know of one place in Florida that lowered its price for a single injection of a rabies shot from $42,000 to $7,000 once the public could see how they compared to other hospitals.

SENATOR MARCO RUBIO

At the last minute, the schedule was shifted to accommodate a fifteen-minute time slot for Marco Rubio, U. S. Senator from Florida. Before him, we were ten minutes ahead of schedule, but he hadn’t arrived yet. He started about ten minutes late and rambled on and on for far too long. The end result was that we ended up a whole hour behind schedule, and remained so for the rest of the day.

It was clear that Senator Rubio didn’t have a clue what proton therapy is. He told a story of a family member who faced a crisis in having leukemia, and how news drugs had helped. He made a few good points when he talked about the fact that in regard to heath care, people are far more informed today than they have ever been before, thanks to the internet. He also marveled at the technological advances of the past century.

He bemoaned the tendency to go for the quick profit rather than for the long run. He said that while he is for small government, that doesn’t mean no government, with regulation playing a key role. He then used our aging demographics as a predictor of terrible problems to come. Our social system isn’t prepared for people to live well into their 90s. Although he said that every American deserves to have the treatment they need, I remember that he voted to toss out the Affordable Care Act (Obamacare), which would have deprived twenty million people of health insurance.

BREAK

During our break I asked one of the representatives from software company Ray Search about using computer models to show the efficacy of a treatment such as proton therapy, rather than depending on trials that can take up to ten years to complete. He said, “You mean machine learning? We have that right now. Well then, let’s start using it.

A STATE-WIDE SELF-FUNDED EMPLOYER PLAN SUCCESS
Dr. Steven Frank, MD, from, M. D. Anderson Cancer Center.

Insurance coverage continues to be a big issue for proton therapy. The speaker described how the University of Texas (which includes M. D. Anderson clinic and has more than 180,000 employees and dependents) established its own self-insurance system, so that the employer was also the payer. They still used Blue Cross Blue Shield to run the program. The retirement center where I live is almost crippled financially by the cost of healthcare for its employees. Large employers can avoid this problem by self-insuring.


Notice the startling results as shown in the above graph, in which he actual figures were vastly better than what they were originally projected to be.

Now they are expanding the program to several other large Texas employers which will cover three million people. These are the kinds of innovative approaches that might give proton therapy a fighting chance, and give the employees health insurance at a very reasonable cost.

Dr. Frank stated that all of the tests M. D. Anderson has done comparing x-rays with protons have come out in favor of proton therapy. Further, even when the initial cost is higher, when considering ancillary costs, proton therapy comes out better in the long run. They are also doing a randomized study for breast cancer treatment. Previous indications show x-rays have a morbidity rate of 6.3% (damage to heart, lungs, other organs) and only 3.8% for proton therapy. They hope to improve upon that.

DISRUPTORS AND DISRUPTION IN THE HEALTH CARE MARKET PLACE
Presenters: Patrick Pilch and Gary Davis

This was a fascinating talk about coming changes in the heath care field. Disruption, they pointed out, comes from the customer, not the provider. Technology and millennials are going to revolutionize much of the industry. That’s important because the way we are going now, by 2025 (only six years away) the cost of heath care will be 20% of the Gross Domestic Product (GDP).

There is high dissatisfaction regarding what we pay and what we receive in return. Millennials were born between 1981 and 1996, all 73 million of them, which is more than the number of baby boomers.


Millennials are all about convenience. They want same day appointments, short wait times, accessible locations, home visits and even alternative modalities. There have been hundreds of startup companies that want to revolutionize health care.

The gathering and manipulation of data is an important factor for our digital future. Considering how Amazon proactively suggests items you may wish to buy based on your history, searching patterns, purchases and preferences. We all leave digital footprints everywhere. Startups take different approaches with differing goals, but they are all reaping the benefits of the digital age, harvesting our information and communicating with us.

A recent alliance was formed between Lyft and Blue Cross Blue Shield (BCBS), Walgreen and CVS. BCBS will pay for the ride to the doctor, and the pharmacy for the ride to pick up the prescription. Apple, Google, Uber, everyone is looking into heath care. It is one of the largest segments of our economy.

The government, however, is going in the wrong direction. President Trump, whose ideas are consistently about twenty years behind time, is pushing Association Health Plans (AHPs) in which small groups join together to have stronger buying power. It didn’t work the first time around, and isn’t getting much energy now.

Instead, companies are looking into the prospects of direct primary care. If you can get enough participants, you could have people pay a fixed fee for medical services, rather like Amazon’s Prime membership.

The startup Oscar, for example, is a narrow network based on analytics rather than cost, matching providers and those who need their services. Collective Health Self-Insured Groups (think of that pilot program in Texas as an example of being self insured) wants to remove inefficiencies, use predictive data to improve outcomes, and enhance the consumer experience. Devoted Health concentrates on a model for Medicare Advantage plans, described as “primary care on steroids.”



Last year (2018) Amazon bought Pill Pack, a company that delivers prescriptions to your door. They are licensed in forty-nine states, giving Amazon a running start in that area. Immediately, the stock value fell for other such competing services. Amazon has a better price point, strong consumer focus, and all of those Prime members. “Alexa, find a nearby podiatrist and get me an appointment for next Tuesday.” Alexa may access medical records, telemedicine, and more. Imagine describing your symptoms to Alexa. New companies are looking into blockchain technology, genomic sequencing, and more.

Last year Amazon, Berkshire Hathaway & J. P Morgan Chase announced the development of a new health care company “free of profit-making incentives.” Surgeon, writer, and public health leader Dr. Atul Gawande was named CEO of the Venture and will be based in Boston. Look at what happened to the stock of its competitors.

And so, CVS bought Aetna for $69 billion. The speaker suggested that CVS will become more of a medical facility, with fewer aisles selling unrelated impulse items and more about medical products and services. A company called Civica RX wants to disrupt the generic drug market. It is a nonprofit striving to fill a need, not appease stockholders.

“There’s an app for that.” The future will improve the care of chronic conditions, with psychological and emotional support given by nonhuman avatars. Apps will organize the current chaos. Artificial Intelligence (AI) will make many things possible via computer, processing large quantities of data, doing virtual biopsies, looking at imaging and finding minuscule clues missed by the human eye, identifying antibiotic resistance, giving alerts for the beginnings of sepsis or seizures. Apple has recently bought several AI companies.

I have just touched the surface of all of the ways that our current system will be disrupted. They didn’t speak directly to proton therapy, but the implication is that self-insurance and improving customer satisfaction could well enhance access to protons.

VENDORS

To encourage us to spend time with the twenty-four vendors, they served a decent continental breakfast and afternoon snack in the vendor area. It wasn’t very big, and the displays were quite simple compared to the grand displays at ASTRO last fall.

I pointed out to the Gold Anchor folks that I have their anchors in my prostate, and will for the rest of my life. They were used for lining me up accurately (along with my thigh tattoos and the laser crosshairs) for the proton beam.

I believe that Pro Tom International has a very attractive product, a small synchrotron and a single treatment proton therapy room that can fit in the place of two Linac (x-ray) rooms. They have a large presence in the radiation world, are corporate sponsors, have big ads, yet have only had one installation (Massachusetts General Hospital) which is yet to actually treat patients. When I joke to them about having deep pockets, they smile. They have come a long way since their faulty start and financial reorganization a number of years ago.

I greatly identified with VR Bridge, founded by a fellow proton therapy recipient who was also inspired to spread the word. I say more about him in the summary. VR stands for Virtual Reality.

There were a number of firms representing architects and contractors who have built proton therapy centers and would gladly do more. One was Stantec and another was Gilbane. Outside of my proton therapy activity I'm a labyrinth builder. I have had two projects in which I built labyrinths for hospitals that were under construction by Gilbane. One of their representatives remembered them (Wooster, MA, and Wheaton, IL).

Equipment manufacturers Varian and Mevion had a large presence as corporate sponsors of the conference. Hitachi was also present in a lesser way. IBA had half of a table. I bemoaned the fact that my IBA stock has dwindled to half of its original value. I guess I should have bought Netflix instead.

The law firm of McDermott Will & Emory had a large presence at the conference, sponsoring breakfasts and being involved in lectures. I found them very informed and up to date about things.

There were other vendors for services pertaining to operating a proton center, billing, staffing, and that sort of thing. I didn’t really spend time at those booths.

THE FUTURE

I was out at the fringes of the conference, yet still was able to grasp the importance of what was being said. I came away even more dedicated to the fact that this is the cancer treatment of the future. It will overcome current resistance and one day be recognized for the incredible life-saving technology that it is.

You can have a part in the promotion of proton therapy. Join me and become a proton therapy advocate.

* * *

Meanwhile, you may want to check out our two other related websites:

www.ProtonTherapyBook.com
This is dedicated to Robert Ferre's books, Best Prostate Cancer Treatment: Proton Beam Therapy and Proton Therapy: Revolutinary Tretment for 80% of ALL Cancers . It has updates and additional information, photos, and more.

www.proton-therapy-centers.com
This site has an up-to-date list of proton therapy centers in operation in the United States, as well as a number planned or under construction.

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