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Neck cancer center pained

April 30, 2006 1:45 am

When Dr. Christopher S. Walsh opened his Mid-Rivers Cancer Center in Montross, the major health insurance companies paid for the advanced radiation treatments that he provided.

In recent months, two insurance plans have decided not to cover some of Walsh's treatments. As a result, some patients have started cancer treatments at Mid-Rivers, only to see their insurance coverage removed midway through their therapy. Walsh also is faced with the prospect of directing some eligible patients away from the advanced treatments to a less costly--and, he believes, less effective--form of therapy.

"This whole battle has completely consumed me," Walsh said.

The change in coverage has upset some residents of the Northern Neck.

"When it comes to access, it seems we're relegated to second-class status," said Del. Robert J. Wittman, R-Montross.

Wittman introduced legislation in this year's General Assembly to require insurance companies to pay for the type of radiation therapy that Walsh provides. His bill was referred to a study commission. Hearings are expected this summer.

"I don't believe they fully appreciate the difference in treatment Dr. Walsh is providing," Wittman said.

The decision by Anthem Blue Cross and Blue Shield and TrailBlazer Health Enterprises, the administrator for the federal Medicare program, illustrates the unpredictable nature of health insurance. A patient's coverage can change quickly. Cancer treatment seen as useful one day can be deemed unnecessary the next.

Montross, a town of about 315 people in Westmoreland County, seemed an unlikely place for a linear accelerator and a $2 million radiation therapy center. But Walsh, the former director of the Cancer Center of Virginia on State Route 3 in Spotsylvania County, took a chance that he could operate a similar center in Montross for the residents of the Northern Neck and Middle Peninsula.

Patients there had been travelling to Richmond, Fredericksburg or Newport News for radiation treatments. They were excited by the possibility of a local cancer center.

Residents packed public hearings and sent more than 6,000 letters of support to the state Health Department in Richmond.

"He got a lot of support from the town of Montross and Westmoreland County," said C.W. "Buddy" Jackson, sheriff of Westmoreland and a lung cancer patient at Walsh's center.

The effort worked. Walsh received the required "certificate of public need" and opened his Mid-Rivers center in September.

The new center meant that Northern Neck residents would not only get needed treatments close to home but also have access to a new form of cancer therapy.

Mid-Rivers is one of many centers in Virginia to offer "intensity modulated radiation therapy," or IMRT. The Cancer Center of Virginia in Spotsylvania also offers IMRT, though its process is different from Walsh's.

Proponents say IMRT addresses the age-old challenge of radiation therapy: How do you kill the cancerous tumor, yet avoid the healthy tissue nearby?

IMRT is just such a tissue-sparing technique, according to its advocates. It uses multiple beams of radiation, aimed from different angles and shaped to reach only the target areas. IMRT has become popular in the last decade as ever-more-powerful computers have made it possible.

Most cancer patients don't get IMRT and would not benefit from it, Walsh said. But for those who do, it can be more accurate than conventional treatment, with higher doses and fewer side effects.

Breast cancer patients can experience less burning of the skin and less scarring or shifting of their implants, if they have them. Lung cancer patients can be spared damage to good lung tissue and to the esophagus, making it easier to swallow and eat.

"Once you start to see these improvements, it's impossible to deny the value," Walsh said.

Sheriff Jackson received 34 radiation treatments at the Mid-Rivers center late last year. His treatments included nine sessions of conventional radiation, called 3-D conformal radiation, and 25 IMRT sessions.

Jackson said it was convenient to receive therapy close to his home and office. He also said he tolerated the therapy well, with no trouble swallowing and only a slight shortness of breath.

"I feel good," he said. "I worked all through the treatments."

The downside to IMRT is the long preparation required before the patient begins treatment. Walsh said it is not unusual for him and his staff to spend 10 to 15 hours mapping the treatment. For Jackson, the preparations took 26 hours, Walsh said.

Planning time for 3-D conformal treatments, the standard radiation therapy in the United States for about 15 years, is usually less than an hour, Walsh said.

In part because of the planning time, IMRT is more expensive than 3-D conformal radiation. A radiation center like Walsh's receives about $617 per treatment from the insurance companies when using IMRT. A course of 26 IMRT sessions for breast cancer might cost the insurance company $16,000.

This compares with $82 per session and $2,100 total for 3-D conformal treatments.

The cost to patients also is less, since they typically pay a portion of the bill.

"It certainly is a huge impact financially," Walsh said.

Both Anthem and Trailblazer once paid for IMRT for all types of cancer. They still recognize IMRT as effective for certain types.

"IMRT, particularly for cancers like head and neck and prostate, is very well proven," said Dr. Charles E. Haley, Medicare medical director for Trailblazer.

But the two companies now say that IMRT should not be seen as a substitute for conventional radiation, and they refuse to pay for IMRT for many other types of cancer.

Beginning Jan. 1, Trailblazer said the use of IMRT was appropriate when a tumor needed a high dose of radiation and was close to a vital organ that might be harmed. Basically, Medicare in Virginia will pay for IMRT if the patient has cancer of the central nervous system, head and neck, prostate, lung or pancreas.

Patients with other types of cancers, such as breast cancer and colon cancer, must receive 3-D conformal radiation if they want Medicare to pay for it. Exceptions can be made if the patient's doctor documents that IMRT is medically necessary.

"With breast cancer, 3-D conformal has gotten so good, you rarely see radiation side effects," Haley said. "It's hard to imagine you could do better with anything else."

Anthem's change, which followed Medicare's, was even more restrictive. Beginning April 1, it said that IMRT is not medically necessary except for some cancers of the head, neck and prostate.

Like Medicare, Anthem does not pay for IMRT for breast cancer. But it also said it will no longer pay for IMRT for lung cancer.

"There were no actual studies that showed that they were better than, more effective or safer than conventional 3-D radiation therapy," said Dr. Mae Ellen Terrebonne, vice president for medical management for Anthem.

Walsh estimates that the change in coverage will affect about one-third of his patients. About half of his patients are treated for lung cancer or breast cancer, though not all of them are insured by the two companies.

If Sheriff Jackson had been diagnosed with lung cancer this month, his Anthem insurance would not have paid for IMRT. As a result, Walsh said, he would have had more damage to his good lung tissue and lower doses of radiation to his tumor.

"Breast cancer and lung cancer IMRT were the reasons I built this center," Walsh said. "They are two major diseases affecting a large number of people in the Northern Neck. I wanted this center to be able to offer the very best, most accurate, safest treatment available."

Trailblazer's ruling applies to Medicare patients in the District of Columbia and four states, including Virginia. Medicare patients in other states, such as North Carolina and Pennsylvania, can still be reimbursed for IMRT for breast cancer.

Anthem is Virginia's largest health insurance company. Its ruling applies to the 14 states served by Wellpoint, its parent company.

Walsh has appealed Trailblazer's decision, and he is optimistic that the federal Centers for Medicare and Medicaid Services, which administers the Medicare program, will eventually overturn it.

He expects to have to direct some Anthem patients, such as those with breast cancer, away from IMRT to 3-D conformal radiation, even though he believes that IMRT would be better for them.

"We haven't had to steer anybody yet, but I'm sure it's coming any day," Walsh said.

He is also helping his patients deal with the change. One patient lost Medicare coverage in January, midway through her IMRT treatments. Another patient, Vickie Savalina, heard from Anthem recently that the treatments she received in April will not be covered.

Savalina, 36 and a resident of Lancaster County, said this week that she had 16 IMRT sessions for breast cancer in March. All of the sessions were reimbursed by Anthem, she said.

However, Anthem has told her that the 15 IMRT treatments she received during April were considered experimental, and the company would not pay for them.

"It's the same treatment," she said.

Savalina said that she and Walsh are appealing the decision.

"I'm optimistic that eventually [Anthem] will be forced to reverse," Walsh said. "But I don't think they'll do it willingly. I think it's going to require legal action or a mandate at the state level."

To reach JIM HALL: 540/374-5433
Email: jhall@freelancestar.com