I read with great interest the interview with Leonard Fleck, PhD, in the August edition of MANAGED CARE. Fleck is entirely correct regarding the discussion of an honest broker to assess the effectiveness of diagnostic and therapeutic interventions.
Health plans cannot provide coverage decisions and care paths and enforce them. If they do, they risk being viewed as restricting or rationing care when a competitor may not. This puts the plan at a disadvantage in the marketplace.
There are some very easy savings to be obtained, such as mandating trial of a generic ACE inhibitor before an ARB for treatment of hypertension, with a savings of $3 billion. No PSA screening unless a digital rectal examination reveals an abnormality, with an estimated savings of $3 billion. Refuse to pay for home uterine activity monitoring for treatment of preterm labor because it is unproven after 20 years of use, with attendant savings of $10 million.
As Everett Dirksen, the late senator from Illinois, is credited with saying, a billion here and a billion there and pretty soon you’re talking real money! And these are just a few easy ones.
But health plans have difficulty going it alone or they risk market share losses. The American public truly does deserve honest debate on rationing, which in most cases is simply acting rationally.
James P. Reichmann, MBA
Senior vice president
While I admit many of the services encompassed by the Center for Medicare and Medicaid Innovation are needed, I am unsure if spending $10 billion and creating a new division with CMS is the way to go, as written in “$10B to Study Payment Systems,” September 2010. As I was reading Richard Mark Kirkner’s article, I couldn’t help but think about how the money could be better spent.
In sub-Saharan Africa alone it was estimated that 20.6 million adults and 1.8 million children were living with HIV/AIDS at the end of 2008 and 1.4 million people died from the disease that year.
Also, 14.1 million sub-Saharan children have lost one or both parents due to HIV/AIDS. It is estimated that 60 percent of children infected with HIV/AIDS in developing countries will die before their fifth birthday.
With the help of medications that are readily available in the U.S. and parts of Europe, the number of infections could come to a standstill and the number of deaths could decrease exponentially; however, in Africa, antiretroviral medications are scarce and come with a high price.
With what our government is spending on proper billing and payment of medical claims, countless adults and children could be saved from the HIV/AIDS epidemic that continues to spread worldwide.
Phillip W. McCreary, PharmD
Director of pharmacy
Spring View Hospital
COEs are crucial
Re: “The Forces That Feed Medical Travel,” August 2010.
Despite the confusion over the definition of centers of excellence (COE), the concept is critical to payers. Plans are eager to identify centers that have superior outcomes and the potential to deliver greater value than others, even if it means sending the member to another location.
As plans drive transparency and providers embrace models like the patient-centered medical home, I expect more travel in the near future.
Derek VanAmerongen, MD
As a UnitedHealthcare medical director, I utilize COEs all the time.
Marshall Dawer, MD
Keep specialists out
Re: “Specialists Putting Mark on Strained Primary Care,” July 1010.
The problem with specialists entering the PCP [primary care physician] space is that they do so not because they wish to work in the holistic, patient-centered setting. They are in it solely for the money and therefore accountability is lacking.
Utilization of services will remain high. They may dabble in care but since they are not 100 percent investors in the concept, the patient will suffer.
We need to reward the PCP, keep the specialists out of primary care, and continue every effort to steer more students into family practice and internal medicine.
Bruce R. Croffy, MD, PhD
Chief medical officer
Blue Cross of Idaho
Trend line needed
Re.: “Drug Pipeline Loses Pressure,” August 2010.
A trend line with the number of new drugs by class in the pipeline would be interesting — oncology drugs, cardiovascular drugs, and so forth.
Blake Williamson, MD
Kansas City, Mo.