Ethical Challenges in Managed Care: A Casebook

By Karen Grandstrand Gervais; Reinhard Priester et al. | Go to book overview

1
Balancing a Plan's Obligations to Individual
Patients and Its Enrolled Population

CASE STUDY

The Benefit Committee at DesertHealth, a for-profit HMO, must decide whether or not labs should be reimbursed for a new test called PUREPAP. Currently, reimbursement is not included in the fee the plan pays to the lab or the provider. Some physicians, as well as some members, have appealed DesertHealth's current position.

PUREPAP is an advanced computerized tool used to rescreen Pap smears. It was recently approved by the Food and Drug Administration (FDA) as a quality assessment tool. This means that the test is approved only for rescreening for the purposes of quality-assessment, not for use as a diagnostic tool for initial screening.

The scientific literature recognizes errors in the detection and interpretation of cervical smear abnormalities as a leading cause of false-negative findings. This is seen as an unavoidable consequence of manual screening: one slide has 50,000 to 300,000 cells, and one technician might review a hundred slides in one day. PUREPAP pinpoints, magnifies, and rank orders abnormal cells that may have been missed by initial microscopic screening, especially cells that are hard for the human eye to detect. It uses computers to identify and magnify images of the 128 highest-ranking abnormal cells on any one slide.

Presently, plans submit 10 percent of their negative slides to a legally required manual rescreening, which detects approximately 8 percent false-negatives. PUREPAP provides a computerized rescreening process that is about 7 percent more effective in detecting false-negatives than manual rescreening of negative Pap smears. In other words, if 10 percent false-negatives are detected under the current manual rescreening system, 10.7 percent would be detected using PUREPAP. For

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