A health insurer actually poses the big question

In today's contentious debate over how to best deliver cost-effective, value-added healthcare, insurers have become the villain du jour, taking a backseat only to Wall Street fat cats. It's largely a bum rap. There are plenty of innovative insurers out there, bringing high-value coverage to their customers.

Most physicians contend that healthcare insurers have only one responsibility: Paying claims promptly and accurately. But according to a recent article in The Oncologist by Lee Newcomer, MD, insurers provide several more important roles; chief among them is creating risk-sharing pools and negotiating with providers to keep costs down for their customers. There is also another important role: parsing out ineffective treatments and drugs (15:32-35, supplement 1, 2010).

For instance, at United Healthcare, an internal study in 2005 showed that 12% of patients receiving trastuzumab (Herceptin) therapy did not have HER2 overexpression, an astounding finding. By being aggressive about determining whether a treatment is actually necessary, correctly applied, or less effective than another therapy, innovative payers like Dr. Newcomer bring dollar value to the complex patient, provider, payer mix.

In his article Dr. Newcomer makes another extremely interesting and, considering the trend toward comparative effectiveness research, timely comment: "Unfortunately, insurers are all failing to perform the most important strategy for healthcare coverage-providing only effective therapies at a reasonable cost."

He goes on to address the one question that keeps players in healthcare reform up at night: "The entire healthcare industry needs to examine the value of the services offered to patients. It should ask the question-how do we get to the desired outcome at the best possible cost? That is the most important and heretofore unanswered question in the debate over healthcare reform."