Published online April 1, 2005
PEDIATRICS Vol. 115 No. 4 April 2005, pp. 1068-1070 (doi:10.1542/peds.2005-0189)
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COMMENTARY

Challenge of Transforming Our Private and Public Pediatric Health Care Systems to Emphasize Value

Stephen Berman, MD, FAAP

Department of Pediatrics
University of Colorado School of Medicine
Denver, CO 80218

Abbreviations: HEDIS, Health Plan Employer Data and Information Set • VZV, varicella-zoster virus • OR, odds ratio • CI, confidence interval

The first 300 words of the full text of this article appear below.

Two articles in this issue of Pediatrics1,2 provide additional evidence that our health care system is not functioning appropriately in the private or public sectors and needs to undergo a major transformation that focuses on value: enhancing quality while controlling expenditures. Most children in the United States have either private employer-based (commercial) health insurance or public health insurance through Medicaid or the State Children’s Health Insurance Program. In the private sector, payments for physician services (and other medical services) are determined by market forces with minimal or no government regulation. Payments usually are based on contracts between payers (the health plans) and physicians who deliver the services. Unfortunately, individual and small groups of pediatricians often lack the ability to negotiate with large for-profit health plans effectively. A central tenet of a private health care system is that quality per unit of cost will be maximized by having a competitive market determine the prices of medical services based on supply and demand. Demand should be based on quality per unit of cost, which is value. When the value of a service is high, demand should create a financial incentive to provide the service. How well is this private health care market system working to ensure that children are receiving recommended preventive care and immunization services? This is an important question, because our society benefits from wide-scale immunization; whole communities are protected, including individuals who are not vaccinated.

McInerny et al,1 from the American Academy of Pediatrics, published a study in this issue of Pediatrics that addresses this question by examining the relationship in the commercial market between state-level physician payments for primary care services including immunizations with visit rates and up-to-date immunization rates. State-level payments were determined by using the Reden and Anders’ national actuarial database. State-level preventive care visit rates . . . [Full Text of this Article]

Address correspondence to Stephen Berman, MD, FAAP, Children’s Hospital, 1056 E 19th Ave, B032, Denver, CO 80218. E-mail: berman.stephen@tchden.org




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