Managed Care - March 2009 - (Page 20) formation and negotiated hospital and specialty pharmacy bills. Some MCOs have good internal resources and 1. Fabrazyme for Fabry’s disease —$500,000 per patient per year can do these things with2. Cerezyme for Gaucher’s disease—$400,000 per patient per year out us.” 3. Elaprase for Hunter’s syndrome —$300,000–$400,000 per patient per year Johnson says that 4. Myozyme for Pompe’s disease — $78,000 per patient (assuming a 20-lb. premature infants are child) per year the number one mil5. Blood clotting factors for hemophilia —$500,000–$1 million per year lion-dollar reinsurance Source: HealthPartners claim that ING receives. The longer a baby is carried, the healthier it is likely settings that have sufficient experience with catato be. Moreover, cost-wise, every extra day in utero strophic claims. Some patients are directed to transsaves three days in an NICU. plant networks and to companies such as BioScrip ROSEBUD identifies high-risk mothers, such as that specialize in high-cost drugs, and cancer manwomen with hypertension or diabetes, and educates agement companies such as ITA Partners. them on proper prenatal care. In 2007, ROSEBUD It is recommended that patients use step-down perinatal cases had an average saving of $4,700; care facilities when appropriate, disease manageneonatal cases, $3,100. ment for costly chronic diseases, and treatment Altogether, clients saved $12.4 million through protocols. Once a claim is received, auditors spring ROSE consulting, education, and negotiation servinto action. From one reinsurer’s case files: An auices, including access to the program’s transplant ditor found $1.7 million in misbilled charges on a and provider networks. $4.7 million claim involving a premature infant. As claims rise, primary insurers and reinsurers The billing facility had not followed standard codsteer patients and providers to appropriate care ing practices, there were inaccurate room and board charges, there were charges for coronary care when the patient was in a medical/surgical bed, point-of-care lab services were charged as separate line items instead of included in the room-and-board charges, and more. The highest dollar claim Crispin has ever seen, $12 million in billed charges, was for a premature infant with congenital anomalies. The increasing incidence of the million-dollar claim brings unanswerable questions: If a single patient can increase health care costs for all and perhaps become a burden to society, what is the responsibility of the many to provide health care to the few? Whom should we keep alive? How much should we pay for it? And finally, what would you do if it were your relative who needed expensive treatment? MC “The good news is that you’re going to be very famous.” Most expensive biologics for rare diseases 20 MANAGED CARE / MARCH 2009
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