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Reimbursement for Prevnar: A Modern-Day Version of Hercules and the Hydra

2002; American Academy of Pediatrics; Volume: 110; Issue: 2 Linguagem: Inglês

10.1542/peds.110.2.399

1098-4275

Gary L. Freed, Matthew M. Davis, Margie C. Andreae, Susan Bass, Howard Weinblatt,

Ethics and Legal Issues in Pediatric Healthcare

Hercules, a hero of Greek mythology, was ordered by King Eurystheus of Mycenae to perform 12 tasks, known as “the labors of Hercules.” Each of these tasks was thought to be all but impossible. One of these tasks—to go to Lerna and slay a creature, the Hydra—is in many ways similar to the task faced by primary care physicians in their efforts to capture payment for the provision of the new pneumococcal conjugate vaccine (Prevnar, Wyeth, Collegeville, PA). The Hydra was a creature with 9 heads who lived in a swamp. One of the heads was immortal, and each of the other heads, if destroyed, would grow 2 new ones in its place. Each time Hercules would achieve a small measure of success in his battle against the Hydra, the creature would retaliate by sprouting more heads, making his task even more difficult. For the primary care physician, receiving appropriate reimbursement for the pneumococcal vaccine could be seen as similar to the experience of Hercules with the Hydra in that each time progress was made toward removing the barriers to reimbursement, new obstacles (heads) would emerge. In a contemporary version of this story, the modern-day hero is a primary care pediatrician in a group practice. Each of the heads of the Hydra represents a different insurance carrier (identified anonymously below, but each represents a real carrier), with the immortal head being that of the federal government. Our story begins back in October 1999, when the Advisory Committee on Immunization Practices first voted to recommend the conjugate pneumococcal vaccine (contingent on licensure) for administration to children (the king’s order). This was followed by enticing articles in Pediatric News in November and December of that year, tempting our Herculean physician to learn more about the task. The confrontationbegan in December 1999, when … Address correspondence to Gary L. Freed, MD, MPH, Division of General Pediatrics, 300 NIB 6E08, Ann Arbor, MI 48109-0456. E-mail: gfreed{at}med.umich.edu