We thank Dr. Fletcher and colleagues for their thoughtful letter describing HPHC's decision-making process and rationale for providing first-dollar coverage of FOBT, but not colonoscopy, in its high-deductible health plan. The HPHC's ethics advisory group, which engages a range of stakeholders, is laudable.

Dr. Fletcher and colleagues defend HPHC's decision to provide first-dollar coverage for FOBT but not colonoscopy by citing evidence-based guidelines, from the time when the coverage decision was made, that regarded the 2 screening interventions as equally effective. In light of new consensus guidelines recommending colonoscopy over FOBT because of the added benefit of early detection and removal of polyps (1), we reviewed the high-deductible health plan information available to potential enrollees on HPHC's Web site and found that colonoscopy is still subject to the deductible (2). Given the plan's goal to design benefits in a way that encourages the use of high-value preventive services, we hope that the HPHC is in the process of changing its high-deductible health plan policy to provide first-dollar coverage for colonoscopy.

Citing the need to control rising health care costs, Dr. Fletcher and colleagues justify the use of cost-sharing to promote use of less-expensive care that produces outcomes equivalent to those of more-expensive care. Although "protecting the medical commons" is indeed an important obligation that we share, it is not clear from existing evidence that an isolated focus on promoting preventive screening will achieve significant cost reductions in the long run. The HPHC high-deductible health plan does not provide first-dollar coverage for highly effective care, such as prescription medications for chronic disease (2); increased cost-sharing for medications reduces their use for such conditions as hypertension, diabetes, asthma, and depression (3). In addition, cost-sharing reduces the use of clinically effective services and less-effective or ineffective services in roughly equal proportions (4). If HPHC is interested in protecting the medical commons, why resort to a cost-sharing policy that will adversely affect the well-being of some patients? Wouldn't it be better to first attempt to eliminate wasteful and inappropriate care (in which risks to the patient exceed the potential benefit) (5) by implementing appropriateness criteria and methods (4, 5) and systematically educating its providers and enrollees in how to use the criteria?