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Maine.gov > PFR Home > Insurance Regulation> Administrative & Enforcement Actions > Document 638 : INS 99-14 : Hearing Decision
STATE OF MAINE
March 28, 2000
Q. Please state your name and your position with Anthem.
A. My name is Robert Scalettar, and I am the Corporate Medical Director for Anthem Blue Cross Blue Shield. I am also the Chief Medical Director for Anthem Blue Cross Blue Shield of Connecticut.
Q. What will be the subject matter of your testimony?
A. I will describe how Anthem Blue Cross Blue Shield develops and administers its medical policies.
Q. Please explain what you mean by medical policy, and its importance in the administration of a health insurance plan.
A. A health plan's medical policy and how it is developed and amended is an increasingly important aspect of a plan's operation. Anthem recognizes that its process for developing medical policy is critical to developing and maintaining the confidence of our members and the professional provider community.
Anthem distinguishes between medical policy and utilization management. I will describe for you the differences between the two and focus on our company's approach to medical policy, commenting briefly on utilization management.
Medical policy is used to determine whether new medical technology is more effective in treating certain conditions than existing technology; whether a new mode of treatment is experimental and/or investigational, or conversely, is appropriate for widespread application; and whether it is appropriate to perform a certain procedure on a patient knowing that a more effective procedure is available. Following the definitions in the benefit certificate for medically necessary and experimental treatments, Anthem creates medical policy based on the current status of medical science.
Q. Could you describe in a general way the extent to which medical decisions are made on a local basis within the Anthem organization?
A. Anthems policy is that individual medical care decisions are made locally. BCBSME currently uses a case management model which integrates clinical and utilization tools to manage the cost, quality and accessibility of care to its members. Anthem employs similar techniques, and anticipates that Anthem Health Plans of Maine will continue to apply them at the local level. As described in Anthems Application for Certificate of Authority to Operate Health Maintenance Organization, filed with the Maine Insurance Bureau, Anthem intends to use BCBSMEs existing Quality Improvement Program and Standards, Access Plan, provider credentialing standards, and utilization standards. In addition, Anthem anticipates that a Maine physician will act as the Medical Director for Anthem Health Plans of Maine, and matters such as medical management and medical decisionmaking will occur at the local level, with the Maine Medical Director and other personnel in Maine working in conjunction with Maine participating physicians.
Q. How does medical policy differ from utilization management?
A. Utilization management focuses on the performance of our delivery system and assessing its effectiveness, considering a number of different criteria. For example, for certain procedures, is care being delivered in the right setting? Is the length of time members are spending in institutional care appropriate? Is the intensity of care delivered appropriate? The health care industry - including practitioners and institutional providers of care - have developed nationally accepted guidelines that address many of these questions. While these are important issues, they are not the subjects of medical policy as Anthem has defined it; rather they are utilization management issues.
Q. Generally speaking, how does Anthem go about developing medical policy?
A. There are two principles that drive medical policy development in our organization. The first, consistent with our operating model, is that medical policy development includes input from network physicians from each of our local operating units. That means that, in the future, physicians in our Maine network with the required clinical expertise will provide input into the development of Anthem's medical policy.
The second principle that drives the development of medical policy is our commitment to evidence-based decision making. Our medical policies place a heavy emphasis on incorporating the very best of what clinical researchers and the current state of medicine proves to be the most effective way to provide care to our members.
Q. Please describe the process used at Anthem to develop or change medical policy.
A. There are four steps that we take in developing or modifying medical policies. The first is the creation of a draft policy. Drafts are prepared by Anthem associates, and are developed after a review of peer-reviewed journals, policies and positions of governmental agencies, opinions of physician consultants, summaries of safety and effectiveness from the FDA and findings of the Blue Cross and Blue Shield Association. Our staff also assesses the impact of proposed policies on long-term outcomes (if information is available); considers whether the desired results can be obtained outside an investigational setting; assesses the medical community's position regarding safety and effectiveness; and considers whether the beneficial effects on health outcomes are outweighed by any harmful effects on health outcomes or risks to the patient.
Once this initial drafting phase is completed, draft policies are reviewed with local network physicians throughout all of our service areas who have expertise in the subject area under review. Local input from our provider networks assures Anthem that it receives the necessary feedback from its contracted practicing physicians.
Those in our medical policy area also solicit internal feedback on proposed medical policies. Feedback from legal, operations and sales helps identify legal, operating or marketplace issues that may accompany implementation of the proposed policy.
The final step in the development of medical policy is review and approval of the proposed policy by Anthem's Medical Director Committee. This committee is comprised of medical directors from each state in which Anthem markets Blue Cross and Blue Shield products. If this transaction is approved and concluded, the medical director of the Maine company will be included on the Committee. This group of medical directors from each of our states gives final approval to any changes to Anthem's medical policy.
I recognize clearly the concern among Maine physicians and other providers over maintaining a high degree of local input into decisions that are made with respect to medical policy. The process I have described outlines a number of steps that help ensure that local medical input into our medical policies is solicited and received. I hope that my description will give the Superintendent confidence in the integrity of our process and the degree to which Anthem solicits input from the provider community in each of our local operating areas.
Q. Does this conclude your testimony?
CERTIFICATE OF SERVICE
The undersigned hereby certifies that on March 28, 2000, a copy of Anthems Prefiled Testimony of Robert Scalettar was served by electronic mail, overnight mail, or via hand delivery on each of the persons listed below.
Robert S. Frank, Esq.
Judith Chamberlain, Esq.
William H. Laubenstein, Esq.
Joseph P. Ditre, Esq.
Michele M. Garvin, Esq.
Gordon H. Smith, Esq.
Donald E. Quigley, Esq.
Sandra L. Parker, Esq.
Kellie P. Miller, M.S.
DATED: March 28, 2000
James B. Zimpritch, Esq.
Last Updated: January 22, 2014
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