FIGURE 10-1 WellPoint, Inc. has various paths for reviewing benefit coverage to make medical policy decisions.
*Depending on the subject, different review committees will be engaged. This illustration includes the Hematology/ Oncology Committee (HEM/ONC), the Medical Policy & Technology Assessment Committee (MPTAC) and the Behavioral Health subcommittee; each of these includes external physician representation.
SOURCE: Nussbaum, 2011.
specific details about who makes these evidence-based decisions, Dr. Nussbaum clarified that “for clinical decisions, we largely use external experts.” For example, if a new therapy was available for cancer, WellPoint would rely on scientists and clinicians to rigorously assess the evidence for treatment.
This exchange prompted committee member Dr. Santa to explore whether the process depicted in Figure 10-1 allows providers to be “in the position of making medical necessity determinations.” Dr. Nussbaum explained that WellPoint’s benefit decisions and medical policies guide the medical determination. Although WellPoint has well-developed processes that allow physician-to-physician dialogue and decisions based on unique needs of the individual patient, physicians cannot make decisions irrespective of medical policy and coverage documents. Physician groups, for example, cannot independently determine that a new cancer chemotherapy is covered, but can and do contribute their viewpoints to the medical policy decision process. All evidence-based medical policies are available on the company’s website.
Health Care Cost Drivers
Benefit design, Dr. Nussbaum cautioned, is not the only driver of the use of health care services. Even within the same benefits package, there is “profound variation in the use of services.” This variation is not necessarily driven by what the benefit package covers. As committee member Dr. McGlynn’s research has shown that patients inconsistently receive recommended care—for example, only 40.7 percent of children who saw a health care provider received recommended pediatric preventive care (Mangione-Smith et al., 2007). Dr. Nussbaum reasoned that health care utilization is also impacted by external factors such as a reimbursement system that rewards volume