Perspectives on Essential Health Benefits Workshop Report (2012) / Chapter Skim
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10 Two Private-Sector Approaches to Benefit Coverage and Design
10 Two Private-Sector Approaches to Benefit Coverage and Design
Pages 109-116
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From page 109... ...
Samuel Nussbaum, Executive Vice President, Clinical Health Policy and Chief Medical Officer at WellPoint, started off by describing that company's approach to building health care improvement into its choice of evidence-based benefits, clinical policies, modes of delivery, and incentives. He stressed that deciding the covered benefits is just the first step, followed by benefit design choices and benefit administration.
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From page 110... ...
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.
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From page 111... ...
and pharmaceutical company information, and external physician input before a value assessment committee determines tier and formulary position. A WellPoint product called GenericPremium exemplifies how formulary decisions can ensure availability of all drug classes while encouraging affordability.
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From page 112... ...
Nussbaum explained the importance of retaining flexibility in benefits by describing the differing outcomes of African American and Caucasian women with respect to breast cancer. A study of women with breast cancer conducted by WellPoint and the American Cancer Society (ACS)
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From page 113... ...
For example, fecal occult blood testing for colorectal cancer screening is covered as a preventive service. A positive test requires a follow-up colonoscopy, which could be treated as an extension of the preventive screening, with no cost sharing, or as a diagnostic service in follow up to a positive preventive screening.
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From page 114... ...
For example, she said that KP "fought long and hard to eliminate the option of insurers selling products in the individual market in California that did not have maternity coverage." But if competitors offer products without maternity coverage (a less expensive product) , KP loses the ability to enroll those individu als looking for the less expensive health insurance product and disproportionately enrolls those intending to, or more likely to use the maternity coverage.
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From page 115... ...
Cosmetic services, reversal of voluntary sterilization, growth hormone as a performance enhancer in adults, and assisted reproductive technologies often fail the "social insurance test" as they are not "generally accepted" for coverage given "today's societal norms." In general, these are considered life-enhancing rather than medically required to maintain or improve patient health. Some of these procedures, though, must be covered in particular states because of state mandate requirements.
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From page 116... ...
and benefit design for quality improvement. PowerPoint Presentation to the IOM Committee on the Determination of Essential Health Benefits by Sam Nussbaum, Executive Vice President, Clinical Policy and Chief Medical Officer, WellPoint, Inc., Costa Mesa, CA, March 2.
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