Public health, academics, pharmaceutical research, managed care, hospital
and health care system administration, management and benefits consulting,
technology and informatics, quality management and safety, risk management, disability and workers’ compensation — at
first glance these fields may appear to have
very little in common. After closer review,
however, one will find that within each of
these industries, as well as many others,
are people with clinical training who play
key roles.
Having chosen a clinical career path that
is “nontraditional,” these individuals work
alongside their nonclinical counterparts,
sometimes in very visible leadership positions and other times “behind the scenes.”
“Oftentimes, people wonder why a clinical professional, after all their years of education, training and experience on the
‘front lines,’ would leave direct patient
care,” says Dr. Wendy A. Richards, national
medical director for Aetna Small and
Middle Market Business. “Personally for
me, it was not so much leaving my field as
it was using my years of education and
experience as a clinician to contribute to
health care in a different way.”
Smart Business spoke with Richards
about the roles and impact of clinicians in
the health insurance industry.
Describe some specific areas where clinicians provide value.
In joining the ranks of health insurance
companies, clinicians have advocated for a
greater awareness of evidence-based medicine and, as a result, are responsible for
ensuring that an insurer’s actions and policies are based on sound scientific and clinical research. Clinicians also understand
how to use evidence-based medicine in a
real-life setting to determine what works in
practice for the patient and his or her
provider, not just what works in theory.
An example of the use of evidence-based
medicine in the health insurance industry is
care management programs. These programs are developed to support improved
health outcomes and promote cost-effective care. Clinicians provide critical input to
the program development and operational processes, which can include clinicians
working directly with members to help
them manage their chronic conditions.
What are some other areas where clinicians
play an important role?
Another area in which clinicians can lend
their expertise is clinical policy development. These policies provide a framework
for coverage decisions around medical
goods and services and must be grounded
in evidence-based medicine. Typically, a
health insurance company will include
clinical subject matter experts, such as
physicians, nurses, pharmacists, dentists
and others, to develop its clinical policies.
Further, many clinicians have depth of
knowledge and experience in data analysis
and statistics. They use these skills to help
plan sponsors craft a care management
strategy that will help their employees
meet their health improvement goals.
How do clinicians collaborate with their non-clinical peers?
While those with a scientific background
and experience gained from years practicing in a clinical field can add tremendous
value to a health care organization, it is
important for clinicians in this industry to
also understand, utilize and articulate the
primary tenets of business and insurance.
For this reason, many clinicians have
returned to school to pursue master’s
degrees or certification in various areas of
business and management.
The best education, however, often
comes from working alongside someone
who has business experience. This is particularly important for clinicians with
external-facing roles who are often members of integrated account management
and sales executive teams. By collaborating closely with members of the field sales
team, these clinicians can more easily convey the organization’s values and describe
the programs, products and initiatives to
multiple constituents, such as plan sponsors, brokers, health care providers, consultants and the public.
What’s next for clinicians in the health insurance industry?
As the managed care philosophy continues to evolve, and the role of the health
insurance industry expands from primarily
contracting and claims payment to include
a focus on quality of care, patient safety,
proactive and preventive health initiatives,
and effective management of chronic
health conditions, clinicians working in the
industry can have an even more positive
impact.
And as more health insurance companies
make the investment in and commitment
to including clinicians in their organizations, employers and plan sponsors are
likely to see a cost savings as evidence-based medicine, care management programs and other clinician-based initiatives
are designed to improve patient safety and
medical quality, reduce medical costs and
improve employees’ productivity.
DR. WENDY A. RICHARDS is national medical director for Aetna Small and Middle Market Business. Reach her at (312) 928-3307
or [email protected].