Real health insurance Featured

8:00pm EDT June 25, 2008

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