Benton Giap, MD MBA Career Opportunities for Physiatrists with Health Plans

22 2 Anthem BC Company Background Anthem is one of the nation's leading health benefits companies. ▪With nearly 69 million people served by its affiliated companies including more than 37 million enrolled in its family of health plans ▪One in nine Americans receives coverage for their medical care through Anthem's affiliated plans. Lines of Business ▪Commercial ▪Government (Medicare and Medicaid) ▪Specialty Business Division (Dental, Disability and Life )

33 3 Objectives Describe career opportunities with health plans (by leveraging unique skill sets of physiatrists) Describe roles and responsibilities for health plan Medical Directors Resources/Tools to enhance understanding of the industry

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55 5 Answer practice clinical medicine

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77 7 Answer more than 10 years of clinical experience or any combination of education and experience

88 8 Background experience solid clinical skills experienced utilization/outcome management group practice administrator effective communication/interpersonal skills business/ leadership training

99 9 Leverage PM&R Unique Skill Sets -Functional Approach -Holistic and Global perspectives to chronic condition management -Integrated approach/appropriateness utilization of resources -Collaborative/accessible

10 Opportunity for Medical Directors -Utilization Management -Grievance &Appeals -Special Investigative Unit -MPTAC -Key Clients/National Accounts Medical Director -Payment and Clinical Innovation -Quality

11 Types of Insurance Plans Health Maintenance Organization (HMO) Exclusive Provider Organization (EPO) Preferred Provider Network (PPO) High Deductible Health Plan (HDHP) Point-of-Service (POS) Employer-based Self-Funded Plan Catastrophic Health Insurance Plan Medicare Medicaid TRICARE Military Plan

12 Health Care Delivery Challenges Variation in care Fragmentation Disparity in care/resources Misperception about health care benefits Lack of understanding on outcomes, cost/effectiveness Experimental/Investigative

13 Regulatory and Decision Making Regulation ▪Utilization Review Accreditation Commission (URAC) ▪Department of Managed Healthcare (DMHC) ▪Department of Insurance (DOI) Decision Making ▪Medical Policy Technology and Assessment Committee (MPTAC)

14 Typical Day Interpret clinical guidelines and medical policies -pre-cert, concurrent -post-service -appeal and grievance Team Conference Call Support Clinical Team (Therapist, Nurses, MDs) Peer to Peer Discussion National Meetings to review revisions in clinical guidelines and medical policies After Hour Calls Projects/Committees Work

15 Team Medical Director Supporting Staff Physician Advisors Therapy Reviewers UM Nurses/CMs

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17 Transition Considerations Be open to start as part time MD reviewer or as expert consultant on a clinical guideline or medical policy Effective Communication/Interpersonal Skills Solution-oriented/Innovative Be better informed about the business side of health care ▪Get involved with Committees at your hospitals (Quality, UM, P&T) ▪“Outcome, Data-Driven” ▪“Innovative”

18 Take-Aways

19 Resources HealthCare Payer News Institute for Health Improvement (IHI) California Health Fax The American Journal of Managed Care Managed Health Care Executive