News Center

Originally published in The Tennessean, January 2016

I started my career as a pediatrician, so I know what it feels like to wonder whether an insurer will cover a procedure or medication I prescribe, and how they make those decisions.

Those are sometimes challenging and emotional situations — especially for parents, who simply want the best for their children and rely closely on the direction of their doctors. As a mother, I know how that feels, too.

More than a decade later, I now work for a health plan, shaping those very decisions. And I bring to bear experiences and perspectives from throughout my career — including time I spent helping lead Tennessee’s critical CoverKids program, where we served tens of thousands of children with limited resources.

At BlueCross, my team is responsible for medical policies that guide coverage decisions for the 3.5 million people we serve. I can assure you these choices are no less complicated and no less emotional than those made in private practice, parenting or public policy.

Our guiding principles are simple and clear, however: to cover broadly supported, evidence-based practices that will lead to better health for our members, and to develop policies that are fair and equitable for everyone we serve.

This isn’t easy, as we must be good stewards of precious resources — namely, the premium dollars paid by our customers. That’s how insurance works: We’re all in this together, contributing to cover one another with peace of mind and financial protection from injury and illness.

When setting medical policy, we know our decisions impact real people every day. That is why we look to the experts, including organizations like the National Comprehensive Cancer Network and the American Academy of Pediatrics, along with groups here in Tennessee. Our standard is to find consensus in the scientific evidence for the efficacy of diagnostic tools and treatments.

We involve our partners in the provider community in the policy-setting process. Panels of physicians from around the state provide input, and we post draft policies for review on our website to solicit additional provider comments.

Provider perspectives are invaluable, and we often review additional evidence they share. Sometimes that means modifying our proposed or existing policies.

Medical policy serves as a way to encourage doctors to follow evidence-based guidelines , which may differ from their habits, preferences or even medical training. Following these standards promotes patient safety and value, though cost is never the chief concern.

A protocol known as step therapy illustrates how this works.

New drugs are introduced every year, even for common conditions like high cholesterol. They may be highly effective — though not necessarily more so than existing options — and they are typically under patent, which impacts affordability. We use medical policy to guide physicians to try safe, proven and cost-effective choices first before covering alternatives.

Medical technology provides similar examples. In many cases, an MRI is unnecessarily intensive because a CT scan gives all the diagnostic information a doctor needs. Our policy guides them to use that tool first. The more advanced or latest technology is not always necessary.

Physicians who combine their diagnostic talents with evidence-based technology can develop effective treatment plans based on their patient’s medical history and needs.

We know Tennesseans want high-quality care that brings better health, and they also expect us to be responsible stewards of their premium dollars. Good medical management helps us deliver on both fronts.

Our medical policy decisions are driven first and foremost by our desire to provide Tennesseans access to quality care that is proven to be safe and effective.

That means following the evidence, and working to ensure our partners do as well.