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> Document 639 : INS 99-14 : Hearing Decision
STATE OF MAINE
March 28, 2000
Q. Please state your name and your position with Anthem. A. My name is John Jesser, and I am a Vice President of Anthem Midwest, Northern Ohio Region. Q. What will be the subject matter of your testimony? A. I will describe how the Anthem operating model works in practice from my perspective as a Health Service Area manager. Q. Please explain what you mean by Health Service Area. A. Anthem's Health Service Areas are geographic regions that are developed to recognize the fact that health care is a local activity. As such, provider activity, employer purchasing preferences, policyholder needs and other competitive matters will differ from state to state or within even more localized areas. In Anthem's Midwest operating region, for instance, we have established 4 separate Health Service Areas which reflect this fact. I am responsible for the health care delivery system in the Northern Ohio Health Service Area. Q. What functions are performed by the Health Service Areas? A. The local Health Service Areas contain many key functions which are performed locally. These include sales, customer service, marketing, quality improvement, network development, provider education and service, medical management, case management and medical director support. The Health Service Areas are at the core of Anthem's business and health care strategy. For instance, employees in the Ohio Health Service Areas work with Anthem's Midwest regional staff to establish general policies or coordinate with respect to the activities I have noted above. The local Health Service Areas are then responsible for administering and implementing these activities within the framework and unique characteristics of each specific Health Service Area. Q. How does Anthem use Health Service Areas to make the delivery of health care more effective? A. Each of the activities I will describe is central to the effective delivery of health plan services to our policyholders within local markets. In describing them, I hope to demonstrate the strength of our operating model in responding to local markets and the synergy that exists between local plan managers and regional support functions. Q. Please describe how Anthem utilizes local sales and marketing efforts. A. In my experience in the Midwest Region, sales and marketing activities at the local level focus on identifying local product needs and working with the Health Service Area management team to attract new business and retain current business. Within the Health Service Area, sales and marketing management works closely with the medical management team to develop provider networks that are responsive to local demands. Local sales and marketing management provides an effective and immediate form of feedback for the medical management team when considering local medical management practices. Q. Generally speaking, how does Anthem go about developing products? A. Product development activities are locally focused and managed collaboratively between local Health Service Area management and regional product development functional management. At the regional level, Anthem Midwest facilitates the development of products with local Health Service Area managers. Focus groups, involving Anthem Midwest employees and employees in all of the functional areas of the Health Service Area, including network development, medical management, quality improvement, sales, customer service, claims and systems, identify and develop new products. Q. You also mentioned that Health Service Areas are involved in quality improvement. Please explain how. A. Quality improvement is one of the key functions performed at the Health Service Area level. For instance, in the Midwest Region, clinical quality initiatives are developed jointly between the Midwest regional staff and local HAS quality improvement staff, taking advantage of economies of scale where possible. Examples of current initiatives within the Midwest Region include:
Q. Please explain in your experience how Anthem develops provider networks. A. Network development is another key activity that occurs locally. Activities related to the development and maintenance of provider networks, including provider contracting and decisions regarding network composition, are made locally. These decisions include minimum network adequacy standards, credentialing standards, competitive network configurations and feedback from local customers. Contract formats developed at the regional level can be modified locally to meet local needs and conditions. Q. Please explain Anthem’s medical management and case management practices. A. Medical management and case management also occur locally. These activities focus on managing specific types of health care utilization. Initiatives focus on areas in which the local experience is unusual or where there is opportunity to produce improved health outcomes. For example, in Ohio, these initiatives focus on:
In performing medical management and case management, Anthem employs onsite medical directors who are available 5 days a week to work with the local provider community. Medical directors are located in each Health Service Area and interact with all functional areas. Each local medical director has the final override within the Health Service Area on clinical issues. Anthem's local medical directors also interface with local provider professional organizations and solicit local physician input on many of Anthem's local initiatives. Q. How does Anthem generally handle grievances and appeals? A. Grievances and appeals are also another local function. All first level provider appeals are performed locally. Member grievances and appeals are managed locally by the local customer service unit. Within each Midwest Health Service Area, there is a local committee comprised of representatives from:
Prior to the member hearing, representatives from these areas review each case and each member is given the opportunity to present their case to members of the local committee. Q. From your perspective, how has the Health Service Area structure made Anthem’s overall system more effective? A. One of the strengths of Anthem's operating model, from my perspective, is the support that a regional infrastructure provides local Health Service Area managers. With regional support, local managers have the resources and support that allows them to concentrate on activities that are most important to local markets. By supporting a number of support activities at the regional level, Anthem is also able to create administrative efficiencies and economies of scale. In addition, my fellow Health Service Area managers and I have the freedom to focus our energy on the specific needs and issues of our local markets. Q. Are there other strengths of the Health Service Area approach that you have observed? A. Yes. Another strength of this model is its flexibility and recognition of differences in local markets. Although the company establishes objectives with respect to many health plan activities, local managers have the authority to identify and implement strategies and activities that are responsive to local markets. This approach also applies to certain operating policies. For example, Anthem's Midwest Region has established minimum provider network adequacy standards and provider credentialing standards. In some rural counties, local Health Service Area managers may have to modify credentialing standards to meet network access standards and local market needs. Health Service Area managers have the authority to make these decisions. Q. Overall, how would you characterize your experience with Anthem’s use of the Health Service Area approach? A. Anthem's operating model, in my view, creates an effective balance between the need to be responsive to local market needs and differences and the efficiencies and economies of scale that are available to a regional company. Within this model, I believe that Anthem can maintain and strengthen the Blue Cross and Blue Shield system's tradition of locally-focused health plans. Q. Does this conclude your testimony? A. Yes. CERTIFICATE OF SERVICE The undersigned hereby certifies that on March 28, 2000, a copy of Anthem’s Prefiled Testimony of John Jesser was served by electronic mail, overnight mail, or via hand delivery on each of the persons listed below. Robert S. Frank, Esq. Harvey & Frank Two City center P.O. Box 126 Portland, Maine 04112 e-mail: frank@harveyfrank.com (Blue Cross/Blue Shield of Maine) Judith Chamberlain, Esq. State of Maine Department of the Attorney General 6 State House Station Augusta, Maine 04333-0006 e-mail: judy.chamberlain@state.me.us (Bureau of Insurance) William H. Laubenstein, Esq. State of Maine Department of the Attorney General 6 State House Station Augusta, Maine 04333-0006 e-mail: bill.laubenstein@state.me.us (Office of the Attorney General) Joseph P. Ditre, Esq. Consumer Health Law Program One Weston Court, Level One P.O. Box 2490 Augusta, Maine 04338-2490 e-mail: jditre@mainecahc.org (Consumers for Affordable Health Care Foundation/Coalition) Michele M. Garvin, Esq. Ropes & Gray One International Place Boston, Massachusetts 02110-2624 e-mail: Mgarvin@Ropesgray.com (Central Maine Healthcare Corporation; Central Maine Partners Health Plan) Bonnie Post Executive Director of the Maine Ambulatory Care Coalition P.O. Box 390 Manchester, Maine 04351 e-mail: bdpmacc@mint.net (Sacopee Valley Health center, Regional Medical center at Lubec, Eastport Health Care, Inc., and the Maine Ambulatory Care Coalition) John Dieffenbacher-Krall Executive Director Maine People’s Alliance 192 State Street Portland, Maine 04101 e-mail: MPA@gwi.net (Maine People’s Alliance) Gordon H. Smith, Esq. Maine Medical Association 30 Association Drive P.O. Box 190 Manchester, Maine 04351 e-mail: gsmith@ctel.net (Thomas D. Hayward, M.D., Maroulla S. Gleaton, M.D., And the Maine Medical Association)
Donald E. Quigley, Esq. General Counsel 465 Congress Street, Suite 600 Portland, Maine 04101-3537 e-mail: quigld@mail.mmc.org (Maine Medical center)
Sandra L. Parker, Esq. John Doyle, Jr., Esq. Attorneys for MHA, Inc. 150 Capitol Street Augusta, Maine 04330 e-mail: sparker@themha.org jdoyle@preti.com (MHA, Inc.) Kellie P. Miller, M.S. Executive Director Maine Osteopathic Association 693 Western Avenue Manchester, Maine 04351 e-mail: meosteo@mint.net (Maine Osteopathic Association)
DATED: March 28, 2000 _____________________________ James B. Zimpritch, Esq. Jeffrey M. White, Esq. Catherine R. Connors, Esq. PIERCE ATWOOD Portland, Maine 04101 (207) 791-1100 Attorneys for Anthem Insurance Companies, Inc.
Last Updated: December 8, 2011 |
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