WellPoint CMO touts evidence-based reimbursement decisions


The insurance industry must make scientifically-based reimbursement decisions while collaborating and communicating with consumers, according to the chief medical officer of WellPoint.

Sam Nussbaum, who also serves as WellPoint's executive vice president of clinical health policy, said the second largest insurer considers scientific evidence as the foundation of every reimbursement decision it makes, MedCity News reported.

"There are about 30 physicians and scientists and practicing physicians, none of whom are employed by WellPoint, who actually review the science," he said at the CED Life Science Conference in Raleigh, N.C. "It involves looking at the overall cost of a treatment, looking at a treatment beyond a specific drug, and its adoption by patients in the real world setting."

Scientific studies are a key element of WellPoint's push toward paying only for quality and performance, WRAL reported.

"At WellPoint, everything we do starts with evidence-based medicine," Nussbaum said. "If a treatment is truly superior, let's embrace it and let's make sure everyone can get that treatment," he added. "If it's comparable, then let's look at the value and the affordability versus the outcome … And if it's ineffective, let's stop doing it."

However, most insurers' reimbursement decisions are effectively the result of a "coin toss," according to Nussbaum, because "that is the likelihood that the care will be scientifically based," reported the Triangle Business Journal.

Nussbaum added that Wellpoint is hoping to use artificial intelligence, particularly its partnership with IBM's Watson supercomputer, to help review the vast amount of scientific literature available to better inform reimbursement decisions.

To learn more:
- read the MedCity News article
- see the WRAL article
- check out the Triangle Business Journal article

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