The Role of the CMO

A health plan CMO may work in only one of these sectors or might touch multiple or even all of them. Certainly, CMOs must deal with many aspects of the insurance business, regardless of the role they occupy. Thus, the ability to collaborate effectively with other departments is crucial for the overall success and effectiveness of the organization and the CMO. Even if a CMO and other leaders have the same goals, compromises often are necessary to realize initiatives and to meet the organization’s overall goals.

Each department brings its unique perspective, expertise, and resources to the table. Only by understanding what motivates different departments can a CMO organize a consensus and develop integrated solutions that will meet the needs of all stakeholders. By sharing information and resources across departments, the inevitable redundancies can be minimized, and tasks can be streamlined.

For instance, if the medical management department has a list of high-risk members, collaborating with the customer service department can ensure that these members receive personalized attention and support that may decrease their utilization of the emergency room. Likewise, collaborating with the finance department can enable accurate budgeting and cost-effective decision-making, and ensure innovations and projects enjoy the financial support needed to get off the ground.

This collaboration also extends to external stakeholders. As a bridge between healthcare professionals and insurance companies, CMOs must collaborate with healthcare providers, hospitals, and clinics to establish and maintain partnerships that support the health plan’s goals. The CMO may be involved in negotiating contracts, monitoring provider performance, and addressing any concerns or issues that arise.

As a key member of a health plan’s leadership team, CMOs analyze healthcare utilization data, identify trends, and implement strategies to address any gaps in care. This collaborative relationship ensures a strong network of healthcare providers who can deliver high-quality care to the health plan members. Frequently, this partnership involves differences of opinion; therefore, a CMO’s ability to diplomatically negotiate solutions is an important part of the job.

I want to specifically mention government and media relations. As a health plan CMO, you will be expected to interact with public officials, regulators, and legislators on a local level, and often will find yourself on committees addressing some issue or another. Health plans typically play a key role in the local well-being of the community and the CMO’s involvement reflects that responsibility.

CMOs often represent the health plan, particularly in the local community. The ability to speak to and engage community members is a key skill. The same applies at a national level, as the CMO will often set the clinical tone for a company and address the contemporaneous issues that arise in the media. At the very least, ensuring that company policies and practices align with the public interests as they evolve is imperative.

A key aspect of the CMO’s role is to provide medical expertise and guidance. CMOs must stay up to date with current medical knowledge, research, best practices, and emerging technologies to ensure that the health plan’s policies and procedures align with evidence-based guidelines and processes that promote streamlined care delivery and optimized utilization of resources.

CMOs are expected to address a variety of medical issues. In other words, CMOs are not valuable just because of their knowledge, but also their ability to learn and educate non-clinical departments about other specialties. For example, a cardiologist may need to learn about podiatry.

A CMO plays a pivotal role in addressing population health management. With a focus on preventive care and chronic disease management, the CMO helps develop programs and initiatives to promote healthier lifestyles and improve overall population health outcomes. By analyzing population health data, identifying high-risk individuals, and implementing targeted interventions, the CMO can reduce healthcare costs, improve patient satisfaction, and enhance the health and well-being of the plan’s members.

KEY CMO RESPONSIBILITIES

Successful CMOs have a variety of qualifications and skills to effectively execute their responsibilities. Their responsibilities encompass a wide range of tasks, focusing on strategic planning, medical management, policy development, and provider engagement. Five key responsibilities of a health plan CMO include:

1. Strategic planning: One of the primary responsibilities of a health plan CMO is to develop and implement strategic plans. This includes setting medical goals and objectives, identifying areas for improvement, and formulating strategies to enhance patient care outcomes. The CMO must be knowledgeable about current healthcare trends, research, and advancements to ensure the health plan remains innovative and responsive to the evolving needs of its members.

2. Medical management: CMOs may oversee medical management activities within the health plan. This involves collaborating with various departments to develop care management programs, utilization management policies, quality improvement initiatives, and clinical guidelines. The CMO ensures that these programs and policies are evidence-based, cost-effective, and aligned with industry standards to achieve the best outcomes for patients. On a local level, a CMO is charged with getting buy-in, managing issues and expectations, monitoring outcomes, and providing feedback.

3. Policy development and adherence: Policy development is an essential function within an insurance company and health plan. A large team that includes stakeholders from many areas of the organization is typically involved in the development of policies. The CMO plays a vital role in policy development, providing clinical insight and guidance. The CMO must collaborate closely with key stakeholders, such as the compliance and legal departments, administration, and others to ensure that policies and procedures are up to date and in line with industry standards.
   
   Importantly, a principal responsibility of a CMO, at a more local level, is to ensure that providers, and occasionally members, understand and adhere to these policies, thereby ensuring the delivery of safe and high-quality healthcare services.

4. Provider engagement: Maintaining effective relationships with healthcare providers is crucial for the success of the health plan. The CMO takes a lead role in engaging with network providers, developing strategic partnerships, and fostering collaborative relationships. This involves conducting regular meetings, forums, and conferences to address provider concerns, communicate medical policies, and seek input for the development and improvement of the health plan’s programs and initiatives. Provider engagement also ensures that members have access to a broad network of high-quality providers and services.

5. Clinical oversight and quality improvement: The CMO is responsible for providing clinical oversight to ensure the quality and safety of care provided to health plan members. They collaborate with clinical staff and quality improvement teams to develop programs that monitor and evaluate the performance of providers and healthcare facilities. Regular audits, performance reviews, and data analysis help identify areas for improvement and implement appropriate actions to enhance the overall quality of care.

The CMO also plays a critical role in promoting patient safety and advocating for evidence-based practices that reduce medical errors and improve outcomes.

TRAINING AND EXPERIENCE

In addition to medical qualifications, a CMO should have experience in the healthcare industry. Advanced training in a relevant field, such as healthcare management or health informatics, while not mandatory, can be beneficial. This may include several years of clinical practice, preferably in leadership positions, where they have developed expertise in managing patient care, healthcare quality, and clinical guidelines. Experience working with health plans, insurance companies, or managed care organizations is highly valued, as it provides an understanding of the intricacies and challenges of healthcare delivery within these systems.

A CMO should have a record of effectively leading and managing teams. The importance of strong interpersonal skills and the ability to build relationships with both internal and external stakeholders cannot be overstated. CMOs must be able to effectively communicate with various stakeholders, including executives, regulators, and policymakers. The ability to clearly articulate complex medical concepts and describe a compelling vision is essential in driving positive change within the organization.

A CMO, like most executives within a large organization, must lead without having authority over all components of an issue. Diplomacy, persuasion, and negotiation skills are important when collaborating with partners, since without them you will not be able to advance your agenda.

An understanding of health plan operations and the regulatory environment is important. A CMO should be knowledgeable about health insurance coverage, payment models, and reimbursement strategies. Familiarity with relevant laws and regulations, such as the Affordable Care Act (ACA) and the Centers for Medicare and Medicaid Services (CMS) regulations, is crucial to ensure compliance and navigate the complex healthcare landscape.

Strong strategic thinking and decision-making abilities are essential to guide the health plan’s medical policies, programs, and initiatives. Analytical and critical thinking skills are necessary for the CMO to evaluate healthcare data, identify opportunities for improvement, and develop strategies, supported by data, to enhance the health plan’s performance.

A CMO should have experience utilizing healthcare analytics and data systems to track and measure outcomes, identify trends, and make data-driven decisions. The CMO should be comfortable using and delivering this data in presentations that support their initiatives.

Given the increasing importance of technology in healthcare, a CMO should have proficiency in health information technology (HIT) and familiarity with electronic health records (EHRs), health information exchange (HIE), and other healthcare software systems. They should be well-versed in leveraging digital tools to improve patient care, population health management, and care coordination.

Excerpted from I Want to Be a Chief Medical Officer: Now What? by Rex Hoffman, MD, MBA, FACHE, CPE.