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by Richard Asinof, ConvergenceRI, contributing writer on health issues
Photo: Martha L. Wofford, President and CEO, BCBSRI
The new president and CEO of Blue Cross and Blue Shield of Rhode Island, Martha L. Wofford, has been working and living in Rhode Island for just two weeks, having waited until her 15-year-old finished up the school year in Colorado before officially relocating, having spent the past few months working virtually since being hired this spring.Those distinct qualities of sense and sensibility emerged throughout the 30-minute conversation last week with ConvergenceRI – along with an eagerness to learn – and an honesty to admit when she did not know things, refreshing traits when it comes to a health insurance CEO in charge of one of Rhode Island’s largest health care firms.Wofford previously served as group vice president at DaVita, Inc., in Denver, Colo., supporting the company’s shift to value-based care and taking full financial and clinical accountability for kidney patients.Prior to joining DaVita in 2014, Wofford had worked at Aetna for nearly a decade in various leadership roles, in charge of stewarding Aetna’s efforts to deliver “simple solutions” to help consumers navigate the health care system, according to the news release announcing her hiring.Wofford received at MBA from the Kellogg School of Management at Northwestern University and a bachelor’s degree in history from Swarthmore College, where she received 12 varsity letters and captained four teams, including achieving national honors in lacrosse.A priorityWofford said she had made it a priority to talk with ConvergenceRI [unlike the former and current Governor]. “I have to say, this is really a treat for me to get time [to talk] with you. I have loved reading your articles. They reflect a depth [in reporting on health], which I think is so rare.”As you know, Wofford continued, “Health care is so complex. And so having somebody who truly understands it, to be able to bring those stories to life, is super helpful,” adding: “I appreciate the opportunity.”ConvergenceRI thanked Wofford for her kind words, admitting that sometimes there was a worry about getting too much in the weeds and too in-depth for readers.“I was at the Governor’s presser the other day, and I asked him a question about Medicaid, and his response was: Well, keep us informed, let us know.”Wofford laughed, saying: Shouldn’t it be the other way around?Wofford continued: “I found your pieces on the Attorney General [Peter Neronha], it was really, as I was going in to meet him for the first time, it was just helpful to get a flavor of the person and his backbone, his ability to really hold people to account. I really found it insightful, so I really appreciate the level of journalism.” [Flattery, of course, always works. So does earnestness.]Here is the ConvergenceRI interview with Martha L. Wofford, president and CEO of Blue Cross and Blue Shield of Rhode Island, taking the helm at a time following the disruptions of the entire health care delivery system by the coronavirus pandemic. [Gail Carvelli, director of Public Relations at BCBSRI, sat in on the interview.]ConvergenceRI: What lessons has Blue Cross Blue Shield of RI learned from the COVID pandemic?WOFFORD: I’ll give you three lessons. I think the first is one that we have all found, which is: a crisis can really serve as a catalyst for positive change.What we found in Rhode Island is that we have been able to really have productive collaboration among entities across the health care system.As an example, we’ve held weekly calls with the provider community to answer questions and provide an opportunity for them to raise questions with the chief medical director or with our other medical directors. It has really helped ensure that Rhode Islanders had access to the care they needed.And, the second area is, it really shone a bright light on the inequities that many of us knew were there, and I think it created more of shared perspective that there is this absolute imperative to make the system better, to build it back better, if we want to use President Biden’s phrase.We are working very hard on health equity. We have a five-point plan there. I’ll give you those five quickly.• First is collecting data to drive health equity with race, ethnicity and language information. We really do believe that you can’t fix what you don’t measure.• Second is targeted intervention, such as addressing maternal morbidity, which is such a big problem [nationally], and it’s a big problem in Rhode Island.• The third is increasing access to coverage. We have been focused on behavioral health. And, there is much more to do there.• Fourth, an area that we’ve been working on for the last few years, is addressing social determinants of health and working closely with community partners on areas like housing and education.• Lastly, around increasing provider diversity and cultural competencies, so that we can really meet people where they are.Those are five areas within health equity. With COVID, we were able at times to focus on fewer things, to really drop everything and really deal with the pandemic. I think that let us move more quickly and have more impact, just by having greater focus.A good example is our making sure that people who are most vulnerable were safe and that we were supporting them.ConvergenceRI: I always look at interviews as sort of like a piece of jazz music: you get to improvise, to listen and then respond. Two quick follow-ups: One is about data and data collection. It would seem to me that data collection for 2020 will always be skewed and will have to have an asterisk, because there were so many disruptions. With the actual data, if you try and compare it in a longitudinal way, it may not work. I was wondering if you had taken any steps to try and analyze the data differently, knowing that you couldn’t use it in the same fashion as you had before.WOFFORD: It’s a really good question. I’m going to answer it in two ways. The first is, the kind of data that we’re talking about is, for instance, things like HEDIS measures [Healthcare Effectiveness Data and Information Set, which measures performance in health care where improvements can make a meaningful difference in people’s lives], which I am sure you’re familiar with, but probably not all your readers would be.You do things like measure diabetes control, A1C3; or you measure screenings; or [whether] bone density screening is happening; and what are the percentage of patients who are hypertensive. We measure all these things.But what we tend to do is measure them on average. And what we don’t do is say: How many patients who were Black are hypertensive? How many are getting the right screenings. What is the A1C3 when you look at it at a population level? What about if you look at it by language? Or, are women who are Hispanic getting the same rate of bone density screening as others?I think, that as a health care system, we have not historically done that. And, once we look at that data, it will show what many of us know: which is, people of color are much less likely to get a lot of the routine screenings and other things that they should be getting.I think it is imperative that we start to measure that. Yes, we will see some pickup [in utilization] in the past year, because people didn’t go to the doctor as much. [The total of] all the screenings will be less than they would have been otherwise.But, on an ongoing basis, [the question is]: How do you start to gather this data at a granular level so you can start to understand what populations are missing out on preventive care.On the question about data [results] overall though the pandemic, I’d say one thing we can do is that we go back to the year before to look at what we would have expected in a normal year. So that can sometimes help, if you sort of pull back, and aren’t looking at individuals, but if you are looking at the market [trends] overall and what you would expect.So, 2020 will always be a little bit of a strange year, with a lot of volatility, but really, we are starting to see normal utilization return this year, and it’s starting to look fairly similar. So, it’s more like a one-year blip, we think, in terms of the data.ConvergenceRI: That’s a good answer. At this point, I’m not sure we will ever return to what was “normal” before, whether it comes to office visits, or to screenings, or the whole way our lives have changed, because so much more is virtual rather than in person.In August of last year, as part what I call your proactive response to the pandemic, you basically stopped co-pays for a number of things, not just things related to COVID but things such as physical therapy. But then the co-pays were begun again on Jan.1, 2021.How important are co-pays? And, what have you learned in terms of the pandemic, moving to the post-pandemic world, how we make that transition? How important co-pays are to your bottom line, and whether or not they add value to what you are doing?WOFFORD: That’s a really good question. I’m going to do my best [to answer it]. I wasn’t here then. First of all, we actually suspended co-pays in March of 2020 for everything COVID-related, I think that was important leadership; we can talk about the return of some of that in a minute.One of the things we did was to remove all co-pays for behavioral health. Which I think is incredibly important, [when] you are trying to improve access.I don’t know all of the categories that co-pays were removed for. And I think it’s really hard to say exactly [what] impact that co-pays have on consumer behavior.I think you want as much preventive care to be happening as possible. But there are obviously some areas that you can tend to see over-utilization without co-pays.If you look at the health economics [research] on some of the [utilization data], chiropractic is sort of the classic example, areas where if you don’t have limits or co-pays, you will see a lot of utilization, some of [which] isn’t always healthy,I’m probably not as deep in [in understanding the history of] this as I could be, in terms of what we did then. But I’m happy to go back and research any of this for you, if that’s helpful.But I think it’s a good question, I think you want to remove co-pays whenever reducing any friction can help a consumer get preventive [care].ConvergenceRI: That makes sense. And, to be totally transparent, the change in January directly impacted me. I have been diagnosed with auto-immune encephalitis, so I am losing my ability to walk. My condition seems to have stabilized recently, and one of the key therapies is physical therapy.If I could, I would do it two times a week, but, when I started getting hit with co-pays for every visit, I had to cut back to once a week, because it was going to be, in terms of the amount of money spent over a year, it essentially made two times a week unaffordable for me.It may not be “professional” to share that, but part of me is being totally transparent and honest, that was something that hit me directly. All of sudden, the co-pays came back into place, and there was no warning about that happening when it occurred. Neither I, or my physical therapist, received any warning when the co-pays were re-instituted.CARVELLI: Richard, I’m not sure that Martha is getting all of the last question. She is freezing up on my screen, so I’m not sure if it is happening on her side as well. I can definitely look into more on that as well.ConvergenceRI: Thanks, Gail. Moving right along, Martha, can you tell me how strong is the financial health of Blue Cross and Blue Shield of RI? And how to define that strength?CARVELLI: Martha, were you able to hear Richard’s question about financial health. It looks like she just froze up again on my screen.WOFFORD: We’re having some Wi-Fi issues today. But we will research that Richard, that’s news to me about when they put [those co-pays] back.ConvergenceRI: Should I repeat the question that I just asked?WOFFORD: That would be great.ConvergenceRI: How strong is the financial health of Blue Cross and Blue Shield of RI? And how would you define that strength?WOFFORD: Thanks for the question. We are in a strong financial position. We turned the company around over the past five years to where we stopped generating losses and now consistently generate a very low margin [of profit], about 1.5 percent, one that is consistent, which is really positive.I would just say that we recognize how hard the pandemic was for the people of Rhode Island, and we gave financial relief to members, giving out [more than] $25 million in premium and debt relief.[The pandemic] was pretty hard on our employees, so one of the things we did during the pandemic was to raise the minimum hourly wage for our associates to $20 an hour.In terms of financial stability, as I mentioned before, health care utilization continues to return to pre-pandemic levels, so we expect more of a return to normal and reduced volatility.[Moving forward], health equity is going to be an area we are going to be investing in heavily. And, in trying to improve the member experience – and in building capability with our provider partners. We’re really focused on how to help physicians keep their patients as healthy as possible – and to be compensated for that. Those are three areas that we are going to be investing in the coming years.ConvergenceRI: In terms of health care costs and financial stability, one of the things that I found fairly remarkable was that an in-depth cost trend analysis for Rhode Island, looking at claims data for 2018 and 2019, found that the major driver of rising medical costs in Rhode Island, across all insurance plans, Medicare, Medicaid and commercial insurance, was rising pharmacy costs. [See link below to ConvergenceRI story, “Prescription drugs, not utilization, are driving high health costs in RI.”] What are the fixes to reduce the cost of pharmacy?WOFFORD: It is both surprising and not. It’s surprising that pharmacy continues to rise so heavily. We saw approximately a 20 percent increase in our pharmacy spend year over year, and that’s a combination of retail as well as specialty pharmacy.Specialty pharmacy has just been exploding in the number of different medications and interventions. The cost [trends] of those are exponential, in terms of the costs that are on the horizon.I think it is very concerning how much pharmacy is now driving overall increases in health care costs – and it is projected to continue to do that, in the pace of those costs.ConvergenceRI: What do you think the fix should be? Does there need to be more regulation? Does the state need to be able to get involved in negotiations directly around pharmacy costs? We are about to see an explosion in costs from the new Alzheimer’s drug, with a projected increase in Medicare spending of $29 billion in one year, according to a Kaiser Family Foundation analysis. How do we deal with this?WOFFORD: I wish I knew. I don’t think anybody has the playbook about how you address the explosion in costs. I think it is going to have to be a combination of things. From the very mundane, such as “step therapy,” which is not popular, but is important to managing costs. [Editor’s note: Step therapy means trying less expensive options before “stepping up” to drugs that cost more, according to a post by Blue Cross Blue Shield of Massachusetts.]
One of the things that happens is that some of these new blockbuster drugs, you know, they get marketed really heavily. And then, if people want [those drugs], [being able to give] the right drug for everybody for that condition, having access is important.But, I think we are going to need the right kind of regulation as well.I think there are lots of questions about this new Alzheimer’s drug, and obviously, with some of the physicians stepping off the panel that approved it, and disagreeing that it should have been approved. It just raises a lot of questions. So, I don’t know what the answer is, but we are going to need a lot of creativity if we are going to be able to keep health care costs down.Which is so important to all of us, because those dollars end up coming out of our wallets, one way or the other.As somebody who is fairly new to Rhode Island, I’m really excited about [the potential the state has to come] out of this pandemic and driving economic growth. I think the stimulus dollars will be helpful. We’re going to have to keep health care costs moderated, so that dollars can go into wages and go into new, really competitive jobs.I think we are going to need creativity [to figure out] how do we manage the drug spend, for sure.ConvergenceRI: You began to talk about “step therapy.” In the past few weeks, when I knew this interview was scheduled, I spoke with a number of folks, including my primary care physician and my neurologist, asking them what questions they would want to ask you, if they had the opportunity.They said they wanted to ask about “step therapy” – and I understand that it is important, from your perspective, for controlling costs. But the concern they voiced was that it sometimes prevented the patient from getting what they needed as soon as possible for what they saw as the best recommended drug.Let me ask you: how can we have a bigger discussion about that? I had never heard about “step therapy” before, until it was raised it with me. Is there an opportunity to engage with other folks in finding perhaps a new collaborative approach to these issues?WOFFORD: We would be happy to have conversations. What we do today is we convene a committee, a “pharmacy and therapeutics” committee, which is comprised of 12 physicians, 10 of whom are in the local market. And, then we have two that are community pharmacists.So, we bring physicians together in the community to assess what is the evidence base, what are new drugs coming to market, how should we handle them. So, we go to the community to get the plan of what needs to go through “step therapy,” and how that should work – what are the steps that people should go through.A lot of it is about patient safety as well as cost Physicians get marketed really heavily by pharmaceutical companies so, trying to cut through some of that noise, to ask: what is the evidence base in those applications, what is the best drug for this individual, is a point of process.I know it can be frustrating. I’ve been on the other side as a patient [advocate]. My mom is 86, and I help her navigate health care, which is very hard.I know it can be frustrating, because it does take longer to get the drug that you want. But I have also had situations where my mother has been put on different drugs that we thought we wanted, and it ended up being a very good solution for her.For consumers or even the physicians, it is very hard to keep up with the evidence base; it keeps growing every week, every month, at a pace that no physician could possibly keep up with, without help. So, I think we are convening these committees to try to provide a process that works. We do try to make it easy for physicians to go through this.We have a website that is intended to make it as easy as possible for them to take their patients through the process and get them to a drug that meets their needs.I’m happy to have more conversation with community members on it. But again, we’re trying to look at what are all of the tools that we have to try and manage cost and quality.CARVELLI: Richard, I’m going to add just one thing, too, to think about, which Martha spoke about, the marketing to physicians and even to the patients themselves. The U.S. is only one of two countries that allow direct consumer marketing for pharmaceuticals. It’s often about patients going into to see their doctors and saying: I want this, because of the advertising they’ve seen. And, it may not be the best drug for them.ConvergenceRI: That’s a very good point, Gail. If it’s OK with you, can I ask my neurologist, who asked me to ask the question, to follow up with you?WOFFORD: For sure. And I will connect him or her with our chief medical officer, because he is the person who oversees this process, if that’s OK.ConvergenceRI: What is your current view of the hospital consolidation plans between Brown, Care New England and Lifespan? Is that something you can talk about?WOFFORD: Sure. I think, personally, I am really optimistic around what this could hold for the state of Rhode Island. Where we are right now is that we are looking for greater levels of detail on how quality would be improved, how would costs be contained, how do we maintain the level of access, and how do we improve health equity in the state. These are areas that are really, really important.It is part of our responsibility to our members. We are looking forward to dialogue with the parties around their plans.ConvergenceRI: Do you have any preliminary results that you can share from the surveys for the third annual R.I. Life Index?WOFFORD: Not yet. We are currently out in the market with the research. We are super excited to be working on the third R.I. Life Index. It’s part of this whole mantra that it’s so important to measure things, so that you can really understand where the gaps are, so that then we can go and fix them.It’s great to be partnering in the community. One thing that I am really excited about is that we are expanding the number of languages that are included as we do the survey – we’ve got Spanish and Portuguese and we’re adding Hmong and I think Cape Verdean Creole.I think it’s 10 more languages that we’re adding to our survey, so we should be able to gather more input from many folks who likely are disadvantaged in their access.It’s a very exciting, important area where we partner with the community. We’ve been able to really pivot with our own giving, based on our finding. Our focus on [affordable] housing has been new in the last couple of years, and we’ve invested $2 million so far. We think it’s really important to the community and to achieving health equity.ConvergenceRI: Blue Cross is one of the stakeholders that has been participating in discussions with the 10-year statewide health plan being developed in collaboration with the Rhode Island Foundation. Have you personally been able to be involved with any of the discussions?WOFFORD: I have spent some time with Rhode Island Foundation folks, not so much in the 10-year plan, but just overall, [looking at] what do we want health care to look like in the market, how do we think about some of the ARP [American Rescue Plan federal] dollars and how those might be spent.ConvergenceRI: Two years ago, there was a data mining analysis by the national Blue Cross Association that found Rhode Island had one of the highest rates of MS in the nation. [See link below to ConvergenceRI story, “ Why does RI have the second highest MS diagnosis rate in the U.S.?]I was wondering, first, were you aware of that, and secondly, what potential follow up there might be. When you do meta-data analyses, how do you follow up?WOFFORD: It’s a great question. And I do not know the answer. I do think there are a lot of opportunities to understand these trends.I will try to find out what the next steps on MS that we’ve taken. I think, in general, the way I look at the data we will be gathering on health equity with the R.I. Life Index is that it will chart the course for us on the areas that we will invest in.When we talk about interventions, we know that maternal morbidity is an issue. The data will help us chart our course forward, by identifying those areas that have some of the biggest gaps.ConvergenceRI: When you talk about health equity, one of the largest health equity zones is the Central Providence HEZ, which has ONE Neighborhood Builders as the backbone agency. In December, they received $8 million from Blue Meridian Partners, and last week, they distributed some $400,000 in grants to local agencies across the city.Have you had a chance yet to dialogue with Jennifer Hawkins, who is the executive director of ONE Neighborhood Builders?WOFFORD I have not yet. And, that’s based on my just arriving to the state, two weeks here on the East Coast. I was working for my first couple of months from Denver, letting my 15-year-old finish up the school year.I may be a little behind in some of those conversations. I am really excited that the health equity zones have been using our R.I. Life Index data to help inform equity zones, on how do you focus investments in a specific geography to move holistically with that population.There are two approaches, to try to address things like screenings across the whole state, or you can do something broadly, where you are touching housing and education and health care access all in a geography. I think that those are both really important tactics, so I am eager to see how this work actually drives impacts.
Richard Asinof is the founder and editor of ConvergenceRI, an online subscription newsletter offering news and analysis at the convergence of health, science, technology and innovation in Rhode Island.