Delivery of Care

Health insurer as counselor, coach and the one making house calls

The changing nature of Blue Cross and Blue Shield of RI’s role in population health and care integration

Photo by Richard Asinof

Kevin Splaine, the executive vice president of Care Integration and Management at Blue Cross and Blue Shield of Rhode Island.

By Richard Asinof
Posted 6/4/18
A conversation with Kevin Splaine, the new executive vice president in charge of care integration and management at Blue Cross & Blue Shield of Rhode Island, offers insights into the way that insurers have morphed into being coaches, counselors, one-on-one advisors and even the ones making house calls.
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PROVIDENCE – In so many ways, Blue Cross and Blue Shield of Rhode Island, the largest commercial health insurer in the state, often finds itself on the front lines, navigating the changes in the evolving landscape of health care delivery in Rhode Island.

In the past month, for instance, Blue Cross was the major sponsor of the documentary produced by R.I. PBS, “The Fix: Examining Rhode Island’s Opioid Epidemic,” which premiered on May 24, looking at potential solutions for the state’s major public health crisis.

The insurer also publicized a major Health of America report issued on May 10 by the Blue Cross Blue Shield Association, entitled “Major Depression: The Impact on Overall Health,” which found that Rhode Island led the nation in major depression diagnoses. [See link below to ConvergenceRI story, “Mind boggling numbers for major depression diagnoses in RI.”]

And, Blue Cross is in the direct line of fire when it comes to calculating the risk of increased medical costs and drug prices as well as the uncertainty surrounding federal health care policies. When the R.I. Office of the Health Insurance Commissioner published on May 30 the requested commercial insurance premium rates in 2019, it revealed that Blue Cross had asked for a proposed 10.7 percent increase for the individual market, a proposed 5.7 percent increase in the small group market, and a proposed 10.6 percent increase in the large group market.

Among the key factors that influenced the rate requests for 2019, according to OHIC, were “increases in the cost of health care services, including prescription drug trends,” as well as the continuing uncertainty of federal policy actions around the Affordable Care Act.

Managing the risk
In January of this year, Blue Cross named Kevin Splaine executive vice president of Care Integration and Management, leading the network management, pharmacy and care integration teams, directing the health insurer’s efforts to make health care more affordable for Rhode Islanders, according to the internal story that accompanied his hiring.

Translated, Splaine, who has nearly 25 years of experience working with hospitals and health systems, will serve as the point person for Blue Cross, responsible for managing the portfolio of care transformation and clinical initiatives.

ConvergenceRI recently sat down to talk with Splaine, to garner his insights into the future role that Blue Cross will play with health care integration, population health management, and interface with patients and members.

What emerged following the conversation was a realization about the way in which the health care delivery system was becoming much like an M.C. Escher image of metamorphosis – such as where the insurer was now taking on the responsibility of making house calls, normally the province of the provider.

Splaine explained how Blue Cross was creating a new initiative to be launched later this year, for instance, a home call program, involving dispatching a multi-disciplinary team, including a social worker, a nurse and when necessary, a physician, to the home of the highest risk patients.

Similarly, in response to $1 million incentive program for providers to improve patient experience where no money had been rewarded because the results showed no improvements, Blue Cross is now providing coaching to providers, helping them learn how to better engage with patients, in effect counseling the providers.

And, with Medicare Advantage insurance plans becoming an increasingly important part of the Blue Cross portfolio, the focus of the insurer at its Your Blue Store consumer outlets is on one-to-one customer interactions.

The Medicare Advantage market, Splaine explained, “caters to the individual. We do an awful lot of service for people at the individual level. Our stores are great examples where Medicare Advantage patients are continuously increasing their touches with us.”

Here is the ConvergenceRI interview with Kevin Splaine, executive vice president at Blue Cross & Blue Shield of Rhode Island, covering the waterfront when it comes to health care integration and population health management.

ConvergenceRI: What role does data analysis play in the integration of networks, pharmacy, primary care and payment models in regard to managing population health outcomes?
It’s extraordinarily important – and becoming even more important. Oftentimes, being able to manage a population is [about knowing] how best to assimilate the blizzard of data that is out there.

And, we’re all producing different types of data. As an insurer, we have claims data; as a provider, you have medical record data. The more that you can bring those sources of data together, the better picture you have on an individual, and the better picture you have on a population.

ConvergenceRI: Do you have your own health IT database that you use?
We have our claims database. We purchase other databases. In certain cases, we tap into clinical data. We bring in lab data in order to see whether or not high-risk patients’ [conditions] are under control or not.

The exciting thing is, more and more organizations are learning how to integrate the data and have it be focused on producing better outcomes.

ConvergenceRI: One of the ways that people have been using data has been related to cost control, where the high-risk patients are targeted, in order to dramatically reduce those high-risk costs.
There are some who have questioned whether or not that is the best strategy, because it puts you in the business of being the catcher in the rye, rescuing all the people, rather than focusing further upstream.
Given current demographic trends in Rhode Island, where there are an increasing number of older residents, and old old residents, who are 85 or older, will that kind of data analysis keep producing results?
There is sort of the Willie Sutton approach, he was the guy who said, when asked, why do you rob banks, and he responded, because that’s where the money is.

From a cost standpoint, your top 5 percent of your highest risk patients usually account for 50 percent or more of your total costs. That’s always going to be an important component.

But it’s a portfolio, as you are pointing out. You’ve got part of the portfolio that isn’t really incurring costs but its risk is rising, and you [want to do] what you can do to mitigate that.

And, you’ve got a part of the portfolio that we all count on to stay healthy. [The focus is on] what can you do to propagate that, to keep people [in good health].

We, like most managed care organizations, are focused on the portfolio. Undeniably, the significant percentages [of costs] are in that top 5 percent.

ConvergenceRI: Significant percentage? Could you define more precisely what you mean by that?
Where do we implement our care management programs, as we look at the top 5 percent, chronic disease is one of the biggest triggers to determine that 5 percent – whether someone was hospitalized, if there are certain drugs or therapies that get started. These [data points can] indicate that there is a high risk that potentially could be managed.

It goes back to your data question: we use lots of sources of data to identify folks ahead of time, as early as possible. Health risk assessment is one of best tools to identify that.

If you look at the actual resources we deploy, an overwhelming percentage is [for] that 5 percent. By the same token, we are as concerned about folks staying healthy. We have a lot of benefits designed, for instance, to [encourage] people to make use of yoga.

ConvergenceRI: Is yoga something that you reimburse a patient for?
We have yoga classes.

ConvergenceRI: Yes, you do offer yoga classes at Your Blue Stores. But, if someone went to a provider, say, complaining of neuropathic pain, and the provider recommended yoga, is that a reimbursable medical expense?
I’ll have to get back to you on that.

ConvergenceRI: Given the demographic trends in Rhode Island, with a growing population of older residents, is there a conscious effort to market Medicare Advantage products?
You bet. We’re the largest Medicare Advantage insurance carrier in the state. I believe we have upwards of 53,000-to-55,000 Medicare Advantage members covered already.

We are probably the most penetrated state already in New England for Medicare Advantage. We’re in the mid-20s; most of the states surrounding us are in the high teens [in terms of percentages].

We still see it as a significant growth area, and frankly, we are actually quite good at it. It is a market that caters to the individual, and we do an awful lot of servicing people at the individual level. Our stores are a great example, where our Medicare Advantage [customers] are continuously increasing their “touches” with us through our stores.

ConvergenceRI: Where are the Your Blue Stores located now?
In East Providence, in Warwick, and in Lincoln.

ConvergenceRI: I saw where you have added a nurse care manager at each of Your Blue Stores. Is that correct?
They are there for on-the-spot advice, in the conversations people have, if they have nutritional questions, medication adherence questions, things like that. It’s taking care of things in the moment.

The one-to-one relationship that Medicare Advantage typically succeeds in [depends] on how one-to-one it is.

ConvergenceRI: In last week’s issue, there was an interview with the dental director at the R.I. Department of Health, and he recommended that dental benefits become part of Medicare as an efficacious way of attending to the unmet and under-served needs of older Americans. Do you agree?
I think extremely highly of that idea.

We do have dental benefits integrated into our Medicare Advantage.

I can just tell you, anecdotally, that my mother works as a practice manager for a dentist. She is 78. The stories that she has in terms of the biggest tragedies are all seniors, who lose their dental coverage.

ConvergenceRI: Has Blue Cross developed an integrated database to look at the combined mortality and morbidity rates for the diseases of despair – alcohol, suicide and drugs?
I am relatively new, so I’ll have to rely on other folks to answer that question. I do think that the exciting thing, though, when you are really looking at values and outcomes, it is forcing us to look at things other than the disease itself, it is forcing us to look at social determinants.

I recently read that the cost of loneliness is being equated to the equivalence of smoking 20 cigarettes a day. Clearly, in an elderly population, as social circles shrink, that is a high cost. That is really getting upstream, looking at how do we impact those social determinants of health.

ConvergenceRI: That’s a perfect lead in to my next question: How do the efforts to establish health equity zones fit within Blue Cross’s strategic plans?
As you know, we insure a commercial population, a Medicare Advantage population; we are not now a Medicaid carrier.

That being said, one of the programs that we are launching and we’re excited about is our home call program, that will be dispatching a multi-disciplinary team to the home of the highest risk patients.

ConvergenceRI: Will those be community health workers?
A social worker, a nurse, and, if needed, I believe, a physician. The highest percentages of people in the highest-risk categories are also [living] in the low-income areas. So, it is a big cross section.

People of means are probably institutionalized or have services brought to them. One of the biggest interventions that people make is making sure that those folks are connected to the community services that they need, such as transportation.

The other thing that we are looking at exploring is: Is there a way that we can incentivize primary care to be localized in those areas?

Because a lot of primary care offices that traditionally serve those populations have tended to retire or are retiring, so what can we do? We are starting to look at that.

ConvergenceRI: Would one of the answers be to make investments in existing community health centers that are very good at providing affordable, accessible primary care.
That could be. We’re looking a lot of different options.

ConvergenceRI: The Care Transformation Collaborative [was] given an award by The Rhode Island Foundation at its annual meeting. What are the takeaways from Blue Cross’s perspective about the future of all payer, patient-centered medical home approach?
We’ve supported CTC from day one. The support has been enthusiastic. I see our medical leadership as extremely engaged with it. I know the financial commitment we have made to it, and it is something that we will continue to make.

I also know that two-thirds of our network is PCMH accredited. Coming in from another part of the country, that number is extraordinary.

When you ask about funding, having been in other regions of the country, that similar question is being asked, because PCMH was never considered a destination; it was always considered to be the first critical step in an evolution.

I think that the foresight people had here to invest in it, and to have such a huge foundation being built, is phenomenal.

ConvergenceRI: How much overall has been invested, at this point?
I know that last year we funded about $25 million in infrastructure, and the majority of that is PCMH funding.

The emphasis has been focused on primary care; the bar that has been set to achieve PCMH accreditation is undeniably admirable. With that foundation, with that infrastructure, we clearly have seen improvements in quality indicators, gaps in care that were not previously filled have been filled.

The question is: how has that related directly to affordability? I think that is the question now in front of CTC, and I know that they are in a strategic planning mode.

Clearly, we, and others, want to see that investment pay off, not just in the long term, but also to continue to pay off in the short term.

ConvergenceRI: How do the patients’ voices get heard as part of the health care process?
The voice of the patient is critically important to getting the patient to team up with their caregivers, to trust them. There are a significant number of patients who will not be honest with their caregivers.

A good part of how we are measured includes patient experience and how the patient relates to us but also with our providers. We are constantly thinking about how we can incent the behaviors of providers to improve that experience. Clearly a part of that is asking the patients.

I know that last year we made $1 million available to improve satisfaction scores.

Unfortunately, we didn’t pay out a dollar; we didn’t see any improvement in the patient experience scores.

So, we took that in, and thought, what else could we do?

Right now we’re funding a program called Help Me Health. It is a program that was designed by folks to help teach health systems and doctors how to help them help their patients.

It is a course that works not just with clinicians but the entire staff, teaching them what it is that patients really want to know.

Patients want to be comforted, they want to be included, they want to be knowledgeable.

It’s really a systemic issue, it is not necessarily an individual issue.


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