PROVIDENCE – Martha Wofford, president and CEO of Blue Cross and Blue Shield of Rhode Island, has her fingers on the proverbial pulse of health care in Rhode Island.

Wofford welcomed the opportunity to talk about the health insurer’s priorities and challenges – and to answer hard questions about the insurer’s policies and programs – displaying a transparency that ConvergenceRI found to be refreshing, compared to the cold shoulder given by some of the other payers and providers in the state, such as Neighborhood Health Plan of Rhode Island and Lifespan, who have both consistently refused to answer questions and engage with ConvergenceRI.

Under Wofford’s leadership, Blue Cross and Blue Shield of Rhode Island has continued its sponsorship of the R.I. Life Index, a data-driven, deep dive into how Rhode Islanders view their own health landscape. [See link below to ConvergenceRI story, “Taking charge in health care.”]

In addition, Wofford has backed new initiatives to support improved access to behavioral health care in Rhode Island. She has also directed investments to be made in support of affordable housing in Rhode Island as a key component of Blue Cross’s philanthropic efforts.

Wofford has also been outspoken about her belief about the need to hold Big Pharma more accountable and the need to rein in the skyrocketing prices of drugs. “Drug costs are the largest driver of rising health care costs, nationally and in Rhode Island,” Wofford said, at the beginning of a recent interview with ConvergenceRI.

Wofford talked about the creation of a new contracting organization, the Synergie Medication Collective, which launched in January of 2023. The goal is to improve the affordability of drugs that are injected or infused by health care professionals in a clinical setting – affecting nearly 100 million Americans.

Wofford, who has been selected to serve on the board of directors of Synergie, the new contracting organization, said that she is “looking forward to working closely on how do we make this platform, with its 100 million members, work for the whole system and bring down drug costs.”

Here is the ConvergenceRI interview with Martha Wofford, president and CEO of Blue Cross and Blue Shield of RI. She was joined in the conversation by Chris Bush, senior vice president of Network Management and Pharmacy Operations, and by Rich Salit, public relations manager, in a Zoom conversation held on Monday afternoon, Feb. 6.

WOFFORD: First of all, I wanted to thank you for coming to the R.I. Life Index launch. It was great to see you there. It’s an important event for us – and it is important to have the conversation with the community about where the big gaps are.

I did want to spend time today talking about specialty pharmacy. As we talked about [the problem] a year ago, it continues to be a very persistent major driver of costs. [See link below to ConvergenceRI story, “The more we do what Big Pharma wants, the higher the costs are going to be.”]

We are employing new levers to try to address the costs, and I wanted to walk you through some of that new work.

I am really optimistic about the Inflation Reduction Act. I think it is an important win for us in the battle with Pharma to control drug costs and the ongoing work to get medications at an affordable price.

I wanted to talk about the issues, and then address some of the levers that we are pulling to try and address [how to lower drug costs].

ConvergenceRI: Go for it.
WOFFORD: Again, you know this, but drug costs are the largest driver of rising health care costs, nationally and in Rhode Island.

We are working hard at Blue Cross and Blue Shield RI to lead improvements in access to affordable, high quality and equitable care.

The thing that gives me heartburn is that we continue to see health care costs rising faster than wages for Americans.

We have an affordability problem. And, again, rising medication costs are the biggest driver of [those increases].

Now, more than a third of total health care costs are spent on medications. I don’t know if you saw some of the data that OHIC put out for the cost trends work.

ConvergenceRI: Yes, I did.
WOFFORD: You probably saw that pharmaceuticals grew 8.3 percent in every line of [the health insurance] business – in commercial, Medicare and Medicaid.

And, specialty drugs are driving that increase. We looked back over the past five years, and [their costs] have grown by 43 percent; now, they are over half of the total drug spend.

I think the thing that is most alarming to me is just the pace of [how the drug costs are] accelerating.

If you look ahead, in just two years, it will account for 66 percent of the drug spend. It is just absorbing more and more [of our health care spending].

I know you know this, but, for your readers who [may not] follow this area, specialty drugs are those high-cost drugs [which are used to treat] complex conditions, such as rheumatoid arthritis, cancer, and multiple sclerosis.

I believe we talked about this before, but again, a very small percentage of our subscribers are using those drugs: -- 2 percent of our subscribers drive 55 percent of the cost overall. And so, as you think about trying to manage toward affordability for everybody, you have to try and manage the cost of these drugs.

The other thing that is interesting is that the composition of these specialty drugs is changing. There are just an inordinate number of drugs in the pipeline, mostly for cancer.

There are five drugs that will come to market this year that will each [cost more than] $1 million alone. I don’t know if there are any questions you have on that.

ConvergenceRI: One of the questions that I have has come up in a number of recent news stories is the way that insurance companies have been using third-party reviewing agencies, if that is the proper term, to determine whether or not a patient gets approval for or denied access to such drugs.

One story was in the Washington Post, written by Carolyn Johnson, a health care reporter, entitled: “I wrote about high-priced drugs for years. Then my toddler needed one.” It detailed the difficulty in gaining insurance approval for expensive drugs.

Similarly, there was a story reported on by ProPublica about a case involving United Healthcare and the denial of specialty drugs for a patient who was a student at Penn State University.

I was wondering how you at Blue Cross look at denials, and what is the most important context when you have to deny a patient access to an expensive drug.

WOFFORD: I am going to ask Chris to help me on this question. But I would just say, as we talk about the problem, as we talk about what we do about the problem, one of the big categories is how do we manage drugs. And then, thinking about utilization management as a component of that.

On utilization management, what we tend to do in partnership with our pharmacy benefits manager, is to select specific drugs that will have a preferred placement on our formulary. The intent there is to drive more people to a drug that has a therapeutic equivalent, but to try to get more volume into one drug to bring the price of that drug down, relatively, and so sometimes that means that you preferring one drug versus another, but it is the same therapeutic equivalency as the objective.

So, at the highest level, it is really an exercise in trying to get some volume to have some leverage in a negotiation with pharma. But Chris, what would you add?

I didn’t see those articles, so I’ll try to go find them and read them.

ConvergenceRI: I’ll send them to Rich Salit, and he can forward them to you
BUSH: I saw the ProPublica article that recently came out.

There are certainly some tangible items that I would react to, in that example. There was, I believe, components of the drug that were being prescribed above the recommended doses, which created kind of one of these unusual circumstances

I would say whenever we have guidelines, particularly with a condition that somebody has been challenged with, for a number of years, we rely heavily on the prescriber, the clinical expert that is prescribing those drugs.

And, we do our best to match those resources not only internally to us, but also through our PBM, and have a good understanding of the challenges a member faces and the course of treatment that is being recommended.

I would say in general we really over-emphasize the clinical guidelines and the clinical treatment. It is up to the provider to give us that perspective that we don’t see, based on a prescribing prior authorization that comes over.

And, I would say, in general, that those guidelines we have are meant to steer consistency and recommendations, consistent with the FDA approval that a drug received, but there are variations that we have to recognize, because every situation is unique.

WOFFORD: I think it is really a balancing act, Richard, right? Between access to life-saving medications, which is what we want to have occur, and how do you balance the very high price tag of those medications.

And so, the attempt to manage and drive people to one medication or another is really part of this: How can you get health care to be affordable for everybody, and high quality, so people are getting the clinical care that they need?

I think we are just constantly trying to balance and to use the clinical guidelines, and use the clinical experts, to get people to medications that are going to work for them.

And, try to continue to manage the process in a way that we can manage cost. Again, it’s a challenge.

ConvergenceRI: It’s also sometimes a challenge for the patient to navigate the system, in terms of how do you make ends meet, when considering the cost of the drug. The insurer doesn’t necessarily control the pricing of the drug, is that correct?
WOFFORD: On the last question you asked, I would add one more thing. One of the things that we do, which I think is really helpful here in Rhode Island, is that we actually fund pharmacists being embedded with primary care physicians, we make them available to specialists, so when people are getting prescribed these drugs, we try to have the help to get them to a prescription that is most likely to work for them,

It [can be] super overwhelmingly and confusing for most physicians, because there has been this explosion in the drug pipeline.

On the question of cost, it’s a really good question about how does the price get determined. One of the challenges that we have is that the price on some of these drugs just gets increased every year, with no additional real value from it.

And so, what we are trying to do is to purchase drugs differently. One of the things that I am really excited about is that we launched what we are calling Synergie, a medication contracting collective, where we are purchasing drugs on behalf of 100 million Americans together.

To get to your question, what is really the starting price, to get that to be as low as possible, so that we can actually make those drugs more accessible to people while managing the overall price of the drugs, and we are doing that in a transparent manner, which isn’t exactly always the way that pharmacy procurement happens. It is really to make it transparent back to the payers, back to the members, about those costs.

We’re trying to figure out ways to bring the starting price to be lower, not just having to try to do things like utilization management on the back end.

ConverenceRI: I can testify personally because I get infusions of Rituximab every six months, to control what is eating away at the myelin in the thoracic region of my spinal cord. But the cost has gone up over the last two years, so that the copay with my insurance has gone up from roughly $450 an infusion to more than $2,700. With infusion treatments twice a year, it means that I am spending more than $5,500 in co-payments for the drug. It is the same drug, and the formulation hasn’t changed, but the price has increased dramatically.
WOFFORD: It is outrageous. One of the challenges with many of these drugs is that there have been bio-similars that have been developed, but they have been blocked from coming to the market.

Another initiative we are working on is to support Civica Rx, [a nonprofit generic drug company founded in 2018 to make quality generic medicines accessible and affordable to everyone]. The goal is to actually manufacture their own drugs, so that we can bring them directly to the market without pharma companies having the ability to block them.

We brought one forward in August to treat metastatic prostate cancer, and then, one that is really exciting, there is an insulin drug that is on the way that they are working on the manufacturing of that, to really bring down the price dramatically.

Yes, it’s outrageous that the price goes up every year, and yes, we have to figure out ways to bring that starting price point down. Chris, do you want to add anything?

BUSH: I would come back to the [idea of] increased competition being a good thing. And, if you look at another drug, again, at a more extensively [used] infused drug that we have had some biosimilar competition over time.

Remicade was first introduced in 2018. If you compare the average sales price from 2018 to 2022, that ASP has gone down not only for Remicade but for biosimilars as well, by 50 percent. As a result, everybody wins, from a cost reduction standpoint.

ConvergenceRI: Let’s move on to another topic. What is happening in primary care in Rhode Island, and what do you see as Blue Cross’s role with that? There have been a lot of complaints recently about the inability of patients to secure appointments with primary care physicians, because there don’t seem to be enough providers to go around to meet the demand.

I was wondering how Blue Cross views the problem about the apparent lack of primary care providers?
WOFFORD: It is definitely a challenge, in Rhode Island, and in the region more broadly, and in the country, to have access to primary care physicians.

What we are trying to do is to work with primary care groups in the state to invest more in primary care, so that they can grow their practice, so that they can bring on new physicians, so they can ensure what they pay their physicians is reflective of the important work that they are doing.

It is really important that we create those contracts with those groups that provide more financial rewards for better quality, so that you have better quality groups that are able to then attract new physicians and continue to grow their practices.

The other thing that is interesting is that if you do this well, you create the ability for those groups to bring on additional types of clinicians and people in their practices.

We think about team-based care for the ability to add a dietician or a social worker or a nurse practitioner to your practice means that you, as a physician can see many more patients.

So, they are able to open up their practices to accept new patients, and the patients get the care they need, matched up to the resources,

I don’t know if you have ever gotten nutritional advice from a physician; it’s good, but it’s actually better to get it from a dietician. And so, if you can match up the need with the expertise, you can then save some of most acute situations for the person with the highest clinical license, the physician, to treat, so you are able to see many more people and it starts to create this virtuous cycle rewarding quality.

BUSH: I would say that the physician burnout component is something we hear about on a regular basis. And, many of the areas that Martha described us making investments in certainly has helped combat some of that physician burnout.

And, more importantly, as we think about the future, it gives us a number of opportunities to have our physicians meet with members, not just face to face, but it might be telephonically, or it might be on a video chat, to meet the members where their care needs are.

ConvergenceRI: I believe that you are collaborating with the Care Transformation Collaborative and investing in their work around innovation. Is that correct?
WOFFORD: Yes, we are. We are working with them, particularly on the connections between primary care and behavioral health, to embed more behavioral health right into primary care, because, if we can get to people as quickly as possible who are having behavioral health challenges, it’s much better for them.

And, as you know, we have such a challenge in the state, in terms of access to behavioral health support in the hospitals, we really need to get to people earlier. It’s an ongoing huge problem, and CTC has been great in terms of working to address it.

BUSH: Richard, I just sent a clip that talks about how Blue Cross has obtained some additional appointments for urgent access for pediatric and adult behavioral health appointments.

Martha, I know you wanted to talk more about Synergie, because I know this was just announced a month ago, to talk about how it works.

WOFFORD: I think it’s super exciting, again, getting this collective contracting to scale, because we can not only bring down price, but because of the volume, we’re going to enter into contracts with pharmaceutical companies that are more nuanced.

If someone gets one of these potentially life-saving drugs, we can track that patient and their health outcomes over time. If they end up not having the outcomes that were promised, we can go back and get some of the money back from pharma.

We can also do things like put caps around inflation, so what you described for the drug you’re taking, with this kind of scale, we can actually contract and say, you cannot raise the cost year over year, more than, x percent, 2 percent, 3 percent, so that they just don’t keep getting increased and increased and increased each year.

I think that Synergie is very important. I had the opportunity to help develop it, and I am actually serving on the board of directors, so I am looking forward to working really closely, on how do we make this platform, with 100 million members in volume, work for the whole system and bring down costs.

BUSH: Well said.

ConvergenceRI: Coming up at the end of March, and officially on May 11, the federal COVID emergency declaration will end. For the Medicaid population, they will start undergoing eligibility checks. How will those changes affect what you are doing at Blue Cross? Can you talk about any type of strategic planning that you have done?
WOFFORD: I will give you a little bit of an answer, but I think probably more to come, on that question.

As far as Medicaid re-determination, we certainly think that more Rhode Islanders will be shopping for individual insurance plans through the exchange, once they lose Medicaid coverage, we would expect to see more people shopping for individual insurance directly.

That’s one factor; we still have state of emergency in the state of Rhode Island that we are dealing with as well.

We are working on these two timelines, and how they might be different, and the implications that some of the processes that we have put in place at the beginning of the pandemic and how to make those smooth for people and connect those two public health emergencies and timelines and processes together.

ConvergenceRI: In terms of behavioral health, will that impact the way that you are looking at telehealth capabilities for behavioral health and other types of care?
WOFFORD: It’s a good question. I am not fully up to speed on the answer to that.

We’re still trying to process what all of the changes are going to mean. So, I am happy to connect back to you when I have a more of an understanding.

[Editor’s Note: Following the interview, Wofford sent along the following statement clarifying the insurer’s plans: “I should mention that, unrelated to any pandemic health emergencies and before they went into effect, BCBSRI eliminated prior authorization requirements on in-network behavioral health services in 2018.

Then, at the beginning of 2023, we went a step further and eliminated prior authorization on all behavioral health services, both in-network and out-of-network. These will not go away with the end of any PHE declarations and are among many initiatives we have undertaken to respond to the rising behavioral health needs we are seeing in Rhode Island and across the country.”]

ConvergenceRI: I also understand that you are considering becoming part of the re-procurement process, for Medicaid Managed Care? You are one of, I think, four or five companies that may be bidding to become a Medicaid managed care organization.

Given the process, I know that you cannot discuss anything related to the re-procurement. But, I was hoping you might be able to talk about why you are considering re-entering the field after a number of years away, and how you see the potential market opportunity.
WOFFORD: Well, you are right, I can’t talk much about Mediciad. The state has announced that they are going to start a new process, which we understand to mean that an RFP or an RFI will be released later this year, for a 7/1/2025 effective date.

We will continue to look at what makes sense for Blue Cross and how we can serve the people of Rhode Island.

ConvergenceRI: What is happening with Oak Street? Are they going to be acquired by CVS? Is that something you are in favor of? I know that you have an ongoing relationship with them now.
WOFFORD: We have a relationship with Oak Street, a joint venture. They operate four clinics in partnership with us, in the state. And they provide great, team-based care.

It’s been important to provide additional access to primary care, which we were just talking about, is a huge problem in the state.

They are continuing to strengthen their operations here locally. I don’t know what is happening with them.

Around potential acquisition, I think reaching out to them directly is probably the best strategy for you.

ConvergenceRI: How big a loss is the fact that Dr. Megan Ranney is leaving Rhode Island and is moving to Yale? I know that you guys seemed quite friendly at the Life Index launch, so I assume that you have some basis of friendship and interaction. What do we have to do to keep talented people like Dr. Megan Ranney here in Rhode Island?
WOFFORD: I read your story today in ConvergenceRI. I am a big reader of ConvergenceRI. I think Megan is terrific, and I am very sad to see her leave the state. I think that Yale was smart to pick her up.

I think it is a challenge. I think we would all really like to see Dr. Ashish Jha return to the state, so that maybe we can start a lobbying campaign to get him to come back.

We have partnered, as you known, quite closely with the Brown School of Public Health, and so, we will miss Megan, and they have a great team of people that we work with there on the R.I. Life Index, and on a bunch of other areas. We look forward to continue to partner with them.

ConvergenceRI: Maybe there isn’t one, but does it appear to be a glass ceiling in operation in Rhode Island, for very talented women doctors to succeed here? Or, is that we’ve done such a great job in creating a fantastic talent pool that others are scooping them up?
WOFFORD: Well, I guess I’m the second woman leader of Blue Cross and Blue Shield of RI. From my vantage point, we’ve broken through whatever glass ceiling was there, in our organization. I don’t know what it was like earlier. I think it is always a challenge, for women to be considered for top jobs, and I think we need to continue to work on how we give women those opportunities.

ConvergenceRI: I know with the Life Index, you paid a lot of attention to the data collection that is involved, which was quite extensive. What kinds of new data constructs do we need in Rhode Island, to help us refocus our direction, when it comes to the health care landscape?
WOFFORD: It’s a great question. One thought that comes to mind, is to actually drill down deeper. So, as opposed to expanding to many more data types, I would love to see us get more granular with the data, so that instead of looking at averages, we actually begin to look at subpopulations.

For example, I think a lot about standards screening. When we think about those HEDUS [the Healthcare Effectiveness Data and Information Set] screenings, and some of those measures, they look fine on average across the population, but if you actually look more deeply, and you look at, for instance, the African-American population in a certain geography, you start to see that there are big gaps in care. What I am excited about is the opportunity to start to dive deeper.

That is actually consistent with where the Centers for Medicare and Medicaid Services is going, where they are also trying to develop a core set of quality measures that would be consistent across the board, so that we can go deeper into those core measures, to look at where there isn’t the right access to care. Sorry if I am being nerdy.

ConvergenceRI: Not at all. Drilling down makes good sense.