PROVIDENCE – Just over the border from Seekonk, Mass., nestled into a new expanded shopping mall on the edge of Route 6 in East Providence known as Highland Commons, half a block down from WPRI-TV headquarters and right next to a nail salon, is the latest version of Your Blue Store, an effort by Blue Cross and Blue Shield of Rhode Island to build out its consumer store presence in the state.

The newly opened store was one of the first featured tours as part of DesignWeekRI, a 12-day celebration that seeks to showcase and brand the image that “Rhode Island is Design.”

On Wednesday evening, Sept. 13, principals from KITE Architects and Kelly Taylor Interior Design, the team that created the makeover for the Your Blue Store in East Providence, described the process by which they created the space. About 30 DesignWeekRI participants attended the talk.

From lighting to privacy, from greeting to waiting spaces, from bill-paying to meeting with a nurse practitioner, from group exercise spaces to working spaces for employees, the architectural and interior design team labeled the concept that unified the design goals as “Your Blue Path” – finding the path to wellness and prevention.

The store is targeted to an older clientele, seniors who are much more comfortable conducting business in person, face-to-face, rather than by computer.

During the month of September, the Your Blue Store in East Providence featured a full calendar of free exercise and nutrition classes for members, including yoga, salsa, Pilates, Tai Ji Quan, Butts & Gutts, Zumba and a Matter of Balance. In turn, employees are encouraged to participate in a steps program of walking, made easier by the design of a circular path in the center of the redesigned store, as part of a partnership with Virgin Pulse.

Consumer engagement
Finding the path to wellness and prevention and building out the relationships with members and with providers serves as an apt metaphor to the investment strategy articulated by Kim Keck, the president and CEO of Blue Cross and Blue Shield of Rhode Island, in a recent interview with ConvergenceRI.

At a time of great uncertainty in the health care and insurance marketplace, both in Rhode Island and nationally, Keck emphasized Blue Cross’s commitment to the local community as a primary responsibility and the best way for the insurer to define its corporate image.

When asked by ConvergenceRI, what was the corporate image that Keck saw for Blue Cross moving forward, and the ways in which she would like to reshape the image of how people viewed Blue Cross, she answered: “I know you called it our corporate image; I think about it as our community responsibility. I think about it as our community involvement.”

It was something, Keck continued, “We take very, very, very seriously. We are very mission-focused; we have our responsibility to the local community, to be focused on the notions of access and affordability to high quality health care. Last year, we donated more than a million dollars, philanthropically, [with many grants] to kids that don’t have access to the kinds of healthy programs we’d like them to have.”

Keck also talked about the fact that Blue Cross employees volunteered more than 8,000 hours, including as part of the insurer’s signature event, Blue Across Rhode Island, as a way to build connections to the community.

We volunteer an incredible amount of hours, I think it was over 8,000 hours in 2016.

For Keck, the biggest challenge that faces Blue Cross are the rising medical costs. “We need to continue to focus on affordability in health care. In Rhode Island, we are in the top 10 in the country in terms of the most expensive states for health care. I don’t mean insurance; I mean health care.”

And, of course, she continued: “Health insurance premiums are driven by the cost of health care.”

For the insurance premium perspective, Keck said, “We feel pretty good that we haven’t had some of the increases in some of our segments that other states have had. But, it’s an expensive place.”

Here is the ConvergenceRI interview with Kim Keck, president and CEO of Blue Cross and Blue Shield of Rhode Island, one year into her job as leader of the state’s largest commercial health insurer.

ConvergenceRI: Could you reflect upon the changing of the guard, the changing leadership in health care, particularly given that Dennis Keefe announced his retirement today? What role do you see yourself playing as the head of Blue Cross?
KECK: Thanks for coming in today and spending a little bit of time, for what I know will be an important topic.

I came here a little over a year ago. I was born and raised in Rhode Island, I consider myself a Rhode Islander. I’ve been in health care for 30 years, exclusively outside of Rhode Island.

I came in and learned about many of the great things that the team here had put in place before my arrival. And, it was one of the reasons why I wanted to come [here] was because of the work that had been underway, including the great work that Blue Cross has done with people like Dennis Keefe and the company he leads and runs at Care New England.

More specifically, I think about what Dennis and Blue Cross have partnered on, things [such as] the Integra ACO that’s been underway for several years and has had success.

It’s been an evolution. But, I think, here in Rhode Island, one of the greatest things about this place – it’s a funny little place, it’s the place I call home – but it’s a place where we can have a big impact, because the state is so small.

Leaders [such as] Dennis bring a lot to the table. I know his successor. I look forward to continue to look to do great things with Care New England.

ConvergenceRI: One of the partnerships that Blue Cross had created with Care New England and The Providence Center through its for-profit division, Continuum, has been HealthPath. The results to date have been promising in efforts to provide wrap-around services for mental health and behavioral health patients for better coordination of care. I understand that there is some research that documents those results. Is Blue Cross ready to share the results of that research?
KECK: I don’t have the statistics ready to share with you today. I don’t know if we have published them. We have talked about them with our board.

The work, although sort of in its infancy as these things go, has been positive so far. But you hit the nail on the head, Richard, with the notion of getting patients access to high-quality, affordable health care. That’s part of the bull's eye in our strategy.

One of the things we’re heard from our partners and from patients is that it is very difficult to have affordable access for things like mental health that are not well defined, where every time a patient turns around there’s a co-pay or a co-insurance charge, of what could appear to be a potential obstacle to coordinate care in a way that thinks about the entire condition, whatever it may be.

ConvergenceRI: If it is possible to get access to that research, I would like to see it. I would plan to give it the kind of in-depth coverage it deserves.
KECK: I think one of the things we have to figure out, I am not a clinician by background, but I think one of the things we should talk about internally first is that it’s a small sample, and often times people I think are afraid to extrapolate beyond what is a small sample.

But it is a great success in the limited sample that it is.

ConvergenceRI: Another effort that your predecessor had been very involved with was investing in the patient-centered medical home model. I believe that my numbers may be out of date, but the last figure I had heard was that Blue Cross had invested some $60 million in patient-centered medical homes.

Is there a more up-to-date figure about how much has been invested by Blue Cross? And, in terms of return on investment, Marie Ganim, the new R.I. Health Insurance Commissioner, quoted a number for an old news release saying that for every $1 invested, there had been a return of $2.50. Do you continued to see this as a positive investment moving forward?
KECK: If we fast-forward to end of 2016, that $60 million is now closer to $80 million, just in excess of $80 million, invested in patient-centered medical homes across a number of different initiatives. They include pharmacists within the medical home, case managers, [resources] provide to PCMHs to adopt electronic health records, anything that gets at the coordination of care.

The returns [on investment] that I look at, first and foremost, are the outcomes, not so much in ROI analytics, but in clinical outcomes.

The results we talk about are things like reductions in avoidable ER admissions, something like [reductions] of close to 20 percent in avoidable ER emissions. And, increased screening for certain cancers, like a 20 percent increase in breast cancer screening.

One of the things we track is: are patients going for follow-up visits with primary care providers? We have benchmarks for how many patients should be seen as a follow-up by their primary care providers; we’re about 35-40 percent higher than those benchmarks [as a result of patient-centered medical homes.]

I think about the clinical outcomes before I think about the ROI and does it pay for itself. I think we’re going to do it because it is the right thing to do.

ConvergenceRI: It appears as if Blue Cross is doing a lot of research. Two years ago, I heard that Blue Cross was developing its own disease database. With the increasing trend toward population health and population health management analytics, what kinds of research do you see as critical for Blue Cross to conduct moving forward?
KECK: I am a huge believer in research. Once again, it was not my strategy; I inherited it. But I am thrilled because I support it.

A few years, ago, before my time, we had developed tools to give to primary care physicians [the capability] to look at gaps in care – to be able to look at your patient panel to see what kind of services they were getting, and importantly, what kinds of services they weren’t getting.

If you are going to drive and pay for [improvement] in outcomes, you have to understand, holistically, that if you’re missing a certain service, it might mean [the patient] doesn’t remain as healthy or get as healthy.

But as I fast forward to 2016 [and beyond], what I would say is that the kinds of investments we are making are in the kinds of tools, technology and data to give to primary care physicians revolves around specialists.

Here in Rhode Island, specialists largely sit outside of the coordination of care. Bringing specialists into the equation is an important aspect of the coordination of care.

I would say that our latest in investment in 2016 is working both with specialists and with primary care physicians, asking: do you know where your patient panel [the number of unique patients under the care of a speicific provider] is going, in terms of efficiency, in terms of cost? I would love it to be more about quality, but we are not quite at that evolution, where we can say: here’s the cardiologist with the best outcomes, or here’s the orthopedic [specialist] with the best outcomes.

We don’t have all of that data, but we do have efficiency and cost information to work with primary care physicians in saying, let’s be thinking about this a little more holistically.

ConvergenceRI: Can you define, from Blue Cross’s perspective, what is population health?
KECK: I use the phrase population health to say almost exactly what the words suggest: thinking about more holistically the entire spectrum of how we manage and potentially pay for, over time, how to get broad bases of people to [achieve] the best health outcomes.

Historically, medicine [has been] episodic, that equates, perhaps, to a fee-for-service mentality, where we go to a doctor, we get a service, we go to another doctor, we get another service.

That service might or might not have been coordinated in a way that actually improves your health.

ConvergenceRI: As part of the evolution toward population health, it seems as if the risk is being put more and more on the providers, on health systems and hospitals, to serve almost as their own insurance company. How would Blue Cross like to see population health evolve?
KECK: I do think, as part of this process of getting paid for better outcomes, it is taking more risk.

It’s not just saying, I’m treating this one issue and not thinking about when you have a specialist to go see. And, if you want to go to see a cardiologist, I want to understand what happened with the cardiologist. I want to understand when that cardiologist says to come back every six months, was that the right thing to do, or not.

As I think about the tools that physicians will need, a lot of it is data; first it is information, but it's turned into data. And, it’s technology and it is information that can be integrated into their practice patterns naturally, not some place where they have to log in four different times after the patient leaves.

There is a lot of support work that has to be done, that’s why we fund things like case managers and pharmacists and nurses in the medical homes of these physicians’ offices.

ConvergenceRI: Is there a trend for commercial insurance companies to develop self-insured products for small businesses with 50 or fewer employees in Rhode Island?
KECK: What I have seen more nationally, and at a growing level in prevalence and in tone and volume, if you will, is employers saying, who have 25, 28, 38 or 48 employees, I cannot take the price increases of [health insurance premiums].

[They are seeking out] an environment that might be more stable, asking: is there is a way to insure their employees on a self-insured basis.

What I have seen in other markets, more prevalently than I have seen in Rhode Island so far, is product development around how to create such a product. These products exist, and it is something important for us here in Rhode Island [to be aware of].

It is something that I see coming down the pike, and it would be something along the lines of [developing] a way to make what is essentially a self-insured product that looks like a fully insured premium.

As an employer insuring 35 lives, you understand every single month what your bill is.

The problem with being self-insured is that when you are a huge company, you can take the volatility in claims, you can take the surprises in your cash flow.

But, as a small business, you’re looking to make payroll, and if you get a large claim, and it can be $50,000 or a $100,000 claim, you don’t want that volatility or that risk.

So, [with the new self-insured product], there is a way to get at – I’m going to call it “leveling out that risk” – and providing some protection against large, catastrophic claims.

Those products do exist in a lot of markets. It doesn’t really exist here [in Rhode Island] completely, but I see it as a future trend.

ConvergenceRI: A concern that was voiced to me by someone with more than three decades in the nursing profession, with a Ph.D., is that it was difficult for her to get reimbursed for home health care. She said that she had to become certified as a community health work in order to be reimbursed for going out on home visits.

Is that something that Blue Cross will consider looking at, particularly as nurses play a more prominent role in the evolution of health care?
KECK: I would say that I do not know of a holistic approach that we have to look at reimbursements. What I would say, going back to our discussion about patient-centered medical homes, is that we will often put nurses in the these practices to get at the very issue you are talking about.

There are roles in health care across the spectrum that need to be coordinated. I believe, and I know that Blue Cross believes, we should have every clinician practice up to their level and not down to a level beneath them.

But there are a lot of challenges in health care around reimbursement, even for a simplistic way for trying to bill for something that may add value to the system, but there is no code to be billed for.

ConvergenceRI: Such as yoga?
KECK: Like yoga. There are many, many examples, such as some of the things around the social determinants of health that determine people’s health outcomes sometimes, but don’t fit into an ICD 10 code or a CPC [common practice procedure] code.

I think, over time, those things are going to have to evolve to a place where we are insuring [benefits] that get at the most effective ways to keeping a population healthy.