Delivery of Care

“Health is so much more than health care”

An interview with Martha Wofford, president and CEO of the BCBSRI, talking about the value of the latest R.I. Life Index data, calling it a North Star to help guide the state’s future health policies

Image courtesy of Rhode Island Life Index website

The 2021 Rhode Island Life Index surveyed some 2,500 Rhode Islands to capture their perceptions about the state of the state when it came to health and well being.

By Richard Asinof
Posted 11/29/21
The latest edition of the R.I. Life Index, a survey of Rhode Islanders about how they view the state of the state’s health and well being, has created an important tool for measuring trends in identifying the unmet needs around the social determinants of health.
What is the best way to use data as a communications tool around public health messaging during a pandemic? When will the state of Rhode Island provide the same comprehensive data analysis and reporting around the continuing epidemic of overdose deaths and substance use disorders as it does with the COVID pandemic? Is there a way to put names and faces on those that have died during the pandemic in Rhode Island? Given the volume of emerging crises around staffing, would it make sense to have an emergency spending bill authorized by the R.I. General Assembly in December? What are the best practices around testing and can they be broadly publicized?
Sometimes the overwhelmingly nature of data gets in the way of storytelling. Recent reports that more than 100,000 Americans had perished during the last year as a result of drug overdoses drew strong reactions from some in the recovery community. As one person posted on Twitter: “100,000: In an attempt to bring some humanity back to this crisis, in the upcoming days, I will be posting pictures and names of the people I have personally lost over the years. F*** your numbers! These numbers have names.”
The Hulu series, “Dopesick,” based on the reporting of Beth Macy, has provoked a similar outpouring of emotional content on Twitter, as the actors recreate the drama around attempting to hold the Sackler family accountable.
Here in Rhode Island, beginning in January, the R.I. Attorney General may be bringing a court case against manufacturers and distributors of opioids. With the recent verdict against three larger pharmacy chains, including CVS, the legal efforts to hold large corporations accountable for their actions continues in the courts. Stay tuned.

PROVIDENCE – We are awash in a sea of data, raising alarms about the increasing threats to our lives, as we urgently try to calculate the best path forward on how to respond to the latest variant threat from COVID, omicron.

Charting a course is difficult when your boat is always being swamped by swelling waves – and when many refuse to row, while others only want to row in a different direction, based upon partisan politics, not public health.

Simple common sense prescriptions should suffice: wear a mask; get vaccinated; get boosted; if you feel yourself getting sick, get tested. And, from a broader perspective, share the vaccine wealth across borders.

And, most importantly, practice kindness in your every-day activities of being a participant in the community around you. Remember: we are all living in the same kettle of fish.

Yet, with all the urgent reporting and all the policy analyses, with all the predictions and political weather maps, it can seem difficult to chart a rational course through the storms raging around us, because of all the intentional misinformation being broadcast and amplified by partisan interests.

We are inundated with endless polling data seemingly taking the daily temperature of the political chaos. We are being asked to read the tea leaves of data sources that compile running tabulations of new COVID cases identified, the rates of hospitalizations, and the demographics of how the virus is afflicting our communities.

But some data can prove to be more significant. Two weeks ago, the Brown School of Public Health, in partnership with Blue Cross and Blue Shield of Rhode Island, released the findings of the third annual R.I. Life Index, a survey of some 2,500 Rhode Islanders, in order to capture their perspective on how they view the health and well being of the state.

Creating a longitudinal measurement tool that can track data trends around what many have termed the social determinants of health has potential enormous value – if the data trends identified can then serve to influence policy directions for the better.

In the first R.I. Life Index, published in 2019, the messaging from the results was straightforward: ZIP codes were more important that genetic codes in determining health outcomes, testifying to the importance of place-based health policies.

Not surprisingly, safe, affordable housing has emerged as a critical need identified across all demographic sectors, in all three of the surveys conducted.

This year, the R.I. Life Index improved its survey techniques to include 11 different languages to capture the larger reality of the state’s diverse population.

Last week, ConvergenceRI spoke with Martha Wofford, the president and CEO of Blue Cross and Blue Shield of Rhode Island, to take a deeper dive into the data and how it reinforces the importance of creating such a longitudinal survey study.

Like so many things begun in Rhode Island as health care innovations, the R.I. Life Index is attracting national attention, with insurance companies and hospitals from across the country thinking about launching similar efforts.

“There are national groups that are interested,” Wofford said. “The social determinants of health, as we call them, have become such an important area for lots of hospitals and insurance companies around the country for many people focused on improving healthy outcomes – and there are not good ways to measure them, and so there we are seen as a bit of the gold standard to having a thoughtful approach to measuring them.”

There is significant interest, Wofford continued. “I do not know what will happen on that front, but we are definitely happy to share our methodology and our findings and help others follow in our footsteps.”

Wofford also talked about differentiating between the urgent, short-term crises now facing Rhode Island and preparing for longer-term policy solutions. Access to safe, affordable housing has been identified as a critical need in all three R.I. Life Index surveys, and, as a result, Blue Cross has redirected its philanthropic investments to target affordable housing, including $4 million this year being granted to the Rhode Island office of the Local Initiatives Support Corporation, to serve as “seed money” to leverage further investments in housing.

As Wofford explained, it will take a long-term commitment to fully address housing issues. “We are going to be [working on] the affordable housing problem for the foreseeable future,” she said. “This is going to be [an issue] for decades that we are going to have be focused as a community in addressing.”

Trying to address the shorter-term gaps, Wofford continued, “is a little bit different than what the RI Life Index does. You can think about it as creating a bit of a North Star – [identifying] where we need to get to over a long period of time.” By identifying the long-term trends, Wofford said, “What becomes clear is the global nature of our situation – and the need.”

Here is the ConvergenceRI interview with Martha Wofford, president and CEO of Blue Cross and Blue Shield of Rhode Island, talking about the way that the R.I. Life Index is attempting to create a navigational sea change by listening to the voices of Rhode Islanders and then steering the policy ship in new directions.

ConvergenceRI: I wanted to talk with you about the R.I. Life Index. This is your third year conducting the survey and publishing the data. I believe it is important to be able to take the pulse of Rhode Island and to hear the voices of what Rhode Islanders actually think, rather than what experts tell us we should think about what is going on.

Such a longitudinal study, I believe, can have great resonance because, over time, it builds up a reservoir of data and information. My first question: How does that data intersect with other flows of data?

In particular, how does it link to, and connect with, data surveys being done by Health Equity Zones, by DataSpark RI, now based at URI, and some of the data analyses by R.I. EOHHS? Is there an attempt to correlate that data?
WOFFORD: We make the RI Life Index data publicly available. Our objective is that other organizations will use it, and do correlations between their datasets and this data. We shared the data recently with Unite Rhode Island [part of the United Us platform].

As you may know, Christopher Ausura, who heads up the HEZ initiative at the R.I. Department of Health, sits as a member of the R.I. Life Index Coalition.

And, I know some other entities are using the data; United Way of Rhode Island does, so does the R.I. Community Food Bank. So, there are ways that they are intersecting our data with their own data, [which is then] being used for planning and reporting.

ConvergenceRI: Blue Cross has enormous [amounts] of data about your membership and what is happening with them. It probably exceeds what people in government may have, not that you can share it publicly, because it is confidential.

I was wondering, in terms of trends that were identified in the R.I. Life Index, how does that subset of data fit into what you are seeing overall in regard to the health of Rhode Islanders, based on membership trends?
WOFFORD: That is a great question. I think the [two sets of] data are quite different. I would say we use the R.I. Life Index to do things like set our philanthropy objectives, when we hear how critical housing is, and how few Rhode Islanders say they have access to safe and affordable housing, that it's really driven our focus on investing in affordable housing in the community.

We have given $3 million in the last three years, and we just made a commitment, which we had talked about [in the Zoom presentation on this year’s R.I. Life Index] for $4 million, which I am happy to speak more about.

That is one area in how we use the data. I know that you had questions about pharmacy costs, and I think that would be worth diving into as well, because that is something we see in our claims data, as well as in this perception data that we get out of the survey.

They are quite different types of data. There are some areas where they intersect but the R.I. Life Index data is for all Rhode Islanders, versus our membership data, which is a different subset. I think it is an interesting question about how best can you use the RI Life Index data to drive policy decisions, which is more how we intended.

ConvergenceRI: I have asked the Governor this question, I have asked Brenda Clement, who heads HousingWorks RI, and I will ask you: how do you define “affordable housing” and what is the best way to define it moving forward?
WOFFORD: For us, we are really focused on how do we work with the community that has been focused on housing for many decades.

We are not stepping in to provide our own definition as much as we are trying to listen to the people who are experts in the field, and then help make grants and write checks to the people who are doing really important work to expand it.

I don’t know if they all have a common definition, honestly, or if it is different. But what we are trying to do is to enable these organizations to make a dent in this very large problem.

ConvergenceRI: That makes sense. The Governor told me one thing; Brenda Clement told me a different thing. And, talking with folks at ONE Neighborhood Builders, they have a different perspective. What I was looking for was some clarity in how urgent the problem is.

As part of the RI Life Index proceedings, you announced a $4 million grant to R.I. LISC, and as you said, you are allowing the organizations to define what is affordable housing. What do you hope to come out of it?
WOFFORD: I really appreciate that question What we are excited about with that opportunity is the idea of creating an anchor to a fund, to put a sizeable amount of money that will then be used to leverage additional investments into that fund, so that is the opportunity.

And, it is specifically going to be used to provide financing, innovative financing to preserve existing housing, as well as producing more housing, and providing some payment assistance to individuals, and also investing in community facilities, as some examples.

So, it is very holistic, what they are trying to do. But the really big opportunity is to attract that additional funding. and to use [the $4 million] as seed dollars to start the process.

Because the way we see it, and I know we say this with the R.I. Life Index, that health is so much more than health care. And, there is so much to be done to address this housing crisis, no matter how you exactly define it.

Clearly, there are people – we hear this loud and clear through the R.I. Life Index – who do not feel like they have access to a safe, affordable place to live.

They are struggling to have that basic security that lets them then focus on school and jobs and all the other things that lead people to have healthy lives.

ConvergenceRI: Do we need to see housing as health care?
WOFFIRD: Yes. We look at housing as health. And so, we are focused on how do we help support all the people of Rhode Island around having this comprehensive health and well being [need met]; that is the goal. It is not just about health care for all of us to have healthy, fulfilling lives.

ConvergenceRI: Some folks shy away from making that leap. Clearly, you seem to be embracing it, if I can use the phrase, “hugging” it…
WOFFORD: [laughter]

ConvergenceRI: …that there is no differentiation, that housing is an integral part of health. Brenda Clement has often used the phrase, “The path to prosperity begins at your front door.”

At the initial feedback session when the R.I. Life Index was first launched in 2019, Angela Ankoma, who is now vice president of equity investments at the Rhode Island Foundation, before that she was in charge on equity investments at United Way of Rhode Island, she asked the question if there was a way to catalogue all the calls coming in through Rhode Island 211 asking for assistance, because she believed that there was a great deal of information to be gleaned from what people were asking for help.

Are there ways that the R.I. Life Index could amplify its findings by getting data from other sources?
WOFFORD: I think that is a really interesting question. I do think that 211 [can serve as] a very interesting and important indicator of health and well being.

We are big proponents of it; we recently gave a grant to United Way of Rhode Island, $500,000 over the next three years, to enable them to connect the people who call into 211 with resources through the Unite US platform.

We would love for the Rhode Island Life Index to continue to be used by other entities, and so, I think it is an interesting question. And, I think there could be interesting next steps to try to intersect the data.

ConverenceRI: Was there anything in this year’s data from the R.I. Life Index that surprised you?
WOFFIRD: Honestly, I thought the data would be worse, given the pandemic. And, I think the fact that it was quite “flat” in a lot of areas we should take as a victory. Many organizations have been working very hard in Rhode Island to address things like food insecurity.

There were a whole bunch of areas that scored surprisingly similarly to the last two years. I don’t think any of us were surprised by the decline in the perception around access for kids to resources, or a decline for seniors to services.

This is a time [during the pandemic] when we have all been cut off from a bunch of those resources. Many organizations have had to shut their doors, at least temporarily, during the pandemic. But I was pleased and certainly surprised by the fact perceptions of insecurity didn’t [increase] during the pandemic.

ConvergenceRI: In regard to the lack of access to services, in the last couple of days, I have heard anecdotal stories form sources, saying that early intervention services by the state have been shut down because of a lack of staffing. Were you aware of that? Had anyone brought that to your attention?
WOFFORD: They have not. But I am aware of many resource constraints in our health care system and throughout the state. But I had not heard that.

ConvergenceRI: I also heard that the census for beds at Hasbro Children’s Hospital was at 120 percent, according to a source, for young people, mostly related to mental and behavioral health issues.
WOFFORD: Hmm.

ConvergenceRI: I have not heard or seen much reporting about these issues. It is hard to dig down during Thanksgiving week, hard to get responses from anyone. So, I appreciate you making time for this interview. My question is: How positioned is Blue Cross to be able to respond to what I would call shifting currents, where things become urgent, and to target additional investments and resources toward those emergent issues.
WOFFORD: That is a good question. I think we did a good job at Blue Cross and across the state around COVID, leaning in and doing things like grocery delivery to members during a time when clearly people were really struggling. I think we do have the ability to pivot and deal with crises when they occur.

Some of the issues are structural and challenging, such as behavioral health, looking at prevention of those issues around access to inpatient beds.

We are trying to chip away at the problems in behavioral health and investing in ways to increase access in the community. But it is very hard. I think, with some of these, you can pivot, and lean into, the problem, and solve it more long-term, while some of the problems feel more structurally challenged. Does that answer your question?

ConvergenceRI: I consider you to be an “expert”; you are involved in directing and investing resources. When people share such information with me, I try to trust my sources [and always to protect them].

It is difficult to verify such items. Clearly, I believe that things are going on. But, I am happy to be able to share those observations with you. And perhaps, given that you may have better sensors on the ground, you may be able to confirm what is happening.

When it comes to the RI Life Index, is there interest in updating the survey more frequently than on a yearly basis? To have updates every six months, because the world is changing so quickly?
WOFFORD: That is an interesting question. We have not thought about doing it more frequently. It is a very big lift, as you can imagine. As I think you know, we added 11 languages this year. When you think about the work to be done – [asking questions] in multiple languages, to really listen and get that input, we had 2,500 Rhode Islanders who participated in this year’s survey – that is not something that we are really equipped to do more frequently.

We are focused now on the trend data, because we have now three years of data, and you can start to connect the dots.

We are talking to people in other parts of the country who are interested in replicating [the RI Life Index]. That might be an interesting way for us to benchmark our progress.

I am a huge believer in measuring, and that by measuring the issue, you can then draw attention to the challenge, creationg a shared agenda with the community to then address that agenda, and try to execute and actually close some of the gaps that we see. So, that is really where our focus is.

If we know that we have visibility, and we can see the big issues, and we can see that they are consistently a problem, then how do you then attack them? Because it takes a long-term commitment to address these issues

We are going to be at the affordable housing problem for the forseeable future. The short-term pieces are important, too,, the crises that you are referencing. And, I think we look at those as more of “how do we reach out to try and address the short-term gaps. But it is a little bit different than what the RI Life Index does.

ConvergenceRI: On a personal note, because you moved from Colorado to take this job in Rhode Island, are you traveling back to Colorado for the holidays? Or, are you fully ensconced here in Rhode Island for Thanksgiving?
WOFFORD: Thank you for the question. I am traveling to Massachusetts, where I am from, to celebrate with my parents, who are in their 80s. That is not a long drive, which is the nice thing. It is just a short trip, versus a flight.

ConvergenceRI: I wish you a very happy and healthy Thanksgiving. I assume you are fully vaccinated. This year, there has been a lot of talk about having rapid COVID tests to bring with you, instead of a bottle of wine. Are you bringing rapid tests with you to your family gathering? Is that something you would endorse?
WOFFORD: Wholeheartedly. I have a rapid test I am getting myself, before dining with my elderly parents. I think it is important for all of us. And, I am eagerly signed up for my booster as well.

I recently heard some best practices around rapid testing, doing it multiple times, 24 hours apart, to get the most reliable data, because they are not as reliable as the PCR tests. I would spread that best practice to your readers.

ConvergenceRI: What haven’t I asked, should I have asked, that you would like to talk about?
WOFFORD: I have to jump to another meeting. But I would welcome a conversation with you about pharmacy drug costs. You and I talked about it a bit, in the summer. And I think it is a really important topic. [See link below to ConvergenceRI story, “Ensuring better access and more health equity.”]

That’s an area that might lend itself to a follow-on conversation, especially around specialty pharmacy costs and some of the challenges, and what we are trying to do about it. We are seeing that as well in our data.

I think it is critical to be able to go into more depth, which I think your format enables. I think that is very helpful, because, as you know, there is so much nuance in health care,  that being able to get into the issues in more detail is very helpful to educate the public. I appreciate the work that you are doing.

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