PART One

EAST PROVIDENCE – Inside the conference room of the busy “Your Blue Store” on Route 6, ConvergenceRI sat down recently with Martha Wofford, the president and CEO of Blue Cross and Blue Shield of Rhode Island, along with director of communications Rich Salit, to discuss the current challenges engulfing the health care delivery system in Rhode Island.

At the same time, in a separate meeting room, a popular chair yoga class was being taught, while a steady stream of customers sought out services.

This conversation comes at a time when there are many market forces disrupting the health care delivery system – financially unstable hospitals, a lack of access to primary care providers, a growing aging population of Rhode Islanders with complex medical needs, and escalating pharmacy costs, especially for specialty drugs.

Holding the interview at the Your Blue Store location was one way for Wofford to drive home Blue Cross’s successful strategy of how best to engage with its customer base, having earned more than a 96 percent retention rate of insurance customers. She, in turn, was surprised to discover that ConvergenceRI had been a regular customer of that particular Your Blue Store for the last three years.

In turn, the conversation was a way for ConvergenceRI to engage with Wofford about how she saw the value of ConvergenceRI as a vehicle for accurate news about the health care delivery system in Rhode Island, a complex topic to report on.

ConvergenceRI: Let me start by saying that I am familiar with the Your Blue Store initiative. How have you enjoyed reading ConvergenceRI? What is the value that you see in the product I am producing? And, how does it give you a competitive advantage, if that is not a leading question, in terms of information that you can’t get anywhere else in the Rhode Island marketplace?
WOFFORD: I read ConvergenceRI regularly because you are covering things that other people are not covering, quite simply. And so, it’s helpful, when you look at health care, which is so complicated. It’s hard to cover it at a high level. You have to get into the details and the nuance.

And, I think you do a very nice job of that. I think we appreciate the very local coverage that you are doing. Housing, as you know, is really important to us as well. And I think you do a lot of good coverage of the affordable housing work.

So, for me, it is a very valuable source to hear about a bunch of areas, which I don’t get as much depth from some of the other news media.

ConvergenceRI: Really?  [laughing] I find that much of the news media’s reporting is a miles wide and an inch deep, and they often miss the story.

 Such as the fact that Optum, a for-profit division of UnitedHealth, is now in charge of the Rhdoe Island’s Medicaid Managed Care Organization’s behavioral health and mental health services for all of the Medicaid-eligible patients in Rhode Island, which is roughly one-third of the state’s population.

And, Optum has a questionable track record, in my opinion, as I’ve reported in numerous stories. In the most recent issue of ConvergenceRI, I reported on how Optum’s second-quarter earnings in 2024 were $6 billion, on increased revenues of $13 billion. The profits came from providing for what Optum called “value-based services” for its members.

Essentially, in my opinion, they appear to be monetizing the health of poor people to make profits, which is not the way that I think that the managed care organizations should be doing business. And, I was a bit surprised that you were excluded from the state MCO contract.    
WOFFORD: I would say that I think you are aware we have been interested in the Medicaid business for a few years. We did submit a bid, and we were disappointed to not be selected. Absolutely.

I guess I would say I really want to take the opportunity to thank all the people that supported our bid – all the providers, all the community members. Our team worked on it for more than a year.

We had an amazing partner in Wellpoint, who serves almost 10 million Medicaid members around the country, with market-leading capabilities. So, I do really appreciate all the work that went into [preparing] the bid.

I am incredibly proud of Blue Cross and our capabilities and the service that we provide to Rhode Island customers and members. Things like “Your Blue Store.”

We have market-leading customer service, as I think you know, as rated by JD Power and by CMS. And so, I’m really proud of all that we have built, in fact, you probably know this, you might not, but one of the reasons why we have such good membership services is because of our “Your Blue Store.” We had over 96 percent retention in our business, and so, we certainly are getting the feedback from our members that they appreciate it.

ConvergenceRI: That’s very high. I know that in the magazine biz, or the publication business, on average, you lose anywhere between 15 percent-20 percent of your market every year, because people die, they change jobs, they get married, they get divorced, there are things that happen that change their orientation for insurance coverage. So, if you have a 96 percent retention, that’s phenomenal.    
WOFFORD: We just won an award from the Blue Cross Association for being the highest in the country at 96.4 percent, precisely. We are really, really proud of what we do every day. I just wanted to make that point, because I think it is important in the context of that process.

I can’t comment on the specifics of [the rejected bid], because we are in the middle of reviewing the bids – and competitive bids – to understand the process.

ConvergenceRI: So, this is not necessarily the end of the discussion, and there may be other ramifications…    
WOFFORD: I just can’t comment on it, because we are in the middle of reviewing the bids.

ConvergenceRI: Looking at the goals of what you want to achieve through your health insurance enterprise, there are many: one is cost control, and another is about providing better primary care physician coverage.

 Sometimes those goals may not fit together. How would you describe the challenges and priorities? Prevention is a great cost-saving device, but you don’t necessarily see it in a six-month return, or a year return on your investments.

 How do you prioritize what your returns are, and where do you see the insurance business going?    
WOFFORD: It’s a great question. And, I agree with how you characterized it. Let me just set the table a little bit.

One thing I would say is that medial costs have been really high. I think you know that. We had over a 10 percent increase in medical costs last year, which led us to lose $23 million in 2023. And, costs are just increasing and continuing to be high. So, we are seeing really high medical costs, to your point.

We are doing a lot of work internally to better manage those costs, and we are going to have to increase rates. And, that is really painful to us, because we are focused on affordability. That is like a context point.

Also, I am a huge believer in primary care as a way to get to issues earlier, to avoid unnecessary hospitalizations and bring down medical costs.

So, we also need to invest to have a thriving primary care system, if we are going to have a really well-functioning overall health care delivery system and have it be cost affordable.

As I think you heard me say at the summit [the health care summit held on May 28, sponsored by House Speaker Joseph Shekarchi; see the link below to ConvergenceRI story, “Bang the gavel slowly.”]

What I really worry about is this balance – the balance between affordability for Rhode Islanders and the sustainability for providers.

And, how do we get this balance where we can get good payments to providers that keep them stable, and we can keep costs affordable, and make them affordable for Rhode Islanders. And, that’s a balance that I think we are struggling with in Rhode Island.

But it’s what we have to do, because what we are selling is access to the health care system.

ConvergenceRI: How do you do that? It’s a conundrum.    
WOFFORD: Right. I think we have to invest more in primary care. We have invested more than $500 million in primary care at Blue Cross in the last 10 years, above rates. But, we need more people to come to the table to invest in primary care.

And, we need to do it faster, because primary care physicians, as you know, as you have written about, they are retiring at a pretty fast clip, because it is a really hard environment [in which to practice].

One of the things we are trying to do is to reduce the administrative burden for primary care. I think you hopefully saw what we have announced

 ConvergenceRI: …about prior authorization…    
WOFFORD: It’s one of those areas that nobody likes. But it is really part of our job that care is appropriate.

We put these new prior authorizations in place, but what we did is, we went though a really careful analysis and said: Where are all the places that primary care physicians get saddled with doing prior authorizations and paperwork and then, we actually approved them?

It’s just a lot of work that’s associated with both the submission of the prior authorization forms and the approval on our side. [We asked:] What if we can reduce all of that work on both sides, because we are likely to just approve those particular codes.

We went though looking at all those codes, and we actually found that for like 65 percent of the codes, there is this really strong correlation for primary care physicians, between what they submit and our saying, “Yup, that totally makes sense,” and approving it.

So, those are the kinds of things that we’re trying to do to get some of that work off of the table for primary care physicians.

How do we do that? How do we make primary care thrive? We have to make sure that we are paying primary care enough. We’ve got to make sure that their jobs, day to day, are not too saddled with administrative burdens. Which are two really important ways.

We’ve got to get to the point where what (we are delivering] is team-based care, in my opinion. I have had the opportunity to work out in the West and, in California, you can see [the impact] of team-based care, where clinicians are operating at the top of their license.

They are managing a bigger patient panel; they’ve got behavioral health specialists; they’ve got case managers; they have dieticians, they have all these different members of the care team that can help somebody with their specific problem.

Here, in Rhode Island, you are much more likely to have a physician, one PCP, be accountable for all of those different issues for a patient, as opposed to saying, “Hey, let’s make sure that we have a pharmacist that is going to help with a pharmacy issue.”

When you pivot to team-based care, you actually are able to take on more patients.  You are actually able to improve access. And, you’re matching up the need with the specific clinician. What we’ve done is push value-based care and to start to move down this path.  We really haven’t transitioned to team-based care in this market yet, and so, I think there is a really big opportunity to do that.

ConvergenceRI: What are the levers to push that?    
WOFFORD: I would say that there are two key levers. One is the contract. Right? Payment. What is the contract under which the primary care physicians are getting paid? And, does it incent the shift to team-based care?

And, second, are there capabilities to be able to take your patient population and stratify them. To say, who are the people who need to be seen by the primary care physician?  Who are the people who could be seen by a nurse practitioner, let’s say.

Who are the people who the big issues they have are a bunch of social factors, and they actually need a social worker to go run down how they are going to get healthy meals.

Or, somebody who is having a lot of struggles with their medications and they actually need help from a pharmacist. If you have the capabilities to take the population and divide them up that way, and stratify them, you can get them to the right clinician. But, that takes data analytics.

So, you need the contracts to be in place. And, then we need the cultural change. Where the patients are used to being seen by a nurse practitioner, let’s say, not the physician. And so, there are three key ingredients to having a transition.

Next week, in PART Two, BCBSRI’s President and CEO Martha Wofford discusses how far away is Rhode Island’s health care delivery system from creating a working culture of collaboration.