Aug. 06--The new head of Blue Cross and Blue Shield of New Mexico has three items at the top of his list of things to do.

Kurt Shipley says the 70-year-old company needs to get better control of medical costs, win a share of the state's Medicaid business after the program is redesigned, and add new members.

"One of my first goals, and I'm passionate about it, we want to be the go-to company," Shipley said. "We really want to grow. The more members we have to spread the costs across, the more efficient we can be."

Shipley said that BCBSNM has 300,000 members in New Mexico. The company recently signed up Dona Ana County, Otero County, the city of Farmington and San Juan Community College.

Blue Cross and Blue Shield was bludgeoned for more than a year after it requested double-digit rate increases for some of the products it sells to individuals. The company said it was losing money in the individual insurance market. Regulators convened hearings where angry customers lambasted the company. Public Regulation Commission members scolded the company at their meetings.

Blue Cross bashing?

"It was hard for us to understand, when we were doing what a lot of our competitors also did," Shipley said. "I don't know if Blue Cross bashing is prevalent. Around the state, people are glad to have a Blue Cross card."

Blue Cross and Blue Shield is working to rebuild bridges. "We are going to talk with members, nonmembers, businesses, legislators, media, all the stakeholders," Shipley said. "We'll try to get out and talk with everybody."

More important, he said, many of the conversations with health-care providers, plan members and employers will be about how to control costs. "We can start to bring costs in line to where they need to be," he said. "That's how to keep premiums down."

Shipley said "the next order of business" is to work with health-care providers to set up payment structures that discourage fee churning and over-delivery of care, improve quality and reward efficiency and innovation. "We'll go to a (physicians) group and say, this is how much we'll give you to manage the patient." Then the company will help the group do it.

Physicians won't be able to manage patients efficiently without access to better information, including data that show what medical procedures work best and details about each patient's history, no matter where the patient has been treated in the past. "There will be information sharing," Shipley said.

Key is information

Patients need information too, in part because of changing insurance options. There was a time, Shipley said, when all insurance followed the 80-20 rule: the patient paid 20 percent of the cost of care, the insurance company paid 80 percent. Healthmaintenance organizations and managed-care plans changed the equation by picking up most of the costs minus copayments. "Members began to believe (the copayment) was what it cost to see the doctor," Shipley said. Patients began demanding more health care than they needed because care seemed to be so cheap, and costs climbed.

Insurers are responding with preferred provider organizations that give patients financial incentives to use providers that have agreed to fee structures and approaches to practicing medicine that the companies believe will improve quality and efficiency. PPOs also encourage members to be more aware of how they consume care, since the wrong choice will raise their out-of-pocket expenses.

Blue Cross can't just throw members into new payment systems that could cost them more money if they aren't careful, Shipley said. "Wherever you go you will need to know the cost," he said. "When we can provide that transparency to members, then we can ask them to put more skin in the game."

Seeing the problem

Most employers who have studied the problem quickly learn that a handful of employees account for much of the cost of health care a company faces. Blue Cross is putting care coordinators in place whose only job is to find ways to improve care for the sickest people.

Insurers only see a few pieces of the puzzle. They know what sort of payment codes providers put on insurance claims forms, but they don't necessarily know what kind of care was provided or how the patient responded. Insurers will need better information from providers, Shipley said.

Health Care Service Corp., which owns New Mexico'sBlue Cross, also owns a subsidiary that develops those kinds of information sharing and caremanagement solutions, and it has deep enough pockets to help implement such systems here.

"A lot of providers today understand the world is changing," Shipley said. "Insurers are changing. Government is changing. Members are changing. What has been happening is not sustainable. We've got to do something different."

He could have added that the way New Mexico plans to run its Medicaid program is changing too. Medicaid today is dozens of programs operated by many different companies, each with responsibility for different populations. Some companies handle behavioral health care, others deliver medical care, still others work with the elderly.

The state Human Services Department hopes to make a handful of companies responsible for the health and well-being of all Medicaid members, from pregnant women and newborns to the elderly member in a nursing home. Shipley intends for Blue Cross and Blue Shield to be one of those companies.

No state has tried to integrate so many moving parts before, Shipley said. It will be difficult to manage such a program and difficult to figure out how to properly pay providers for delivering care. He expects the BCBSNM connection to Health Care Service Corp., the fourth largest health insurance company in the country, to carry some weight.

The company also has strong provider networks statewide and a long history of working with patients and providers in New Mexico, he said. "We understand the state. We've been here a long time. We will be here a long time."

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