Delivery of Care

In search of the health data equation

An interview with Dr. Farah Shafi, the new chief medical officer at BCBSRI

Photo courtesy of BCBSRI

Dr. Farah Shafi, the new chief medical officer at Blue Cross Blue Shield RI.

By Richard Asinof
Posted 11/20/23
With primary care at the crossroads in Rhode Island, with complicated issues involving prior authorization and increasing drug costs, with increasing focus on the social determinants of health, the interview with the new Chief Medical Officer at BCBSRI, Dr. Farah Shafi, begins a conversation about how the state’s largest commercial health insurer is thinking about its future strategic priorities.
What is the best way to rectify the lack of data concerning the diagnoses of long Covid in Rhode Island, particularly broken down by income levels and access issues? Is there an equation that insurers could share with the public concerning the alleged ways that prior authorization processes save money, and for whom? The patient? The doctor? The hospital? The insurer? Where do the patients’ views come into play about the problems they encounter with attempting to navigate the health care system in Rhode Island? How does BCBSRI follow up on its philanthropic investments for affordable housing in terms of accountability? What is the status in the General Assembly of the proposal by OHIC to raise provider rates for Medicaid by $45 million? What will be the headlines to emerge from the RI Life Index reveal of the data findings?
Much ado has been made about the chronic problems of chronic absenteeism in schools in Rhode Island and across the country. Some of the push has come from corporate consultants such as McKinsey and Co., pushing for corporate solutions for what it has termed “learning loss” because of COVID. What have not been addressed are the ongoing root causes of chronic absenteeism, related to chronic [and preventable] cases of asthma from air pollution and poor housing conditions, as well as childhood lead poisoning.
In the Nov. 13 edition of ConvergenceRI, the story, “The missing data when it comes to chronic absenteeism” provided the data documentation that had somehow escaped from the new initiative being promoted by the Governor and the Education Commissioner.
In that same vein, ConvergenceRI came across the 2023 KIDS COUNT data profile for Rhode Island, collated by the Annie E. Casey Foundation. It found worsening conditions for the following metrics: Young children [ages 3 and 4] not in school, 56 percent, from 2017-2021; Fourth-graders not proficient in reading, 66 percent, 2022; and eighth graders not proficient in math, 76 percent, 2022.Overall, Rhode Island ranked 33rd in the nation.
For economic well-being, Rhode Island ranked 24th in the nation, with the data showing worsening conditions for the following metrics: Children in poverty, 15 percent in 2021; children whose parents lack secure employment, 32 percent in 2021; and children living in households with a high housing cost burden, 33 percent in 2021.
Imagine if Blue Cross Blue Shield of RI launched an initiative to bring the low-cost Corsi-Rosenthal filter boxes into every classroom in Rhode Island as a way of counter- acting airborne pollution and contaminants?

PROVIDENCE – This is a big week for sales, advertising and relationships. It promises to be filled with plenty of extra helpings of family, food, shopping, and traveling – all to be punctuated, hopefully, by a common denominator, “Thank you!”

Beginning with Thanksgiving, followed by Black Friday, and then Giving Tuesday, we are entering a frenzied week of consumption – and yes, with it, lots of heartfelt opportunities to say: “Thank you!”

So, let me begin this story by saying, “Thank you!” for the opportunity to interview Dr. Farah Shafi, the chief medical officer at Blue Cross Blue Shield of Rhode Island, who assumed her new post on June 28, 2023, five months ago.

I am grateful that my persistence in seeking an interview with her has been rewarded. The interview took place on the phone, on Thursday afternoon, Nov. 9, for a half-hour.

Dr. Shafi, an OB/GYN, had previously worked for seven years as Deputy Chief Medical Officer at Mass General Brigham Health Plan. In her new job at BCBSRI, the state’s largest commercial health insurer, she will serve as a member of the health insurer’s executive leadership team, reporting directly to President and CEO Martha Wofford, [someone with whom ConvergenceRI has interviewed a number of times].

“After a national search, it was clear Dr. Shafi was the best candidate for the job, with her impressive clinical credentials and strong operational experience,” said the news release from July 1 announcing her hiring. “Most importantly, she has extensive expertise in the key areas of focus in our three-year strategy: health equity, particularly maternal morbidity; behavioral health, and value-based care.”

The news release continued: “She will take the helm of our Clinical Affairs area, overseeing utilization management, medical policy, behavioral health, and health equity.”

The next two weeks also promises to be a big news time for Blue Cross Blue Shield of Rhode Island, with the release of the fifth annual RI Life Index survey on Wednesday, Nov. 29, at the Brown University School of Health. The RI. Life Index details Rhode Islanders’ perceptions of health and well-being, drawn from the results of a survey of residents, focused on the social factors influencing health outcomes – including access to quality care, affordable housing, nutritious food, and transportation. The keynote speaker at this year’s event will be Dr. David Williams from the Harvard T.H. Chan School of Public Health. [See link below to the ConvergenceRI story about last year’s R.I. Life Index, “Taking charge in health care.”]

The RI Life Index data reveal will be preceded by the gathering on Monday, Nov. 20, hosted by Rhode Island KIDS COUNT, when the community advocacy agency will share its priorities in how best to improve children’s health outcomes in the state in the coming year.

Translated, between the RI Life Index release and the RI KIDS COUNT gathering, two important new data-driven results that document state’s health and well-being will be introduced as evidence about the state’s precarious economic future.

When added to the recent data releases from the 2023 Housing Fact Book by HousingWorks RI, the lack of data about the nonprofit sector in Rhode Island, and the ongoing data emerging from the R.I. Quality Institute, it may help to shape an accurate picture of what is happening in Rhode Island. [See links below to ConvergenceRI stories, “It’s all about the data, the data, the data,” Parts One, Two and Three.]

And, it adds to the import of the ConvergenceRI interview with Dr. Farah Shafi, OB/GYN, the chief medical officer at Blue Cross Blue Shield of RI, during a time of great disruption in the forces enveloping the health care delivery system in Rhode Island. The interview touched on a number of hot-button issues: prior authorization, long Covid, women’s maternal health, the high cost of drugs. Richard Salit, BCBSRI’s public relations manager, listened in on the interview.

ConvergenceRI: In a recent interview with Attorney General Peter Neronha, he indicated that he would be asking questions of insurers about the difficulty for Rhode Islanders in finding primary care providers. [See link below to ConvergenceRI story, “A heart-to-heart with AG Peter Neronha.”] He likened it to health care plans selling him a car without any wheels on the vehicle, if customers cannot access a primary care provider who is taking on patients. How would you address this issue?
SHAFI: So, that’s an interesting question. I know that the Attorney General has a strong interest in improving the health care system in Rhode Island. Honestly, we share many of the same concerns as he does about improving affordability and access – the access that you were speaking about related to primary care.

We will be interested when his proposals are finalized and presented to the public. But you know, right now, I don’t have any plans of his to comment on. But, I know that we will be talking about, obviously, one of his areas of focus being primary care. We agree that it should be a priority of any efforts to improve health care in Rhode Island.

As you know, our state and the entire country are facing a shortage of primary care providers. So it is going to take a variety of collaborative efforts among health care leaders, state officials, and colleges and universities to address the problem.

We’re not going to fix this overnight. And so, [we need to] really be focusing on being innovative. I think I have shared in numerous forums [the RIBGH health summit, the Providence Business News health summit] about how Blue Cross is really being intentional on our movement toward value-based care to help address some of these PCP [primary care provider] shortages.

ConvergenceRI: Given your specialty as an OB-GYN, I was wondering what you saw as the top priorities for women’s health care in Rhode Island?
SHAFI: So, the top priorities, obviously, with women’s health care in Rhode Island are, I think, our focus on maternal health care inequities that we are seeing. And that has been one of the strategic priorities at Blue Cross.

Blue Cross Blue Shield of RI has made health equity a strategic priority. Under that bucket in terms of some of our clinical initiatives is maternal health.

We are doing that through a variety of channels. We have been enabling anti-bias training for our provider network. We have increased working with doulas, increasing the number of engagements with our doula community, and making sure that we are expanding the network of doula providers.

We are also working on care management efforts to address some of the issues to help to decrease some of those disparities. I would say health inequity is one of the areas in women’s health.

Because women’s health goes more broadly than pregnancy, I think we really need to focus on other areas as well. And so, really building on some of those initiatives is important to me.

ConvergenceRI: One of the issues that came up at the RIBGH health summit was prior authorization. Can you expound and expand on your answers at the forum about what changes you would like to see in Blue Cross’s policies and practices on prior authorization? [See link below to ConvergenceRI story, “Primary care at the crossroads.”]
SHAFI: Prior authorization is a really complicated topic. Because this is something that, as we all know: prior authorization can save the health care system a significant amount of money. But we know that it is burdensome for providers. And so, we are looking at ways to make it less burdensome. It is definitely part of our strategy in the next year to address some of that burden.

I think it is a little bit too early to share the details of what we are doing, but we are definitely looking at the volume of the authorizations that we perform, and seeing if there are providers that already have a number of significant authorizations. So, this is what we call gold carding – them being able to pass them through the system where they are not going to be requiring that prior authorization.

So, we are looking at being able to look at gold carding; we’re looking at ways that we can automate the process, to make it a lot easier.

But, I also want to call out some of the work that we’ve already done. There are a number of changes that we are making for 2024, in terms of decreasing prior authorization.

And I should call out the fact that in the behavioral health space, we don’t perform prior authorization, which is huge, because we’ve taken this intentional focus on access.

I feel like prior authorization is a really challenging topic, because we recognize that it is incredibly burdensome for providers.

At the same time, there is a discussion about how health care costs are rising and premiums are rising, and you know that there is some component of prior authorization and utilization management that still needs to occur.

ConvergenceRI: Have you had the opportunity, as part of your job, to review cases of prior authorization, where procedures and surgeries have been denied? 
SHAFI: I have the chance to review… I oversee the clinical affairs department at the health plan, so there are folks that report up to me that are typically the ones who are reviewing these cases. There may be cases that come across my table, and I have performed utilization management in that capacity in my prior roles as medical director at other health plans. So, I am familiar with the process of prior authorization.

ConvergenceRI: I was curious, since July, when you began at Blue Cross, have you had the opportunity to review any prior authorization cases in your new job?
SHAFI: Those cases, being the chief clinical officer at the health plan, I will be aware of cases, so it may not be me who does the primary review, but there are cases that will come across my table, or that I will hear about from my staff, because of the fact that they are being reviewed through the prior authorization process.

And I should say, Richard, that this is typical of most plans. Most of the time, at most health plans, the clinical leaders are aware of the processes that these cases are going through.

ConvergenceRI: I was just curious if any of those cases had come across your desk, or not? Your answer is that they could, but I was asking if any of them had?
SHAFI: I think I would yes, they have.

ConvergenceRI: Do you think that you will be seeing an increase in the number of those cases that you would look for?
SHAFI: I don’t know that I understand your question. That more cases will be coming across my desk?

ConvergenceRI: Yes.
SHAFI: I don’t think necessarily so. I think that the same processes that we have for prior authorization are going to continue, and these are processes that are well within the regulatory standards for the state and other regulatory agencies that health plans have.

ConvergenceRI: One of the things that has happened with COVID is that there appears to be an increase in what is known as long COVID.  As chief medical officer, have you developed any strategies for how to deal with the continuation of cases known as long COVID?
SHAFI: That’s a great question. I think that this is certainly a topic that a lot of health plans across the country are struggling with. We know that long COVID occurs; it’s really hard for us to quantify the absolute impact to our health care system, both in terms of how it is impacting members’ health, and how it is impacting the health care system in terms of money spent.

And, I will say that’s really because of the lack of really robust data on the incidence of long COVID.

We have done some studies at the end of last year where we looked at our population and we followed a cohort of patients from our population who had had COVID and had then tried to follow them out, compared to a population who had not had COVID, and we are seeing higher health care costs in the population that had COVID. And that’s just in our internal analyses that we’ve done.

I would say a lot of the studies that are out there really are not well-designed studies, and we just need to wait a little bit more time to have data for us to develop a true strategy for long COVID.

ConvergenceRI: What types of data would you like to have? You said that the problem is with the data. Beyond these studies, looking at the local population, what types of data will be important to improving outcomes, or improving care?
SHARI: I think what is really tricky with long COVID is because there is a list of at least, I believe somewhere around 10 to 12 different symptoms that are non-specific symptoms that can be attributed to long COVID.

And, I think what can be a little bit tricky to tease out in the data is whether those symptoms in a member that had had COVID are new symptoms, or if those are symptoms that they have had related to other chronic conditions.

And so, that’s where we need more data to be a little bit more intentional about focusing on what is the trend that we are seeing and what is some of the noise that we tend to see.

The other limitation in some of the COVID studies is that while we have a unique diagnosis code for long COVID, not all providers are using the code. There hasn’t bee a lot of uptake in [the use of] that code, and as we get more uptake in people attributing the symptoms to a diagnosis of long COVID, then we are really going to be able measure the financial impact of the outcomes of long COVID.

ConvergenceRI: How about in terms of equity? I know that the RI Life Index is coming out in a couple of weeks. That’s one way that you have to measure what patients are telling you; what Rhode Islanders are telling you. What types of potential improvements in equity access can you see, particularly related to COVID and ongoing care?
SHAFI: We’re excited about the RI Life Index coming out and really happy that we’ve been supporting this initiative in conjunction with the Brown University School of Public Health.

I think that what it helps to inform us about is the social determinants of health that are measured in this study. We develop our programs and initiatives based on the data that we glean from that study.

So, that would be inclusive of all social determinants of health and whether COVID – I don’t think that they are looking specifically at COVID per se – but I think that the impact of COVID is certainly woven through some of the data that we are seeing in that RI Life Index.

ConvergenceRI: Will there be an effort to dig down deeper into that this year, in terms of the questions?
SHAFI: I actually am not familiar with the details of the questions that were asked during that survey. I can certainly take that as a takeaway.

ConvergenceRI: That would be helpful to know. Blue Cross has put housing as its number-one  philanthropic priority. Can you talk about the idea that housing is health care, from your position as chief medical officer?
SHAFI: I would be happy to. Honestly, the data that we’ve gotten through the RI Life Index and other channels really talks about the impact of social determinants of health. And housing would be one of those.

Obviously, lack of transportation, racism, income – those are other types of social determinants of health. The lack of affordable housing is a chronic problem that Rhode Islanders face. As a result of that, Blue Cross Blue Shield of RI has put a lot of effort into strategic philanthropic investments toward housing. I think that makes a lot of sense. I think it certainly speaks to the fact when we are thinking about health care, we know that it is not just people’s health that is impacting health care.

We are really trying to think beyond just the physical health; we are trying to think about those social impacts [as well]. I would say that our philanthropic support of housing really speaks to that thought.

ConvergenceRI: Are there any innovative programs that you are thinking about implementing? I know, for instance, that Dr. Mona Hanna-Attisha has developed a program of prescriptions for food as part of her pediatric practice. Is that something, once again, looking at the social determinants of health, for pediatric patients to be able to access food on a regular basis, as part of an ongoing initiative that Blue Cross would consider? [Dr. Mona Hanna-Attisha is the pediatrician from Flint, Mich.]
SHAFI: I am familiar with her work, actually. She has a book out on her efforts…

ConvergenceRI: Yes, What the eyes don’t see.
SHAFI: Issues related to food insecurity are certainly some of those initiatives to address social determinants of health that we are focused on. I would say that there are a lot of different initiatives. I think it is an interesting thought about prescriptions for food being one way.

I would say that there are other ways that Blue Cross Blue Shield of RI has helped to alleviate food insecurity. I can speak about our efforts donating to the Rhode Island Food Bank through our annual employee fundraiser.

We also support older Rhode Islanders through Meals on Wheels. And, we also offer food and grocery delivery to our duals population. So, I think that there are many different ways to address that particular issue of food insecurity. And certainly, prescriptions are one way. But there are other ways that I spoke about.

ConvergenceRI: Are you a regular reader of ConvergenceRI? I am sure that Rich Salit [public relations director] forwards it to you on a weekly basis. I assume that you are a regular reader. Are there any stories that particularly caught your interest in the last few weeks?
SHAFI: I am a regular reader, actually. Rich does forward it to me. I find the work really interesting. I take the time to read the articles, and I think it really gives me a bit of input about what is going on in Rhode Island, within health care and beyond. So, I think it really helps.

ConvergenceRI: Some of the recent stories have been dealing with data. And I know, as you said in one of your earlier answers, that you are really focused on data. What do you think are the most important priorities now for health care in improving data, such as the ability to get everybody in Rhode Island signed up for the health information exchange, CurrentCare?
SHAFI: I would say that lack of data, as I alluded to when I was speaking about long COVID, is certainly a challenge. And so, I think the ability to support having the data to share between entities that a member will go to is certainly important.

Obviously, there are challenges with sharing the data that we want to make sure that confidentiality is preserved. But I would say, in the interest of more coordinated care, these efforts, like CurrentCare, make a big difference.

ConvergenceRI: I know you have a hard stop in six minutes [at 3 p.m.]. What questions haven’t I asked, should I have asked, that you would like to talk about?
SHAFI: I’m trying to think. I guess I’m trying to think about what is interesting to you? What questions did you ask my predecessor?

ConvergenceRI: I had numerous conversations with Matt Collins. One of the questions that he looked at was the high incidence of multiple sclerosis in Rhode Island. It was the number-two state for the incidence of multiple sclerosis diagnoses in 2019. [See  link below to ConvergenceRI story, “Why does RI have the second highest  MS diagnosis rate in the U.S.” authored by Matt Collins, the former chief medial officer at Blue Cross Blue Shield of RI.]

SHAFI: Wow. I didn’t know that.

ConvergenceRI: And, that the largest [demographic of the disease] was middle-aged women. Because you just said that you didn’t know that; is that something that you would be willing to follow up, pulling the data about the incidence of multiple sclerosis in Rhode Island, and perhaps, its relationship to other immunologic disorders.
SHAFI: Yes, I would certainly be interested in looking into that.

ConvergenceRI: Rich, could you follow up on that and provide me with the data about what the incidence of MS is in Rhode Island now? And, if the most predominant demographic is still middle-aged women?
SALIT: Absolutely.

SHAFI: When you mentioned multiple sclerosis, I start thinking about all of the medications that are utilized to treat multiple sclerosis. While I wasn’t aware of Rhode Island being the number-two state, in terms of diagnoses, in my mind, I think it makes sense because of the number of claims that we are seeing for some of those medications—the “d-mod” medications -- for disease-modifying treatments.

I think there is a broader point about the pharmaceutical costs that are rising, that we are seeing in this country, and how much pharmacy costs, and specifically, specialty pharmacy costs, are contributing to the rise in health care premiums.

And so, when you are bring up multiple sclerosis, I am thinking about it in the context of how many pharmacy claims we are seeing for some of these expensive drugs.

ConvergenceRI: Do you review pharmacy costs across the board then, because it is such a driver of overall costs in the health care marketplace? Are there other reviews that you’re thinking about because you have noted the increase in dollars for claims?
SHAFI: As part of my work as chief medical officer, I work very closely with other segments of the business. And, one of the areas that we’re looking at is the health of our population – looking at medical claims costs and pharmacy claims costs.

We look at how we are performing in some of the expenses we are seeing this year, as compared to prior years. A lot of the drivers remain with high pharmacy costs, and specifically related to high specialty pharmacy costs. MS drugs are typically treated as specialty pharmacy drugs…

ConvergenceRI: Such as…
SHAFI: …This is consistent with my experience in Massachusetts as well. And, I think this is consistent with the industry in general. But, we are seeing a lot of that – the increase in health care costs being driven by the innovations in the pharmacy industry.

On one hand, the innovation is wonderful, and on the other hand, I think our health care system needs to think strongly about how we are going to be able to afford this in the long term.

ConvergenceRI: Is rituximab one of those drugs that because it is used, across the board, for immune disorders, one of those drugs that you are looking at?
SHAFI: Rituximab is certainly a drug that is given by an IV infusion, and is one of those specialty pharmacy drugs that comes at a higher cost. And, I am not saying that that drug is not appropriate for certain conditions.

I think we also have to take into consideration that these drugs, as there is an explosion of these drugs on the market, and these drugs have expanded indications for use, we are just starting to see that play out in some of our medical claims.

And, I think you had conversations with Martha Wofford [President and CEO of BCBSRI] in the past related to how we, as a company, are addressing some of those skyrocketing pharmacy costs.

ConvergenceRI: To be totally transparent, I had a surgery canceled by EviCore, two days before the surgery, in August. [EviCore is a third-party prior authorization firm based in South Carolina that has been hired by BCBSRI.] Because they said that an MRI, which had been done 8 months prior to the scheduled surgery, did not meet the protocol of 6 months prior to the scheduled surgery, which seems absurd to me. The surgery cancellation was done by EviCore on your behalf. Is that something I can send to you on appeal to look at?
SALIT: I’ll just step in here to say for your interview for ConvergenceRI, or for any media interview, Richard , we never comment on any individual cases, yours or anybody else’s; it would just be inappropriate.

Convergence:RI: That’s fine; I can only ask the question, and you jumped right in. Maybe I will appeal, and maybe I won’t; it depends on the information that I can obtain. But anyway, thank you, Dr. Shafi. It has been a great conversation, I look forward to doing it again soon.
SHAFI: Thank you so much, Richard.


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