Health care coverage in America is dominating conversation nationwide, becoming a defining focus of the Obama administration, and registering as an issue of contention across political parties. With the country largely divided about the proper role of government in health care coverage, ABILITY Magazine’s Chet Cooper sat down for a talk with Leslie Margolin, President of Anthem Blue Cross, the largest health care provider in California.

Cooper: When we first met, I heard Maria Shriver describe you. Do you remember that?

Leslie Margolin: Yeah, she had been teasing me. I had had dinner at her house the night or two before, and I asked her if she had ever done a spin class. She hadn’t and I was so glad, because I’d never done a spin class either. When Maria asked about my biking, I told her I’d done several of the AIDS rides and had biked across country, but I’m embarrassed that I don’t know how to spin. So the night I met you she proceeded to tell the story, “Leslie said she doesn’t spin, but she rode 4,000 miles across the United States, the northern route, through the mountains!”(laughs) “And she’s run nine marathons.” She just sort of went on and on. And then when I was sufficiently embarrassed, we got on our bikes and did some spinning. (laughs)

Cooper: How did you like the spin?

Margolin: I enjoyed it. I had injured my knee at the time, though.

Cooper: Motocross?

Margolin: (laughs) I wish! No. Taking a misstep off a little shuttle bus. That was my first day back on my bike after my injury. I hadn’t done anything before that.

Cooper: Fortunate thing that you work for Blue Cross. What are your views on universal health care?

Margolin: Well, first off, I think it’s an embarrassment that we have 45 or 46 million people who don’t have coverage, and for years I’ve worked trying to address that issue. For all of the controversy and all of the areas of additional work and additional refinement, on the core health care issues, there’s great alignment within the health plan industry, with hospitals, doctors, and with the President. I think there is agreement that parts of the system are not working, that change is needed, that we have to find a way to have universal access or near-universal access, and that there is a way to get there.

But we haven’t figured out the details of the financing, and that’s a very important, very complex part of it. The key to success here involves working together—between the government and the health plans, hospitals, and physician groups—to make sufficient strides in simplifying administration on the insurance side, and to address, in a systemic way, issues of quality and safety, so that we have improved health care but so we also have tremendous savings that will be able to finance the expansion of it.

Cooper: And those savings will come from where? Where is the fat?

Margolin: Roughly a third of health care dollars are spent in areas that have to do with medication errors, redundant testing, redundant medicine, medicine that’s practiced defensively, safety issues in hospitals and in-care settings. But one of the things that have happened in the past is that everybody has blamed everybody else for the problem, and we’ve become crippled by that debate. We need to bring in data and technology, so we can look at every single hospital and medical group and determine what its experience and outcomes have been. Then we can look at comparisons between systems. If we do this in partnership with hospitals and with medical groups, we can use that data to drive towards systemic improvement.

I’m working on this strategy in California right now with the leaders of the hospitals associations up and down the state. If we, as the largest health plan in California, could partner with the associations representing 95% of the hospitals in this state, if we could pick two or three issues and make a commitment based on our data and some of our technology, we could basically wipe out hospital-based infections or reduce them to minimal numbers. In the past, people have figured out solutions to those problems in an ad hoc and kind of on-off basis. What haven’t happened are commitment and collaboration between and among all involved in driving these systems of care and safety across the whole health care delivery system.

When you look purely at the dollars—if you look at medication errors, wrong-site surgery, neonatal intensive care—issues of concern are two-fold. Some are safety issues, and some are issues that have to do with, for example, voluntarily inducing labor before the full term. The difference in the health of the child who goes to full term at 39 weeks, versus the child who is born at 38 or 37 weeks, is stunning. If we could just—

Cooper: How would you create a system throughout your vast network to say that something like early inducement is a practice they shouldn’t allow?

Margolin: I tend to approach things through education. If people understood, if parents understood, if physicians and hospital leaders were all uniformly aware of the statistics of the data—

Cooper: So you propose a health literacy program for educating parents?

Margolin: An educational program, yes. And commitments from doctors to offer that health literacy so it’s really about helping people, doctors and hospitals understand systematically what the odds are, what the expenses are, and what the safety improvements are for a given procedure. And to go back to your original question, I don’t think that all this will fully fund expanded access or universal access, but it will provide a pretty big chunk of the funding. The issues around taxes are quite tricky. But, being an optimist, I do believe that if we have a common interest in improving quality, safety, and cost, and in expanding access, we can figure out the funding for this.

Cooper: In the work that I do, I get to see and talk to really different groups that are actually sometimes working in the same arena, but there are silos that exist to keep them from communicating with each other. It’s almost like I’m working for them, trying to be a kind of silo-buster. “I know you’re doing this over here and you’re doing that over there, but if you could start communicating, you’re actually doing things that will help you both.”

Margolin: I love your term, “silo-buster.” That’s exactly what it is like when every hospital or hospital system goes off and does its own thing. It doesn’t make sense. I fully recognize and appreciate the need for us to compete, but I don’t think we have to compete on everything.

I serve on the board of the California Association of Health Plans and have gone to the board and I’ve said, “What if we as an industry thought about the things that are the greatest obstacles to accessing care, the greatest dissatisfiers for hospitals and physicians and members? And what if we as an industry made a commitment to address those obstacles? What if we went to common claim forms and common applications? Think about the difference it would make in every physician’s office across the state of California if there were only one form that clients had to understand. What if we made our data universally available across the system?”

I will continue to try and drive that effort, because I think it’s where the answers lie. We’re not going to compete on having the best application, the best claim form or the best web portal. Technology is a perfect example: there’s so much opportunity in health IT to consolidate our systems and our paperwork.

But it’s going to require a very different approach from the health plans, and from the hospitals, frankly. Everybody’s going to have to agree that this is an area in which, rather than spend the money and develop our own systems, we ought to have a common portal and we all ought to work on refining and expanding that technology.

Cooper: That’s going to be the challenge. Unless you have government regulation that says, “This is now the standard by which to operate and do the business you’re doing,” someone is still going to say, “These are my marbles and I’ll use them over here and I’m not gonna share.” So it seems that you almost have to have a higher power to say, “This is a mandate here. ”Have you taken your suggestions to the government?

Margolin: I have, although I would like to see the industry come together and do this modification on a voluntary basis rather than having to be told to do it. I guess my judgment is, if enough of us do this, if Blue Shield and Blue Cross and Aetna and Cigna all came along, few would want to be an outlier. But if government regulation is required, ultimately I’m okay with that. I just don’t think it should be necessary. We met just last week with the Department of Managed Health Care to talk about this issue of health IT and possibility for a common web portal.

Cooper: What happened?

Margolin: There was great excitement about it. Several organizations have bought into it already. I think the problem, though, is that if everybody is developing a common portal, we don’t know which common portal is going to win.

Cooper: I visited Doha, in Qatar. It’s almost growing faster than Dubai. Every building there is a double building—there’s so much growth that every building has a mirror image building of itself. So I asked around, “Is everything accessible?” They have the opportunity to build the most accessible city in the world with all of this construction going on. But most people there aren’t thinking about disability issues, even though several top officials are saying, “We care about people with disabilities, about getting them the best education, getting them employed and independent.” They’re saying all the right things. But they just don’t seem to think about it in a larger more universal way. They are so close. It’s frustrating.

Margolin: It’s not at the top of people’s minds.

Cooper: It’s not. The architects and city planners have this great opportunity. Doha is contracting the best architects in the world to create these elaborate designs.

Margolin: But you don’t fully appreciate the problems of a person with a disability if you’ve never had that disability. We’ve all had that experience, when you break your arm for the first time, of trying to do everything with your other hand. I was on crutches a year or two ago, and just to get from the sink to the paper towel dispenser with wet hands was an effort. You just don’t think about these things until you’re put in someone else’s shoes.

Cooper: Often I’ve seen people with specific disabilities lobby for that disability and ultimately forget the others. I was talking yesterday with Jerry White, who has a prosthetic leg. He was saying, “There’s a pecking order. Oftentimes, unless I pull my pant leg up, the disability community won’t accept me.” I think it’s very much like other civil rights movements or race. “He’s not black enough. He’s too white.” There are the little issues of what they’re experiencing as discrimination. But until, like you said, you’re in their shoes, you don’t get it.

So how do you really get people to experience something else that’s not part of their daily lives, or that which they don’t think is part of their daily lives? Even though we say that disability is a part of the fabric of all our lives, we don’t look at that part of the fabric all the time. But on the average, a person experiences 13 years of one or more disabilities in their own lifetime.

Margolin: I hadn’t heard that.

Cooper: As you know many of the health conditions which cause some disabilities are preventable. So maintaining a healthy lifestyle can reduce the likelihood of that sort of outcome.

Margolin: Right. Personally, I try to stay fit enough that at any given point in time, I can run a marathon—with two or three months intensive training. So I try and keep a base of five or so miles a day, running, and then I try and walk another three to five during the day. And on weekends I try to get a 10- or 12-mile run in.

Cooper: Is that why you’re wearing those sneakers around you neck? (laughter). With all that’s going on with the economy and health care reform right now, how does Anthem Blue Cross distinguish itself in the marketplace?

Margolin: We’re leading this effort. We’re leading the development of systems of care and quality, and we’ve got the courage to call the whole industry out and say, ‘We can make this different.’

One of the efforts that I’ve been encouraging on the board of the California Association of Health Plans is not to wait for legislation or regulation, but just to look at ourselves and at what’s broken in the health care system and at what parts of it we could fix tomorrow. We need hospitals and doctors to contribute because we can’t fix the whole thing alone. But there are so many parts that are quite within our control. We could, for example, move to a common application and just make the paperwork simpler, cheaper and easier to understand. There’s expense involved in credentialing for physicians or credentialing for hospitals and every health plan has its own system. Many things make Blue Cross different, but one of them is our willingness to stand up and lead efforts like this.

Cooper: I know that the government is putting forward money to try to streamline things. For instance, the single application situation. What do they call it? EHR?

Margolin: Yes, the Electronic Health Record. That’s one of the key areas that we’re leading. We have a pilot going with Cedars-Sinai here in LA, and in Northern California. It’s our electronic medical record deployed to emergency rooms so that when the patient comes in in an emergency situation, the emergency room doctor can look up his medical history, medications and previous health issues. One of the things that we’re working very hard on is figuring out how to perfect that system, how to deploy it across all hospitals in the state of California and beyond. We’re trying to make a health records system that works for all health plans, so you don’t have to go to a hospital that specifically has Anthem Blue Cross’s medical record or Cigna’s or Blue Shield’s. All records can just be plugged into one system.

The things that are competitive advantages between insurance providers include cost, product, service, leadership and relationship. But there are a number of things, like EHRs, that we should all be figuring out how to make work for everybody. And I think Blue Cross has stepped out in front of virtually everyone else to accomplish that... continued in ABILITY Magazine

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Oct/Nov 2009