Statement of Scott P. Serota President & CEO Blue Cross and Blue Shield Association Before the Senate Finance Committee on "Approaches to 'Bending the Growth Curve' of Health Care Spending"

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June 16, 2008

Introduction

Senator Conrad, Senator Crapo and other distinguished Members of the Committee, my name is Scott P. Serota, and I am President and Chief Executive Officer of the Blue Cross and Blue Shield Association (BCBSA).  I want to thank you, Chairman Baucus and Ranking Member Grassley for inviting me here today to discuss bending the growth curve of healthcare spending.  As a national federation of 39 independent, community-based Blue Cross and Blue Shield companies that collectively provide healthcare coverage for more than 100 million individuals – or 1 in 3 Americans – BCBSA has the expertise, knowledge and relationships to work collaboratively with policymakers and key stakeholders to improve today's healthcare system.

Blue Cross and Blue Shield strongly believes everyone in our country should be insured and is pleased that Congress has made expanding coverage to all and improving quality a national priority.  Our current system is greatly challenged by the unacceptable fact that 47 million people are uninsured – including 10 million children.  Escalating costs are the main reason people are unable to obtain health insurance.  In addition, rising costs make those with coverage fear they could lose it because they can't afford it.  To assure affordable, high quality coverage for everyone, the underlying problems of our current delivery system must be addressed.  We can get to tomorrow's coverage – but first we must change incentives in today's system to improve quality and attack rising costs, while simultaneously working to expand coverage to all.    

As we look ahead to 2009 and beyond, this bipartisan summit represents a critical opportunity to bring policymakers and other key stakeholders together to lay the groundwork for enacting comprehensive reforms that not only expand coverage, but make coverage affordable. 

Today, I would like to focus on three key areas:

1. Examine what is driving the cost of coverage;
2. Discuss what Blue Cross and Blue Shield Plans are doing in the marketplace to address these challenges; and
3. Identify specific areas where private payers and public programs can collaborate in a partnership to build on our employer-based system and improve coverage throughout the country.

I.              Drivers of Higher Healthcare Costs

Before we can seek solutions to the problems of quality, access and cost, it is critical that we understand what is driving the rise in healthcare costs. 

A.  Lack of Information about What Works Best

We simply do not have enough information about what works best in medicine – and even when we do know, that advice is all too often ignored.  Consider the following:  

• Approximately 30 percent of all healthcare spending goes toward ineffective, redundant or inappropriate care.  (Wennberg, 2003)

• Only 54 percent of acute care and 56 percent of chronic care conform to recommended standards of care.  (McGlynn, et al., 2003)

B.  Misaligned Incentives Causing Wide Variations in Cost and Quality

Today, providers are generally paid based on the number of services they provide – regardless of quality or outcomes. 

• Use of beta blockers within 24 hours of admission for heart attack – a nationally recognized standard of care – occurs only 50 percent of the time in Alabama compared to 86 percent in New Hampshire.  (Dartmouth Atlas Project, 2006)

• Knee replacement surgery occurs 50 percent more often in Eau Claire, Wisconsin, compared to Phoenix, Arizona.  (Wennberg, 2007)

• In Fort Myers, Florida, the number of Medicare enrollees receiving hip replacements was 45 percent higher than the national average, while in Miami, the procedure rate was 37 percent lower than the national average.  (Health Affairs, July 2004)

• Medicare spending in New Jersey for the last two years of life is nearly $40,000 compared to $24,000 in Idaho.  (Dartmouth Atlas Project, 2006)

C.  Inadequate Tools and Information to Make Informed Decisions

Too often, consumers and providers do not have the information and tools they need to make informed decisions about quality and cost when it comes to healthcare.  We must move healthcare into the 21st century by adopting new technologies such as electronic health records and interoperable systems to provide consumers and providers with the real-time information they need to make good healthcare decisions.  Much of our healthcare system is stuck in an old-fashioned, paper-based model even though we have the technology available to move to electronic systems that are more efficient and would greatly improve healthcare quality.

• Currently, the physician adoption rate for electronic health records is low – 18 percent, and even lower in solo and small physician offices at only 8 percent.  Hospital rates are low too.  Only 11 percent of hospitals that responded to a 2007 American Hospital Association survey reported a fully implemented electronic health record system.

D.  Prevalence of Chronic Disease

One of the greatest challenges facing the healthcare system is managing the care for the growing number of people with chronic illnesses.

• According to the latest study from the Agency for Healthcare Research and Quality, 6 in 10 adults have at least one chronic condition.

• The costs of treating chronic illness account for 75 percent of healthcare spending.  (Anderson and Knickman, 2001)

• A 20 percent increase in the share of Medicare patients receiving treatment for five or more chronic conditions accounted for virtually all of the growth in Medicare spending from 1987-2002.  (Thorpe, et al., 2005)

II.  Blue Cross and Blue Shield:  Providing Real Solutions to Our Challenges

With nearly 80 years' experience in providing health benefits at the national and local level, Blue Cross and Blue Shield has first-hand knowledge that can help improve the system.  Earlier this year, BCBSA put forth a comprehensive, five-part proposal – The Pathway to Covering America – designed to build on today's employer-based system to improve the quality and value of our healthcare system while simultaneously extending coverage to all.  The first four of our five recommendations are designed to make healthcare more affordable while our fifth point addresses how to extend coverage to everyone.  Our five-point plan includes initiatives to:

1. Encourage Research on What Works;
2. Change Incentives to Promote Better Care;
3. Empower Consumers and Providers;
4. Promote Health and Wellness; and
5. Foster Public-Private Coverage Solutions.

In each of these areas, our proposal outlines what the Blue Cross and Blue Shield System is currently doing, along with recommendations on what the government should do.   Today, I will focus my testimony on the first four initiatives designed to make healthcare more affordable.

1.      ENCOURAGE RESEARCH ON WHAT WORKS

The first of our recommended initiatives is to encourage research on what works.

Today, only about half of patients get the recommended course of evidence-based care.  We can and must help doctors and other caregivers deliver better and more consistent clinical care to their patients – based on peer-reviewed, best clinical standards.  Better, safer and more consistent care will help make more effective use of our healthcare resources.  

What Blue Plans Are Doing

• BCBSA's Technology Evaluation Center:  Since it was founded by Blue Cross and Blue Shield more than 20 years ago, the Technology Evaluation Center – TEC – has helped physicians and other caregivers across the country improve quality. 

TEC has led the development of scientific criteria for assessing the effectiveness of medical technologies through comprehensive reviews of clinical and scientific evidence. TEC is one of only 14 evidence-based practice centers for the U.S. Agency for Healthcare Research and Quality – publishing an average of 15-20 clinical assessments annually.

Recently TEC assessed whether computer-assisted navigation improved alignment of the implant during knee replacement surgery.  TEC's study found that there was little existing evidence that computer-assisted navigation technology helped improve patient outcomes compared to conventional knee replacements.  

• Blue Health Intelligence:  To further support evidence-based medicine, we created Blue Health Intelligence (BHI) – our nation's largest, most comprehensive healthcare data repository – which will have patient-protected health claims information on 80 million Blue Cross and Blue Shield subscribers by the end of the year.

BHI will be a powerful research tool that can inform decisions that will ultimately improve care.  It can benefit employers by providing them with information on trends and utilization that they can use to develop state-of-the-art wellness programs.  It can also provide information on breakthrough treatments and potential problems in care delivery.  For example, if BHI had existed a few years ago, we may have known sooner about the link of Vioxx to increased risk for heart attack and stroke.

What Congress Can Do

Blue Cross and Blue Shield believes Congress should create a new, independent comparative effectiveness research institute – insulated from political pressures – that is directed and staffed by experts and devoted exclusively to support comparative research evaluating the clinical effectiveness of different procedures, drugs, devices and biologics.  I applaud the leadership of Senators Conrad and Baucus on this issue and look forward to working with them and other Members of Congress to establish such an entity.

In order to be successful, Blue Cross and Blue Shield believes a comparative effectiveness research institute must:  support a broad range of research, including clinical trials; be structured as a federally chartered not-for-profit entity so that its findings are trusted; and have significant and stable funding.  Ensuring that this institute makes a difference in improving quality and value in our healthcare system also depends on effective dissemination efforts and providing the right incentives for incorporating comparative effectiveness research information into patient care.  The starting place is to make sure comparative effectiveness research information is available to providers and patients in formats they can access and use easily.

In addition, we recommend:  (1) ensuring new comparative effectiveness research is incorporated into clinical decision support systems; (2) allowing public health programs to use comparative effectiveness research to inform pay for performance, reimbursement, and coverage decisions; and (3) aligning medical malpractice reforms with comparative effectiveness research findings to increase the likelihood of new comparative effectiveness research improving our healthcare system.

Legislation in this area will be a critical step to improve the safety, quality and affordability of healthcare for all Americans.

2.  CHANGE INCENTIVES TO PROMOTE BETTER CARE

Turning to the second element of our plan, we must change incentives in the current system to advance the best care possible, not just more services.  Despite the ongoing efforts by private payers and public programs, our delivery system too often rewards care that is fragmented, duplicative, and wasteful.    

Providers should be rewarded for delivering high quality care with incentives to coordinate care, especially for the increasing number of individuals with chronic illness.  Properly aligned incentives can reinforce adoption of evidence-based practice standards and transparency in outcomes and quality information.  Raising the bar on quality – while working to eliminate wasteful spending – will result in better outcomes and more prudent use of resources. 

What Blue Plans Are Doing

• Blue Distinction Centers:  Furthering our efforts to ensure delivery of the best care available – to help raise the quality of healthcare across our country – we created Blue Distinction to give consumers information about some of the best hospitals and healthcare facilities for cardiac care, bariatric surgery, transplants, and the treatment of complex and rare cancers.

In creating this program, we collaborated with providers and professional organizations to establish quality thresholds for facilities to meet or exceed.  Our hope is that the program encourages all facilities to work toward meeting data-driven quality measures. 

Today, more than 800 Blue Distinction designations have been awarded to facilities nationwide, and I am pleased to report that our initial effectiveness study shows that facilities recognized as Blue Distinction Centers (BDCs) deliver better outcomes at lower costs than their peers.

As you know, heart disease is the leading cause of death in the U.S. (and has been for the past 80 years) and is a major cause of disability. 

Sixteen million Americans had heart disease in 2005; 469,000 coronary artery bypass procedures (CABG) were performed.

Risk-adjusted claims data from WellPoint, one of our member Plans, demonstrates that patients who underwent a CABG procedure at a Blue Distinction Center for Cardiac Care had a lower rate of readmission in the 90 days following the procedure – 8.3 percent at Blue Distinction Centers versus 10.6 percent at other facilities – and 20 percent lower episode costs.

• Patient-Centered Medical Home:  BCBSA and Blue Plans are now piloting 29 Patient-Centered Medical Home Demonstration sites across the country with the goal of fundamentally changing the way primary care is delivered and financed.  Under these demos, physicians are paid for the overall coordination and care management of their patients.  This could include payments for phone calls and/or emails with their patients or other providers, which are currently not reimbursed.  The intent is to move away from payments based strictly on the volume of patients they see and procedures they perform, and instead incentivize high quality outcomes based on coordination of care.

For example, Blue Cross and Blue Shield of North Dakota partnered with providers to implement an innovative, patient-centered diabetes management pilot program that rewards physicians for delivering coordinated care.  The Plan provided a $20,000 grant for a large clinic to establish an on-site disease management program and used performance measures recommended by the American Diabetes Association.  Through a coordinated team approach, the program included development of an action plan based on the member's medical history, self-management education, close monitoring of care needs, and ongoing communication.  To further incentivize providers, any savings yielded by this increased level of care coordination were shared equally between the clinic and the Plan.  The program proved successful--patient compliance improved, and as a result the rates of costly ER visits and hospital admissions decreased, with an associated $520 on average saved per patient in the pilot's first year.

• Reducing Hospital Infections:  Highmark Blue Cross and Blue Shield's QualityBLUE pay-for-performance program has reduced rates of hospital-acquired infections to less than 1 incident per 1,000 line days among participating hospitals.  This rate compares very favorably to the national average of 5 infections per 1,000 line days.  By rewarding providers for improving the process of care through adherence to preventive measures, such as the use of dedicated equipment, proper hand hygiene and wearing protective clothing and masks when treating patients, Highmark saved an estimated $32 million in medical costs per year.

On a national level, BCBSA has joined the Institute for Healthcare Improvement (IHI) in the expansion of the 5 Million Lives Campaign by providing a $5 million contribution to support the efforts of hospitals nationwide to reduce the incidence of infections and preventable errors in U.S. hospitals.  This new campaign builds on the successful 100,000 Lives Campaign in which over 3,100 hospitals changed their processes and clinical procedures, resulting in a reported reduction of inpatient deaths by 122,000 in 18 months.  This new campaign will reach an additional 4,000 hospitals.

What Congress Can Do

The federal government needs to be similarly focused on changing incentives for federal health programs and promoting the best care for patients. 

• Pay-for Quality:  Medicare should follow the private sector's lead in adopting more pay-for-quality incentives for healthcare providers.  Implementing a value-based purchasing system for providers would help change our reimbursement to one that rewards providers for delivering quality outcomes.  As a way to pilot such a concept, the Centers for Medicare & Medicaid Services (CMS), in collaboration with Premier Inc., a hospital performance improvement alliance, established the Hospital Quality Incentive Demonstration.  Through this program, CMS awards varying incentive payments to participating hospitals for their performance in several clinical areas.  Second year results showed that patients treated at participating hospitals live longer and received recommended treatments more frequently.
  
  
• Improve Access to Safe, Affordable Generic Drugs:  To promote competition and bring down drug prices to consumers, Congress also should remove barriers to safe, effective and affordable prescription drugs.  For example, Congress should give the FDA authority to approve scientifically feasible and safe generic versions of biological products, without imposing inappropriately long periods of market exclusivity for brand biopharmaceutical products. 
  
  
• Enact Comprehensive Malpractice Reform:  We also recommend Congress enact medical liability reform legislation to address rising medical malpractice premiums, which threaten the ability of patients to receive quality care.  Rising malpractice premiums are fueling the rise in the practice of defensive medicine – increasing utilization of unnecessary and sometimes harmful healthcare services.

3.      EMPOWER CONSUMERS AND PROVIDERS

Our third initiative is engaging and empowering consumers and providers.

Too often, consumers and providers do not have the information and tools they need to make informed decisions about quality and cost.  Enhanced transparency – consumer friendly information on quality and costs – and greater use of health information technology are key to achieving this goal.

What Blue Plans Are Doing

The Blue Cross and Blue Shield System is strongly committed to advancing health information technology which can improve healthcare quality and safety and create efficiencies.  Blue Plans across the U.S. are leading efforts to promote widespread adoption of electronic medical records, e-prescribing, personal health records and consumer decision-support tools.  

• Claims-based Electronic Records:  Many Blue Plans are giving providers access to comprehensive information on a patient's health and past medical history through payer-based electronic health records.  These records are populated with pertinent claims data such as recent health encounters, diagnoses, medication histories, prescription refill status from pharmacies, and test results from laboratories.  This information enables providers to better coordinate care.  When emergency department physicians at Christiana Care's level-one trauma center in Newark, Delaware, were able to view a payer-based health record offered by Blue Cross Blue Shield of Delaware, the total costs for each patient treated were reduced by an average of $545.  The savings resulted because information in the record on a patient's past treatment history enabled physicians to avoid unnecessary lab tests and procedures.
  
  
• Personal Health Records:  Blue Plans also are providing personal health records (PHRs) for their members, which are auto-populated with key claims data, including medications, immunizations and provider information, and can be self-populated with other important information such as family history and over-the-counter drugs.  A PHR can help consumers be better informed and more actively involved in their healthcare.  By authorizing providers to view their PHR, patients can avoid having to fill out the same "clipboard information," (e.g., allergies, family medical history) every time they see a new provider.  A PHR's ultimate value to consumers is improved care through more complete information and better coordination among caregivers.
  
  
• Electronic Prescribing:  Blue Cross and Blue Shield is very pleased at the high level of interest among Members of the Committee in advancing e-prescribing.  Blue Plans are leaders in facilitating e-prescribing.  For example, in 2006, Blue Cross Blue Shield of North Carolina launched an e-prescribing program where they provided more than 1,000 high-volume prescribing physicians with a handheld personal digital assistant (PDA), software licenses and wireless network hardware free-of-charge.  Using claims data, BCBSNC uploaded the physicians' patient information into the system, delivering point-of-service information including immediate alerts of potential adverse drug events (ADE), generic alternatives to prescription drugs and formulary benefits.  Since the program's launch, the improvements to patient safety have been impressive.  More than four million electronic prescriptions have been submitted.  Of those prescriptions, 59 percent received drug-to-drug interaction warnings; 32 percent of the orders were flagged as formulary warnings; and 2 percent were halted altogether because of patient allergy alerts.  These prescriptions were changed accordingly because of the availability of member medical and prescription histories at the point of service. 

What Congress Can Do

The federal government also has an important role to play in empowering consumers and providers.  We believe the government should require physicians participating in Medicare to electronically prescribe and we support the bipartisan E-MEDS Act, sponsored by Senators Kerry, Stabenow and Ensign.  We also commend Senators Baucus and Grassley for advancing e-prescribing in their pending Medicare bills.  This would improve quality and safety – and also save the program, its beneficiaries and taxpayers billions of dollars over time.  And – more importantly – it would help drive wider adoption of e-prescribing and other health information technologies to benefit all Americans.  We urge Congress to enact a Medicare e-prescribing mandate this year.

The federal government should also continue to partner with the private sector to promote greater quality and cost transparency for consumers and providers.  Given the significant variation in quality and costs among healthcare providers, it is important that information be made available to consumers in easy-to-understand formats to help them make informed healthcare decisions.  The government should continue using consensus-based quality measures, such as those developed by the National Quality Forum (NQF), the Hospital Quality Alliance (HQA) and the Ambulatory Quality Alliance (AQA) to promote transparency.  The National Quality Forum's consensus process for endorsing measures provides a way to accurately compare the quality of care across organizations and geographic boundaries.  For consumers, such information can serve as a guide for making important treatment decisions and choosing the right provider or hospital.  For providers, knowing more about their performance and how it compares to that of their peers will allow them to develop strategies to improve.

4.  PROMOTE HEALTH AND WELLNESS

One of the greatest challenges our system faces is managing care for a growing number of people suffering from chronic illnesses, such as heart disease, hypertension, diabetes and stroke.  Together, chronic illnesses account for 70 percent of deaths and 75 percent of total healthcare costs, according to the Centers for Disease Control. 

Clearly, meaningful incentives that encourage patients and caregivers to aggressively tackle these diseases can go a long way to improving patient care, saving lives and keeping healthcare costs in check. 

What Blue Plans Are Doing

• Encouraging Healthier Lifestyles and Exercise:  In 2003, BCBSA launched Walking Works to encourage healthier lifestyles and combat obesity and related diseases.  A daily routine of brisk-paced walking can help individuals lose weight, lower cholesterol, strengthen the heart and reduce the likelihood of serious health problems in the future.  Blue Plans also are working to do a better job engaging consumers by promoting healthy lifestyles.  This includes sensible diet, exercise and disease management and preventive programs – and dealing with social issues such as tobacco, alcohol, drugs, violence and public health concerns.
  
  
• Congestive Heart Failure (CHF) Management:  Blue Cross of Idaho launched a disease management program in 2001 designed to reduce hospital admissions and improve medication compliance for members with congestive heart failure (CHF).  The program used educational materials and one-on-one physician coaching and outreach to improve self-management techniques, as well as offered biometric monitoring equipment to high-risk CHF members that allowed them to report on their conditions from home.  The coordinated efforts led to a 5 percent reduction in hospital readmission rates among members with CHF. 
  
  
• Diabetes Management:  Horizon Blue Cross Blue Shield of New Jersey is utilizing critical health IT tools while also offering primary care physicians financial incentives to provide comprehensive, coordinated patient care and management of chronic diseases.  Under this pilot, Horizon shares pertinent claims data with providers that can tell the physician which of his or her patients have diabetes and which have not had important tests or screenings as part of their recommended care, such as a blood glucose test within the last year.  With this information now readily available, physicians are able to reach out to the patient to make sure they are getting the care they need.  This program is yielding impressive results.  In just one year, blood sugar testing compliance rates for patients with diabetes jumped from 40 percent to over 90 percent. 

What Congress Can Do

BCBSA believes there are a number of areas where the federal government can do more to promote health and wellness.  Improvements in health-related behavior and treatment for the seven most common chronic diseases (cancer, diabetes, heart disease, hypertension, pulmonary conditions, stroke and mental disorders) could cut the annual cost impact by $217 billion in 2023, according to a 2007 report from the Milken Institute.  We recommend the federal government:

• Encourage Employee Wellness Programs:  Congress should remove barriers that hinder employers from encouraging healthy employee lifestyles (e.g., current law requires employers to give non-smoker discounts to smokers who enroll in, even if they do not successfully complete, cessation programs).  Tax incentives also should be provided to encourage employers to adopt smoking bans and promote employee exercise.
  
  
• Educate Children on Healthier Lifestyles:  The federal government should support school programs that encourage healthy lifestyles such as:  assuring physical education classes for all grades five days per week and providing nutrition, tobacco and health literacy education.  The nutritional quality of school meals also should be improved and vaccinations should be provided to all children.  BCBSA commends Senator Harkin for his ongoing commitment to prevention and wellness and we are pleased to support his legislation -- the "Fitness Integrated with Teaching (FIT) Kids Act" (S. 2173) -- which will support public school efforts to provide ongoing physical education and promote healthy lifestyles.  This effort and others like it will go a long way towards combating obesity and other preventable chronic diseases.
  
  
• Provide Incentives and Education on Nutrition and Health:  Medicaid should provide robust coverage for smoking cessation programs and incorporate wellness and disease prevention incentives.  In addition, tax incentives should be provided to encourage full-service grocery stores (e.g., selling fresh fruits and vegetables) in underserved neighborhoods.  The food stamp program should provide nutritional counseling and incentives for healthy food purchases as well as health literacy education.

As we undertake these critical initiatives to improve healthcare quality and enhance affordability, we also must work simultaneously to extend coverage to everyone.  Our fifth initiative addresses fostering private-public sector solutions to cover the uninsured, primarily through subsidies to help people afford health coverage, tax credits to assist small employers and their low-wage workers, and expansions to government programs.

Other Payer Initiatives that Bend the Growth Curve of Health Care Spending

The Blue Cross and Blue Shield Plans, as well as other payers, are uniquely positioned to implement other initiatives that can help slow the rise in healthcare spending. 

• Combating Healthcare Fraud:  It is estimated that fraud robs our healthcare system of as much as $100 billion annually.  Working with the FBI and other national and local law enforcement agencies, Blue Cross and Blue Shield Plans are at the forefront of aggressively tracking down and preventing healthcare fraud.  Last year alone, the Blues' anti-fraud efforts resulted in savings and recoveries of nearly $249 million and prevented the additional loss of $134 million.

• Designing Benefit Packages that Encourage Value Purchasing:  Blue Plans across the country are offering a broad range of new benefit designs that encourage consumers to use cost and quality information in choosing their providers and treatments. For example, Plans are offering consumer-directed health plans (CDHPs), some with a financial account funded by the consumer, employer or both, and are tied to high deductible plans.  A study by BCBSA found that consumers enrolled in CDHPs were more likely to seek information about doctor and hospital quality and cost before seeking care and were more likely to positively act on that information, such as participating in an exercise program.  Another example includes initiatives to encourage the use of generic drugs.  Blue Plans' are aggressively promoting the use of generic drugs, where appropriate, that can save consumers between $8 billion and $10 billion annually, according to the Congressional Budget Office.

• Investing in Technology that Adds Value and Increases Efficiency:  Blue Cross and Blue Shield Plans are making major investments in new technologies to use our claims' data in creative ways so that consumers, providers and employers can make better decisions and bring our healthcare system into the 21st century.  In addition, we are investing in technology to improve customer service and reduce our own business and administrative operating expenses. 

Conclusion

We all know only too well that there is no single nor simple solution to the nation's healthcare dilemma – to improving the quality of care and patient safety, reining in out-of-control costs to keep healthcare affordable and extending coverage to all, including the 47 million among us who are forced to go without the security and peace-of-mind of having health insurance for themselves and their loved ones. 

The real solution is a comprehensive series of public-private sector programs to attack our healthcare problems on multiple fronts.  Blue Cross and Blue Shield Plans are committed to working with key leaders and stakeholders to deliver on the initiatives I discussed today.  We applaud the Senate Finance Committee leadership and other policymakers at the forefront of healthcare reform for making this a top domestic priority.  We urge Congress to take immediate action to improve the quality, safety and value of our healthcare system -- starting with creating an independent comparative effectiveness institute to evaluate the effectiveness of different procedures, drugs, devices and biologics.  We also pledge our continuing support to work with you and others to extend health coverage to everyone. 

Thank you for the opportunity to present the views of the Blue Cross and Blue Shield System.