ing their success in controlling costs and are arrogant with the state and with: customers.

They say the Blues should be quicker to recognize their limitations and to step back, allowing the state a greater role in containing the surging costs of health

care.

Such views suggests that the Blues will be operating in a different regulatory climate in the days ahead.

On the near horizon, questions are likely to be raised about the merger proposal being considered by Surgical Care and Blue Cross.

MUCH WEAKER

Surgical Care is in a much weaker financial position than Blue Cross. Blue Cross, with twice the claims load of the Blue Shield unit, had a statutory reserve fund about 35 times as big as Surgical Care's as of last Dec. 31.

This has led Blues observers to suggest that the merger plan is, as much as anything, a bailout of the Blue Shield unit and the doctors by Blue Cross and the doctors by Blue Cross and the hospitals.

Hearings on the merger, if pursued by the Blues, could come late this summer and could be controversial, according to one Blues watcher.

IMPORTANT ISSUES

The State Insurance Department may well call other hearings, too. State Insurance Commissioner Harold Wilde and his aides are believed likely to propose hearings on what could become a string of rule making issues. Some possible questions: whether there should be more disclosure on advertising and promotional expenses and executives' benefits, whether to require a Blues plan to do more than simply notify the department when it proposes a rate increase, how to improve handling of customer grievances, whether the public has enough say in the Blues plans, whether the Blues are doing enough to contain costs.

Businesses being smacked with big rate increases by the Blues, and state officials who sense the political gains to be made by questioning the increases aren't likely to discourage such hearings.

THIRTY PERCENT INCREASE

Take, for instance, General Motors Corp., one of the state's largest employers with 11,400 workers. GM says its outlays for comparable Blues coverage in Wisconsin have risen nearly 30% in the last five years.

That's a smaller increase than GM has seen in many other states, but GM officials fear the increases here will accelerate, rather than ease up, in the months ahead.

Bernard Brown, personnel manager at GM's big assembly plant in Janesville, said the company may seek representation on the Blue Cross board to win more attention for GM's concern about health care costs.

CHANGE IN COMMAND

Another new factor is the change in command at the State Insurance Department. The new commissioner, Wilde, is described as more interested in regulating the Blues than were his predecessors.

"Historically, the Blues have enjoyed a special status," he said. "They have been insulated a lot from regulations. By virtue of their position, they must have a high standard of responsibility."

The Blues contend they are doing a lot to hold down costs-they point to statistics that show medical service prices rising slightly less here than in the rest of the country. They point to moves, made or planned, to add more public board members.

RISE IS CONTINUING

Surgical Care points to a four month freeze, lifted April 1, on physicians' fees. Blue Cross boasts of its rate review program.

However, statistics show that prices of medical services in Wisconsin are continuing to rise notably faster than prices generally. That breeds discontent. Lucey, who appointed Wilde, is among the discontented.

"I think they may be doing all they can," Lucey said of the Blues. "They have to consider that their constituency is.

"I think you have to take into account the fact that Blue Cross is in a relationship with the hospitals that does not permit them to impose the kind of tough cost containment that the situation calls for."

This view is not just Lucey's.

Blue Cross was started in 1940 by the hospitals, shortly after similar plans had begun in many other states. In essence, the plans filled the role of a bill collection agency for the hospitals, assuring for them the revenue they needed to keep going. Later, as big worker groups won a lot of new health care benefits, the Blues plans grew explosively. Today, the three Blues plans in Wisconsin-Blue Cross ($212 million in claims), Surgical Care ($104 million) and a second Blue Shield plan, the Madison based Wisconsin Physicians Service ($107 million)-hold the lion's share of the business in the state.

CRITICS ARE MANY

Yet many believe the Blues are still operating primarily in the interests of the hospitals and the doctors.

One of the foremost critics of Blue Cross is Sylvia Law, a professor at New York University and author of the 1975 book, "Blue Cross: What Went Wrong?" She has described Blue Cross plans as the "financing arm of American hospitals." Ms. Law noted that the American Hospital Association owned the name Blue Cross and the Blue Cross insignia until 1972 when the association agreed to transfer ownership of both to the Blue Cross Association, a trade group representing Blue Cross plans. The two groups also eliminated their interlocking directorates.

TERMED A RESPONSE

Ms. Law quoted AHA officials who said the changes were a response to changing public attitudes but they did not represent a cooling off between Blue Cross and the AHA.

State Rep. David Clarenbach (D-Madison) charges that the Blues have not built enough public interest into their system. Clarenbach, who heads the Assembly subcommittee on health care and the consumer, held hearings on the Blues last year. He said he may hold more later this year.

Other legislators, unhappy because legislation to contain medical care costs was scuttled in the last session, also sense that the matter is becoming a more important issue.

WAITING FOR RECORD

Among these is Rep. Joseph Czerwinski (D-Milwaukee), chairman of the Assembly Committee on Health and Social Services. Czerwinski said the strengthened rate review committee should have a track record by early next year. If the record isn't good enough, he said, a bill to put rate review entirely in the hands of the state is likely.

Lucey and his aides are watching Ohio, where the Blues challenged a state insurance commission rule. They won in court, but legislators responded by writing the rule into the law books through legislation.

The Ohio law gives the insurance commissioner power to reject portions of a rate increase proposed by a Blues plan. Wisconsin's new law gives Wilde explicit power to reject fully a Blues rate increase, but such a move would be certain to draw a strong legal challenge. Wilde cannot reject a portion of a Blues rate increase under the new law here.

REGARDED AS MODEL

One state health care specialist termed the Ohio law a model because it requires. the Blues to make a good faith effort at cost containment. The new Wisconsin law deals only indirectly with cost controls.

There's also a strong feeling that even the strengthened rate review committee won't be able to do enough to hold down costs.

The new role of the committee will be to develop standards for judging hospital rate requests.

Some examples of the issues to be confronted in drawing up the standards: How much more sharing of equipment and services should hospitals be forced into?

Are depreciation accounting techniques allowing the hospitals to overstate their need for higher charges?

At what level do occupancy rates get so low that hospitals should be forced to close?

A subcommittee is expected to draw up the new standards. Several persons familiar with the rate review process believe the subcommittee will become a major battleground for tussles between the state, pressing for cost control, and the hospitals, trying to defend, in some cases, their very existence.

SOME PESSIMISTIC

There are those who believe the strengthened rate review process won't be enough. "It's not going to work," one source predicted. "It's going to the Legislature eventually, but everyone's willing to give it a try to see if it's going to work." Lucey urged a state rate review committee two years ago, but his proposal died in the Legislature.

Blue Cross and the WHA contend that rate review has shaved more than $15 million from rate increase requests in its first 31⁄2 years. However, the governor estimates that Wisconsin hospitals are passing on to their customers more than five times that amount each year in unneeded costs because hospital rates are based partly on vacant beds that were part of unnecessary construction projects.

OFFICIALS WATCHING

State officials, finally, are looking closely at the performance of the Connecticut Commission on Hospitals and Health Care, which claims far greater savings than the Blue Cross-WHA rate review committee. In Connecticut, legislators ordered the state to combine into the commission several functions that still are divided or not performed at all in Wisconsin.

The commission is in charge of all regulations affecting planning, rate review and certification of need. This consolidation, supporters argue, has enabled the public to hold medical care organizations more accountable for their actions.

And that, critics of the Blues contend, is something that's been missing at the Blues and in the health care system in Wisconsin.

BLUE CROSS Loss QUESTIONED

(By David Beal)

Did Blue Cross of Wisconsin have a net operating loss of $10.4 million last year, or was the loss only $4.6 million?

Did the Blue Cross plan's reserve fund shrink from $37.7 million at the beginning of 1975 to $32.3 million at the end? Or did it grow, to $373. million from 136.4 million, during the year?

The answer depends on whom you ask.

If you ask Blue Cross and its accounting firm, Arthur Young & Co., you get the gloomier set of figures. Blue Cross lost $10.4 million. Its reserve fund fell about $5.1 million.

STATE'S VIEW

If you ask the Office of the State Insurance Commissioner's Office, you get a picture that is less bleak. Blue Cross lost $4.6 million. Its reserves increased by about $900,000.

The explanation for the variances rests in the use of different accounting systems.

Blue Cross says it uses "generally accepted accounting principles" to put together its financial statements. State insurance department regulators, on the other hand, require the plan to report its financial condition on a "statutory basis." Department auditors told Blue Cross, in a state examination last year, to begin reporting the statutory basis figures in the annual report Blue Cross distributes to the press and the public.

Thus, the Blue Cross annual report for 1975 does include a "statutory basis balance sheet." However, the report did not include the statutory basis income statement, as given to the state. And in a news release accompanying the annual report, Blue Cross emphasized the $10.4 million loss without mentioning the $4.6 million loss figure.

Joseph E. Voyer, senior vice president for finance at Blue Cross, and Robert H. Walker, director of the Insurance Department's Operational Review Bureau, explained the differences in separate interviews.

Voyer said the state's view is that Blue Cross should describe its operations for 1975 as the financial statements would appear if the plan had stopped doing

business Dec. 31, 1975. One effect of reporting that way is to include a financial statement item called "deferred premium credits," the excess of premium income over claims payments, in the income statement, instead of listing the credits as a liability in the balance sheet.

DIFFERING TREATMENT

Thus, he said, Blue Cross reported $6.9 million in deferred premium credits to the state as income, but the plan's accountants excluded this income in their report to the public. Most of the differences in the loss and reserve figures are due to the differing treatment of these credits, he said.

Voyer said the differences happened to be significant in 1975, but weren't likely to vary much for 1976.

Voyer was asked by a reporter whether Blue Cross emphasized the more gloomy figures in order to make a better case to the public for premium increases. Not so he replied.

[From the Milwaukee Journal, June 11, 1976]

PHARMACISTS DEALT BLOW BY BLUE CROSS

(By Neil D. Rosenberg)

Dozens of Milwaukee area pharmacies that have been battling delays and rejections of claims for prescriptions they have given Medicaid recipients now have a further problem.

The delays are due in part to delays in transferring eligibility notices between the state Welfare Department and Blue Cross and Surgical Care Blue Shield, which handle the fiscal arrangements for the program.

To circumvent this problem, pharmacists have invested hundreds of dollars in photocopying machines so they can copy their customers' Medicaid cards. They have sent the copies with the claims to prove their customers' eligibility. But Blue Shield has sent a letter to all pharmacists saying this practice conflicts with state and federal regulations.

PROCEDURE ALTERED

"Previously, Medicaid claims that were rejected were normally processed the following month if a copy of the patient's Medicaid indentification card was attached to the claim form," the letter said.

"It has become necessary to alter this procedure to more closely align Milwaukee County procedures with the rest of the state and to provide stricter compliance with state and federal regulations governing the Medicaid program. "It will no longer be of any particular benefit, or necessary, to attach copies of the Medicaid recipient's eligibility cards to our office.

"It should be noted that rejections frequently occur because of the time lapse between the date the Welfare Department issues Medicaid cards and the date that notification is received by Surgical Care to update the computer eligiblity file."

MORE BACKLOGS

An official of a chain of six pharmacies said the new policy would cause even longer delays. He said he had been told unofficially that pharmacists could call Blue Shield if a customer wanted to check on his eligibility. If Blue Shield does not list the person as eligible, the pharmacist will be told not to fill the prescription because it won't be allowed.

"What am I supposed to tell the customer who has the Medicaid card right in front of me?" he asked.

He said he had waited five or six months for some customers to be certified. And he said that he feared the situation would become worse under the new system.

He said Blue Cross had advanced him $25,000 to cover delays in payments. "They act like they are doing you a favor in giving you the money, but it is my money, not theirs," he said.

BLUE CROSS PROBE SOUGHT

(By Neil D. Rosenberg and David Beal)

A California congressman says he plans to seek a congressional investigation into Blue Cross of Wisconsin, particularly into the organization's use of a $200,000

private plane and a fleet of 118 cars, including a 1976 Mercedes-Benz and other luxury cars.

Rep. Fortney H. (Pete) Stark (D-Danville) said in a telephone interview that he would ask the oversight subcommittee of the House Ways and Means Committee to investigate. A spokesman for the committee said the investigation might begin in less than a month.

Stark's call for an investigation came after he learned of the plane and luxury cars in a federal audit, a summary of which was obtained by The Milwaukee Journal. It was unclear whether the investigation would include Surgical CareBlue Shield.

The audit showed, among other things:

In 1974 Blue Cross sold a Piper Aztec twin engine plane, which it purchased in 1970 for $88,840, and bought a twin engine Cessna 414 with a pressurized cabin for $201,642.

Maintenance and operating costs jumped from $33,138 in 1973, when the Aztec was used, to $52,869 in 1975.

Blue Cross overcharged the federal government $726 in 1975 because it used luxury cars instead of nonluxury cars to transact some Medicare business. There were also overcharges of $61 in 1973 and $61 again in 1974. The audit concluded that the 1973 and 1974 overcharges were not significant, but it recommended that Blue Cross repay the $726.

Twenty-two of the 118 cars in the fleet are classified as luxury cars. (A Blue Cross spokesman said the government defined a car costing more than $5,262 as a luxury car, for purposes of the audit.)

Most of the cars in the fleet are given to employes for personal use as well as business use. In return, the operators have to pay for all gas, for business and personal use, except for certain business mileage. They get 4 cents a mile for business mileage of more than 500 miles a month in the Milwaukee area and 5 cents a mile for business mileage of more than 600 miles a month outside the Milwaukee area. They are reimbursed for all maintenance, repairs and parking.

Stark, with Rep. Charles A. Vanik (D-Ohio), chairman of the oversight subcommittee, has informally investigated other Blue Cross plans and their use of cars and planes. He said Blue Cross here had one of the largest transportation fleets of any such plan in the country.

"This is so flagrant that it offends public sensibility," Stark said. "There is no question this is one of the biggest plane and car fleets of any plan.

"Why should we pay Medicare money to keep that group in abject luxury? It is absolutely ridiculous."

PLANE RAISES QUERY

Stark questioned the need for any plane, though the audit found the costs charged were reasonable for a private plane and comparable to costs of commercial airlines or privately owned autos. The audit was done by the U.S. Department of Health, Education and Welfare.

Stark, himself a pilot and familiar with both types of planes, said there was no way a plane could be cheaper to operate on a trip to say, Madison or Green Bay, than a car. Stark, who was born and grew up in Milwaukee, said he was familiar with the state.

Leo Suycott, president of Blue Cross, emphatically rejected Stark's charges. "It's easy for him to sit in Washington and make these wild statements," Suycott said. "It makes good news to seize upon us and make noise about an emotional issue such as health care. Medicare is getting a pretty good buy. We're doing a good job for them."

FIGURES RELEASED

Separately, a Blue Cross official released figures from Blue Cross that said the insurer's cost of handling Medicare claims had dropped from an average $6.07 a claim in 1972 to $4.83 last year. The 1975 figure is lower than average handling costs for other, similar sized Blue Cross plans, commerical insurers and the government, he said.

Suycott said he drives the Mercedes. He said the car has a diesel engine, making it efficient and economical. The car is a model 300D with five cylinders, he said. Suycott would not give the price of the car, but such models currently sell for $14,000 to $18,000 new, depending on optional equipment.

Suycott also said he saw no impropriety in the use of Blue Cross cars for personal purposes.