Latest / Becker’s Healthcare Podcast / Navigating Cost Pressures and Data Driven Partnerships at EmblemHealth

Transcript

Navigating Cost Pressures and Data Driven Partnerships at EmblemHealth · Becker’s Healthcare Podcast

0:02
This is where health insurance leadership comes together.
0:05
Becker's fourth annual spring payer issues roundtable brings
0:09
together over 400 payer and health plan executives
0:12
and more than 100 speakers to Chicago April.
0:16
This year's event includes keynote conversations with the
0:19
industry's top leaders and former president George W.
0:23
Bush. For the full agenda and event details,
0:25
visit beckershospitalreview.com
0:27
and click on the events tab in the
0:29
upper right. We're looking forward to hosting you
0:31
here in Chicago.
0:34
Hello, everyone, and welcome to Becker's Healthcare podcast.
0:36
I'm Scott King. Thrilled today to be joined
0:38
by a very special guest, Heather Tamberrino,
0:41
chief financial officer with EmblemHealth.
0:44
Heather, how are you doing? Thanks so much
0:45
for joining us.
0:46
I'm great. Thanks so much for letting me
0:49
join you today. I'm so excited.
0:51
Of course. We have, you know, new year,
0:53
some same issues,
0:54
in health care and and with health plans
0:56
and and some some new ones as well.
0:59
But before we jump into all that, I
1:00
was wondering if you could just please tell
1:01
us a little bit about your background
1:03
and your career journey.
1:05
Sure thing.
1:07
I've been here now with EmblemHealth as the
1:09
chief financial officer for the last five years,
1:12
and and that entails what you would expect
1:14
it to entail, controllership,
1:16
actuarial,
1:18
FP and A, treasury,
1:20
the the norm.
1:22
And my background's a bit of a a
1:23
mixed bag. You know, I started with Deloitte,
1:27
in the traditional accounting space,
1:30
moved into
1:31
working in enterprise risk management and performance management,
1:36
and have bounced around
1:38
in both IT spaces,
1:40
operational performance spaces,
1:43
and both
1:44
profit and nonprofit.
1:46
Probably my last, twenty years has been in
1:49
the nonprofit space,
1:51
with a variety of blues,
1:53
and now here at EmblemHealth.
1:55
Well, excellent. Thank you so much for sharing
1:56
all that info. Heather, really appreciate it. You
1:59
you're coming from a lot of different, experience
2:01
and perspectives there. The first topic I wanna
2:03
get to, how are your relationships with providers
2:06
changing
2:07
as both sides face cost pressure and workforce
2:10
shortages?
2:11
Yeah. It's as you said, it's a it's
2:14
always been a question, but as with the
2:17
more recent
2:18
challenges,
2:19
it it can be a little challenging now.
2:21
But our goal is to continue
2:24
to move, focus on the relationship,
2:27
and move to value based
2:29
and really focus on integration
2:31
in a cost efficient manner.
2:34
But, you know, it's strained with those pressures.
2:37
All that said, I think what we're continuing
2:39
to do is look at opportunities
2:41
to really think about unique contracting
2:44
opportunities,
2:45
you know, hybrid
2:46
contracts, you know, blending fee for service versus
2:49
pure value based,
2:51
and really focus on what is the common
2:53
goal for both the payer and the provider.
2:55
And that's putting our members and patients right
2:58
at the middle, right at the center.
3:00
And we're working on engaging on a number
3:02
of fronts,
3:04
really focusing on educating our provider partners on,
3:07
you know, what can drive premium incentive dollars
3:10
and sharing
3:12
actionable info
3:14
in a really consultative way
3:17
and show them how that improves the outcome,
3:19
not only for the patient, but for their
3:21
reimbursement and financials.
3:24
We're also
3:25
doing things like providing predictive analytics
3:28
to our providers,
3:30
so we can help catch rising risk and
3:33
again allow both the payer and the provider
3:35
side to nudge members towards lifestyle
3:38
or
3:39
engagement
3:40
channels
3:41
and changes.
3:43
And the other thing we're trying to do
3:45
with our providers is when we think about
3:47
contracting,
3:48
it's how do we take a multiyear view
3:51
on measures and improvements. So we're not asking
3:54
a provider to step immediately into a new
3:58
reimbursement
3:58
methodology or something when they're struggling with other
4:01
cost and
4:03
revenue challenges.
4:04
And we think as long as we take
4:06
these multi year
4:07
views on measures and improvements
4:10
that can help with chronic care management, that
4:12
can help with,
4:13
both outcome improvement
4:15
on the payer and provider side.
4:17
And last, I would say
4:20
we're in a slightly unique position at Emblem
4:23
because we have our own provider group. And
4:25
given that many of our members are tied
4:27
to our own provider group, that's Advantage Care
4:30
Physicians,
4:31
this gives us a great opportunity to really
4:34
incubate and sort of test and pilot
4:37
new solutions,
4:38
new capabilities,
4:39
technologies
4:41
that really support the long term management
4:45
of our member needs. And then we can
4:46
work to extend those capabilities
4:49
to our provider or broader provider base because
4:52
we've had the opportunity to test them. And
4:54
that can help minimize cost and investment to
4:57
the providers when we're all trying to manage
5:00
through these,
5:01
this pressured period.
5:03
Where do you see the biggest gap today
5:05
between payer strategy and operational execution?
5:10
I think if you
5:12
focus on fundamental strategies
5:14
on the payer side,
5:16
it's really gonna be around
5:18
member engagement and outcomes.
5:20
And when you think about the gap,
5:22
it sort of takes two to tango, you
5:24
know, in that
5:25
in
5:26
that support of the member and getting that
5:28
outcome and engagement.
5:30
Payer strategies focused on partnership with the providers
5:33
are gonna continue to to be critical to
5:36
deliver the care and quality that our members
5:38
need.
5:39
And so Emblem's focus, our focus, is to
5:43
continue to prioritize how do we engage these
5:45
providers
5:46
through sharing data and technologies,
5:49
easing administrative processes,
5:52
creating capabilities that really support shared decisions regarding
5:56
care and patient engagement.
5:57
But but when you think about that, that's
5:59
our that's our
6:01
focus
6:02
to close that operational gap. You gotta do
6:04
that in an efficient
6:06
sort of cost effective manner. We just talked
6:08
about all the pressures both the payers and
6:10
providers are facing.
6:12
You know, one place you're gonna see people
6:14
focusing is on AI capabilities.
6:16
But we really need to be artful and
6:19
thoughtful in our strategies of AI utilization.
6:23
So we're focusing
6:24
on areas that specifically ease the administrative burden
6:28
regarding the integration of process
6:31
with the payer and the provider.
6:33
So this creates an opportunity for clinicians and
6:36
administrators
6:38
to spend time and resources really focused on
6:40
patient care and engagement
6:42
versus back office.
6:44
And when we think about,
6:46
you know, where we need to invest,
6:49
that's where we have to invest, capabilities that
6:51
meet our common goals
6:53
and and really focus on operational execution. It's
6:56
meeting those common goals, and then both sides
6:58
can come to the dance floor in a
7:00
real way for our members.
7:02
Heather, could you could you dive a little
7:04
deeper maybe into into what Emblem is kinda
7:06
looking to focus on in regards to AI
7:08
in 2026?
7:11
I would say, you know, it is one
7:14
of the key investments that most of the
7:17
payers that or providers that you'd be talking
7:19
about would be would be addressing.
7:22
If I look at it from our provider
7:24
side, it's around revenue cycle. They're looking at
7:27
AI opportunities
7:28
there.
7:29
I think if you look at it on
7:30
the health plan side,
7:32
you know and, again, this is one of
7:33
our most sort of critical initiatives.
7:37
We have to go beyond
7:39
I think many payers are gonna focus on
7:43
what's the most advantage advantageous
7:46
to the health plan itself.
7:48
And I think our initiatives will need to
7:50
go beyond
7:51
those internal operations of the health plan and
7:54
focus on how do we extract data,
7:58
focus on driving it to the payer
8:00
in a way that's easy for them to
8:02
digest into their systems.
8:04
Absolutely.
8:06
Heather, let me ask you, what's one investment
8:09
or initiative you believe will most
8:11
reshape how health plans operate over the next
8:14
two to three years?
8:17
I mean, we started to talk about it.
8:18
Right? We started to talk about
8:22
AI, and I think that is going to
8:24
be one of the ways.
8:26
But, again,
8:27
that that AI focus
8:30
and investment focus really around the integration with
8:35
providers,
8:36
deepening both sides, technical capabilities, and common goals.
8:39
It doesn't have to just be AI. Right?
8:41
It can be looking to say, how do
8:43
we leverage data integration? How do we leverage
8:46
other components
8:47
that allows us to
8:50
drive actionable activities
8:52
to the providers in such a way that
8:55
they can utilize it in a fashion
8:58
that that's where we're spending a lot of
8:59
our time, interoperability,
9:02
engagement of data.
9:03
And as we continue to see these escalating
9:06
costs
9:07
and these diminishing revenue levers,
9:11
partnership in these initiatives for data exchanges that
9:13
really manage outcomes
9:15
and risk and reduce system wide administrative costs
9:18
will be the key to ongoing longevity.
9:21
There's an increasing urgency here.
9:23
Again, leveraging
9:25
our provider practice ACP,
9:28
it's a good way to test
9:29
the interaction
9:31
systemically
9:33
between the two, the the payer and the
9:35
provider,
9:36
and make sure that as we're deploying these
9:38
investments, we can make sure that it works
9:40
in real time, and then we can lever
9:42
that to some of our other,
9:44
provider partners.
9:46
If you could change one regulatory
9:49
or industry practice tomorrow
9:51
to improve affordability and access,
9:53
what would it be and why?
9:56
Well, if you're only giving me one,
9:58
I would say
10:00
and and we're sort of I I think
10:02
I keep coming back to a similar theme.
10:04
It really would be how do we focus
10:06
on a framework?
10:08
Can be an industry framework, but a framework
10:11
that really allows us to integrate decision support
10:15
right in the electronic health record.
10:18
You know, how do we provide actionable data
10:20
and feedback
10:22
at the point of encounter
10:24
so that it helps delivered improved quality and
10:27
improved outcomes?
10:29
This framework can leverage
10:31
provider data and payer data
10:33
to allow providers to close care gaps immediately.
10:36
This can eliminate
10:38
this back and forth
10:40
post visit with the provider.
10:42
Limiting that follow-up,
10:44
you know, between the health plans and their
10:46
partners,
10:47
you know, helps
10:49
with the the overall cost structure that we've
10:51
been talking about. It helps align incentives.
10:54
It makes transparency
10:55
better.
10:57
If you you said one. If you were
11:00
gonna let me pick an additional area of
11:02
opportunity,
11:04
you hear about it all the time, but
11:05
how do we think differently
11:07
about prior authorization?
11:10
The goal between a payer and a provider,
11:12
it it's the same.
11:14
We wanna make sure that we're delivering the
11:16
right care at the right time and location.
11:19
Location's important
11:20
to to us.
11:22
You know? And in emblem, that's what we're
11:24
focused on today. We continue to sort of
11:27
iterate and ideate on how do we
11:30
provide more immediate electronic feedback,
11:33
ease the entire process electronically,
11:36
only seek to address
11:38
areas of most critical need.
11:40
And then this really helps avoid the delay
11:43
in care
11:44
that is a constant point of friction, but
11:46
more than friction trust for all parties, whether
11:49
you're the member or the provider or the
11:51
payer. So
11:52
I picked two.
11:54
One really around
11:55
actionable common framework in the electronic health record
11:59
that we can support each other. And then
12:01
the the second one really around how do
12:03
we think continue to think differently about
12:06
where and how to do prior authorization, but
12:09
do it in a way that's really
12:11
efficient
12:12
and immediate.
12:14
I'm glad you broke the rules and pick
12:15
two because prior authorization is is a very
12:17
big deal. I appreciate your your thoughts on
12:19
it there, Heather. The last question I have
12:21
for you,
12:23
what issue is putting the most pressure on
12:25
health plan margins right now, and how are
12:27
you responding differently or or are going to
12:29
respond differently in 2026?
12:33
It's interesting you asked that because you could
12:34
pick five or six things that are putting
12:36
pressure on health plan margins right now.
12:39
One thing that I would say we're explicitly
12:42
focused on, and I bet if you ask
12:44
many payers, it's it's a or providers,
12:47
it's a common item.
12:49
It's really around pharmacy costs
12:51
because I think anything you look at or
12:54
read, whether you're a national,
12:56
for profit, not for profit,
12:58
pick a product segment,
13:01
pharmacy costs today are continuing to rise and
13:04
continuing to be a pressure point.
13:07
What are we doing differently?
13:09
Really important thing, and we started this back
13:12
in 2024.
13:13
We reevaluated
13:14
our PBM,
13:16
and we selected a partner that we thought
13:18
really had a similar mission and goals
13:21
that we had with and a real focus
13:24
on transparency
13:26
and growth.
13:27
So EmblemHealth recently announced that we did pick
13:31
a new pharmacy benefit collaboration,
13:34
with Prime Therapeutics, and we think there's an
13:38
opportunity to really provide a more transparent
13:41
and affordable
13:42
pharmacy experience for our members.
13:45
And I think it's more
13:47
really focusing on giving members,
13:50
you know, within a construct,
13:52
more choice and convenience and how they access
13:55
their medications,
13:57
including, like, real time competitive referrals for specialty
14:01
prescription drugs,
14:03
and,
14:04
you know, fast home delivery through Amazon pharmacy.
14:08
You know, this is a time when both
14:11
health care and pharmacy costs are rising. That's
14:14
putting pressure on our margins,
14:16
but we're trying to introduce,
14:18
you know, innovative solutions
14:21
that give our members
14:22
real time information,
14:25
you know, clear picture of the cost for
14:27
them
14:28
and convenience for them that puts their needs
14:31
right in front. And we think by putting
14:33
our members sort of more in the driver's
14:36
seat of their pharmacy experience,
14:38
we can potentially remove some of the friction
14:41
points
14:42
that tend to lead towards nonadherence,
14:45
missed doses, you know, and poor health outcomes.
14:48
That drives cost into the entire system for
14:50
everybody.
14:52
The transparency components that we're working through as
14:55
well
14:56
with Prime also puts us in a position
14:59
where we can more actively manage the cost.
15:01
We know where they're driving their margin. We
15:03
know how to get the most affordable outcomes.
15:06
So it's a bit of a win win
15:08
for all of us, and that was critical
15:09
in our choice.
15:11
The last little bit on that, when you
15:13
think about pharmacy
15:14
beyond what we've discussed,
15:16
it's really about the gene therapies. Right? As
15:19
more and more gene therapies emerge,
15:22
we don't have all the answers, nor does
15:24
the rest of the industry. But there is
15:26
a real need to address
15:29
thoughtful care management
15:31
and look at risk transfer arrangements that work
15:34
for all the parties when you're talking about
15:36
these drugs that are
15:38
really critical to improving
15:40
member health,
15:42
but also common 2 and $3,000,000
15:45
price tags per dosage.
15:47
So those would be the couple of key
15:49
things that I would highlight we're really focusing
15:52
on
15:53
in 2026
15:54
as one of the pressure points
15:56
on our health plan margins.
15:59
Heather, thanks so much for joining us on
16:00
the podcast. It was a great conversation. We're
16:03
really looking forward to you speaking at the
16:04
spring payer issues roundtable.
16:06
Thank you so much for inviting me. Happy
16:09
to participate, and and I think it's gonna
16:11
be great fun when we get together at
16:13
the roundtable.
16:14
Definitely will be.