Latest / Becker’s Payer Issues Podcast / Sam Melamed, CEO & Bret Voith, Chief Strategy Officer of NCD

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Sam Melamed, CEO & Bret Voith, Chief Strategy Officer of NCD · Becker’s Payer Issues Podcast

0:00
Hello, everyone. This is Jacob Emerson with the
0:02
Becker's Payer Issues podcast.
0:04
Thrilled today to be joined by two special
0:06
guests from NCD.
0:07
Sam Melamed is the CEO of NCD, and
0:10
Brett Voigt is chief strategy officer at the
0:13
company. Sam, Brett, thanks so much for taking
0:15
the time to be with me on the
0:16
podcast today.
0:18
Thanks for having us. We're excited.
0:20
Awesome. Well, before we dive into everything, we
0:22
wanna talk with you about everything that's going
0:24
on in Washington affecting health plans.
0:27
Can you both tell us a little bit
0:29
more about yourselves, your background in health care,
0:32
and what it is that you're doing today
0:33
at NCD? Brett, I'll come to you first.
0:37
Great.
0:37
So as you mentioned, my name is Brett
0:40
Voigt. I'm chief strategy officer at NCD.
0:43
I actually started my career as an investor
0:46
where I spent a meaningful amount of time
0:48
investing in health care services
0:50
and other highly regulated industries.
0:53
In 2013,
0:55
I saw an interesting dynamic emerging regarding some
0:58
changes
0:59
in the financial flows and division of responsibilities
1:02
between payers and providers,
1:05
which which really was some of the early
1:07
days of what now today has become
1:09
more broadly known as value based care or
1:11
accountable care.
1:13
And at that point,
1:15
I made the decision to chase that intersection
1:17
of payer and provider as an operator.
1:20
I've spent the last eleven
1:22
years operating in high growth risk bearing entities,
1:26
including Stops as an early employee at Bright
1:28
Health,
1:30
where I helped that business grow from $0
1:32
in revenue and 20 employees to 4 and
1:35
a half billion in in revenue and about
1:37
2,000 people,
1:38
as well as started my own carrier, Tenure
1:41
Health, before joining NCD via acquisition
1:44
third quarter of last year.
1:46
As chief strategy officer, I partner with Sam
1:49
and the rest of our leadership team to
1:51
to really define the future for for NCD
1:54
and where we're going.
1:56
Fantastic. How about you, Sam?
1:58
Yeah. So I call myself the chief insurance
2:01
nerd here at NCD, and, I started my
2:04
career really as a failed insurance agent. I
2:07
was trying to sell insurance to feed my
2:09
family and just really struggling to succeed.
2:12
And, so at that time, I started a
2:14
website called insurance forums. That's now the largest
2:17
insurance agent,
2:19
website in the country. Gets about 80,000 unique
2:22
agent visitors a month.
2:24
I really got my
2:26
education in the insurance ecosystem from managing that,
2:30
managing that community.
2:32
I also got a job at a trade
2:35
association's
2:36
insurance program called the ABC Insurance Trust, and
2:39
I was there for about fifteen years climbing
2:41
through the ranks, eventually took over as CEO
2:44
until about four years ago when I moved
2:45
over to be the CEO of NCD.
2:48
So NCD is a product development and distribution
2:51
company. We partner with leading insurers to build
2:54
interesting supplemental health products
2:57
and then to work with Medicare and ACA
2:59
distributors to have them distribute it. So really
3:02
no one is in the business of exclusively
3:04
selling dental or vision or stand alone supplemental
3:07
health coverage,
3:09
And so we build products and partner with
3:11
distribution
3:12
in both of these markets, and that's why
3:14
we pay so much attention to the regulatory.
3:17
Fantastic. Well, Sam, Brett, like I said, we
3:20
really appreciate you both taking the time to
3:22
chat with us today. I wanna get started
3:24
by talking about regulatory, Sam. There's there's obviously
3:28
a lot going on in Washington right now
3:30
and certainly a lot that will be affecting
3:32
the health plans and the leadership listening in
3:35
right now. So
3:37
let's level set for a for a moment,
3:38
and and can you talk to us a
3:40
little bit about some of the key
3:42
regulatory shifts within under the ACA,
3:44
that health plans should be preparing for right
3:47
now from your perspective?
3:49
Yeah. Well, the the timing for the question
3:51
couldn't be better because the new regulations
3:54
just dropped
3:55
a couple days ago around the ACA, and
3:58
these are the first regulations that the Trump
4:00
administration has dropped.
4:02
And it was no surprise. Actually, Peter Nelson,
4:05
had telegraphed his views pretty clearly in some
4:08
white papers he had released, and lo and
4:11
behold, the regulations really seem to,
4:14
to shape around that.
4:16
And I would call it mostly a vibe
4:18
shift before you get into any specificity of
4:21
what the new regulations are.
4:23
The previous administration
4:25
seemed to focus on growth of the ACA
4:28
at all costs,
4:29
that growing this program will instantiate it. It
4:32
will lock it in. It's, a public good,
4:35
and there's a lot of
4:37
philosophical reasons for it. But most of the
4:39
regulations
4:41
that they put out of the the four
4:44
years of the Biden administration were really designed
4:47
to shore up or strengthen the ACA marketplaces
4:51
in the way that they felt was appropriate.
4:54
Whereas
4:55
right now, the new regulations that dropped are
4:58
really focused on cleanup and integrity.
5:02
So, really, a lot of people assumed, and
5:04
there was a lot of ink spilled around
5:06
how the Trump administration would look to hurt
5:08
the market or would look to get rid
5:10
of the ACA.
5:11
And I think they were pretty clear that
5:14
that wasn't their intent,
5:15
and you can start to see that play
5:16
out now with some of these new regulations
5:19
that, yes, we might see growth slow or
5:22
more likely some shrinkage,
5:24
but their focus is less on,
5:27
getting rid of the marketplaces and more around
5:30
making them economically viable
5:32
and removing a lot of the waste, fraud,
5:34
and abuse.
5:36
You know, the the big debate in DC
5:38
is around the extension of subsidies. That was
5:41
the thing that really grew the ACA more
5:44
than anything.
5:45
And, actually, the new regulations could signal
5:49
perhaps that there's some view that the subsidies
5:51
might extend because a lot of the new
5:53
regulations that dropped,
5:55
which would not go into effect until 2026,
5:58
which is when the subsidies end, are really
6:00
designed around
6:02
tweaking elements of those subsidized members.
6:05
Fascinating. Okay. So from a bird's eye level,
6:08
Sam, you're you're basically saying the Biden administration
6:11
really focused on the growth
6:13
of the ACA, and now the Trump administration
6:15
is focused on integrity
6:17
under that program.
6:18
And it's there were possibly seen signals of
6:21
an extension of the premium tax credits, which
6:23
would certainly be very good news for health
6:25
plans and hospitals
6:26
all over the country.
6:28
But, Brett, would love your take here as
6:29
well.
6:31
Yeah. Of course. And, you know, recognizing that
6:34
we at NCD bring the perspective of a
6:36
dental provider,
6:38
one of the things that we track really
6:40
closely with regulation is the interplay
6:42
of dental and other supplemental benefits in the
6:46
ACA market.
6:47
An example of this is is last year,
6:50
the Biden administration
6:51
enabled states for the first time to include
6:54
adult dental
6:55
as an essential health benefit benefit for plan
6:58
years as early as 2027.
7:01
Though a number of complicated
7:03
questions remain regarding how this is gonna ultimately
7:06
be administered,
7:07
such as, you know, what what will a
7:10
reference plan look like?
7:12
And with the change in administration, for us,
7:14
it's gonna be really interesting to see how
7:16
the current administration
7:18
addresses this proposal
7:19
and others like it that are set to
7:21
go in effect in future years,
7:24
and and to see, you know, will this
7:26
interplay of dental and ACA offerings really play
7:28
out, or will the administration
7:30
change directions there?
7:33
Yeah. Absolutely. It's it's interesting to think about.
7:35
And, you know, one thing I wanna do,
7:37
Brett, is step back for a second for
7:38
our audience. I think this would be helpful,
7:40
to ask you what the state of ACA
7:42
market enrollment is right now, because Sam mentioned
7:46
the growth that happened on the previous administration.
7:49
Have have you all been seeing any notable
7:51
year over year trends up until this point
7:53
in terms of who is enrolling in ACA
7:56
plans?
7:57
Yeah. Great question. And as Sam had mentioned,
8:00
you know,
8:02
CMS's own communications over the last four years
8:05
have consistently put that emphasis on growth.
8:08
Right? With the market today now at an
8:11
all time high with over
8:12
20,000,000
8:13
Americans enrolled in the ACA.
8:16
The thing that's most notable about growth,
8:19
over the last year is that that we've
8:22
seen
8:23
both states that run their own exchanges
8:25
see the greatest level of growth
8:27
as well as the fact that states that
8:30
typically have voted Republican in presidential elections have
8:34
actually seen the strongest growth in in recent
8:37
years.
8:38
And
8:39
it it it's gonna be really interesting to
8:41
see how that trend evolves,
8:44
going forward from here,
8:46
particularly in light of Sam's point about the
8:48
shift in focus from growth to stability and
8:51
integrity of the ACA market.
8:54
We definitely see some early indications
8:56
that the Trump administration
8:58
is focusing on issues like
9:01
risks with auto enrollment. And
9:04
while it's hard to be declarative about what
9:07
specifically will happen, we certainly have the expectation
9:11
that
9:12
growth will
9:13
likely meaningfully decelerate and and potentially
9:16
even see enrollment decline
9:18
in the upcoming year. I would add to
9:21
that
9:21
that we clearly saw that some of the
9:23
broker enforcement rules
9:25
that were put in place in response to
9:29
really the wave of fraud that did come
9:31
out of, you know, some of the easy
9:34
additions
9:36
to the ACA since the premium subsidies were
9:39
created,
9:40
that a lot of that did shift where
9:44
there was less new business being written on
9:47
healthcare.gov,
9:49
but the total number of enrollees through the
9:52
federal exchanges did still grow because of how
9:54
easy it was to auto enroll.
9:56
And so one of the very interesting
9:58
pieces of the new regulatory proposal that was
10:02
just put out is the requirement that there
10:04
be a de minimis $5
10:06
fee for anyone who,
10:09
had no cost share previously, but who had
10:12
not affirmatively
10:14
resigned up to a new plan.
10:16
And so I do think plan executives
10:19
do have to take a look at
10:21
what are the signals in their current book
10:23
of business
10:24
that some portion, maybe some small portion of
10:28
their membership
10:29
might not really even realize that they're in
10:31
a health plan and therefore, of course, have
10:33
no utilization.
10:34
And if the $5 fee is gonna kick
10:37
a bunch of those people out because
10:40
they will either get rid of fraud or
10:42
they'll realize they had a plan that they
10:44
didn't think they had or maybe they qualify
10:46
for Medicaid,
10:48
then what does that do to their potential
10:50
MLR? And so I think that
10:52
there's a lot of focus in the new
10:54
proposed regulations
10:55
that have a lot of impact around program
10:57
integrity
10:59
that smart plan
11:01
administrators and insurers
11:03
right now have a war room thinking about
11:06
how do we project our MLR and price
11:08
our plans prop properly for 2026.
11:12
So, Sam, let me come back to, something
11:14
you had mentioned earlier. Peter Nelson being appointed
11:17
to lead the Center for Consumer Information and
11:21
Insurance Oversight.
11:23
As you know, he's an he's an ACA
11:24
expert. He has a lot of knowledge about
11:26
state innovation waivers, price transparency,
11:29
health reimbursement
11:30
arrangements.
11:32
So so what do you think his appointment
11:34
means for for the insurers listening in and
11:36
for the consumers and the members that they
11:38
serve?
11:40
Yeah. You know, I have a huge amount
11:42
of respect for Peter Nelson. He's been writing
11:45
and thinking about and talking about the ACA
11:47
and health care more broadly for a really
11:49
long time.
11:51
And in many ways, his appointment is really
11:53
good news for health insurers because he's been
11:57
pretty clear about what he sees as potentially
12:00
broken
12:01
in the healthcare ecosystem
12:03
and in particular in ACA
12:06
and what are some of those ways that
12:08
it can be,
12:09
it can be addressed. And so he's put
12:11
out publications
12:13
that specifically talk about
12:15
why the ACA structure or some of the
12:18
regulatory structure has an extra cost to consumers
12:23
with even pretty specific calculations
12:26
of what each of these new laws, whether
12:30
they're preenrollment
12:31
SEPs
12:33
or allowing states to update and modernize their
12:37
essential health benefits
12:39
or narrow de minimis variation actuarial values. There's
12:42
any number of them where he's very specific
12:45
in his analysis of what the premium impact
12:47
is gonna be.
12:48
So while the regulations that were just released
12:52
come out of a playbook that you can
12:54
find in his previous writings, I think a
12:56
lot of smart insurers are saying, alright. Let
12:58
me read everything he's written. Let me listen
13:00
to everything he's been recorded as saying. Because,
13:04
he has been pretty clear about his perspective
13:06
for a while.
13:08
I think the other thing that's becoming clear
13:11
is to the point I made earlier,
13:13
there was a lot of ink spilled when
13:16
there was an election
13:17
going on, and there was maybe a political
13:20
reality to the discussion
13:22
that
13:23
the Republicans
13:25
wanted to scrap the ACA or wanna get
13:28
rid of the ACA.
13:30
But to Brett's point, some of the growth
13:32
in red states that the ACA has seen
13:35
and where the population that is being subsidized
13:37
right now lies,
13:40
and given
13:41
the two year cycle for
13:43
Congress and the slim majority,
13:46
it's
13:47
very hard to imagine,
13:50
any kind of wholesale change
13:53
that's going to really hurt a lot of
13:55
those people who are being subsidized right now.
13:58
So it's somewhat of a contrarian take, I
14:01
think, from the rest of the market. It
14:03
does seem like many people think the premium
14:06
subsidies will not be extended,
14:08
but I would bet actually that the premium
14:11
subsidies may be extended,
14:13
maybe with some tweaks like,
14:16
work requirements.
14:18
And
14:18
so it does not appear that they're looking
14:20
to undermine the ACA
14:22
as much as they are looking to,
14:25
really focus
14:27
on
14:28
not being wasteful and not allowing fraud, some
14:31
of which has
14:33
propagated over the last few years.
14:35
No. Your your point is well heard, Sam.
14:37
And it's certainly it's an argument we've heard
14:39
from insurance executives on earnings calls with investors
14:43
talking about the sustainability
14:44
of of the ACA
14:46
moving forward and and the popularity of of
14:49
that program with,
14:51
with people in Republican led states.
14:53
It even specifically mentioned among Trump supporters specifically,
14:56
and and that's certainly been an argument that's
14:58
been used when discussing Medicaid cuts or potential
15:01
cuts as well. So it's it's an interesting,
15:04
it's interesting to hear your perspective on that
15:06
in terms of what could happen to the
15:07
to the subsidies.
15:10
But, Brett, I wanna I wanna I do
15:11
wanna switch gears in just a sec, but
15:13
I'd also wanna get to the crux of
15:14
things, before we move on from the ACA.
15:17
Given all these changes that we've talked about
15:19
today that have been announced or that could
15:21
be on the horizon in this market,
15:24
How should
15:25
marketplace plans be thinking right now about repositioning
15:29
themselves
15:30
for long term success over the next few
15:32
years?
15:34
Yeah. That's a great question. And
15:36
when when you think about
15:38
those in the market who are ACA focused,
15:41
you know, obviously, you have you have carriers,
15:43
but you also have,
15:45
distributors who have who over the last few
15:47
years have largely built their business
15:50
serving the ACA markets and in in enrolling
15:52
individuals,
15:54
in ACA plans.
15:56
Our view is that right now is really
15:58
the time for those ACA focused distributors
16:02
to add resiliency to their businesses through diversification.
16:07
You know, now is the time for them
16:08
to expand their horizons beyond, you know, just
16:12
considering themselves
16:13
ACA distributors
16:15
and and really thinking about the ways they
16:17
can more broadly serve the needs of their
16:19
clients
16:20
through through the sale of a number of
16:23
related ancillary health products that frequently,
16:26
you know, complement
16:27
ACA plan coverage.
16:30
Additionally, by by by diversifying their book of
16:33
business, they can also create additional value
16:35
for for their clients,
16:37
and and deepen their relationship with their their
16:40
client base by by solving a greater number
16:42
of of needs.
16:44
And, you know, obviously, there there's a range
16:46
of compelling ancillary health products.
16:49
You know, at NCD, we're we're particularly partial
16:52
to dental and and vision being some of
16:54
the the most notable. But but there there
16:56
really is a a broad opportunity for ACA
16:59
participants to think about these these these other
17:02
products and how how they can bring them
17:04
bring them to clients,
17:06
in in the months ahead.
17:08
Absolutely. Yeah. No. It's great advice,
17:10
for for everyone listening in.
17:13
I do wanna switch gears here and and
17:14
talk about Medicare Advantage because, obviously, it's been
17:17
a wild year for that program,
17:20
and certainly for for carriers,
17:23
in Medicare Advantage.
17:25
We've seen enrollment growth slow now that the
17:27
the data is out,
17:30
slow to,
17:31
at least the the the lowest it's been
17:33
in decade in a decade.
17:35
Plan benefits are shrinking.
17:37
Millions of seniors are being left with coverage
17:39
gaps, certainly within dental care.
17:41
So, Brett, how do you think this shift
17:43
within MA is impacting the demand for stand
17:46
alone dental,
17:48
vision, and hearing plans?
17:51
Yeah. That's
17:52
that's a great question. And and
17:54
it's worth calling out that these reductions,
17:56
you know, don't look the same in in
17:58
every market.
18:00
Right? Sometimes they take the form of the
18:02
removal of a benefit
18:04
in entirety.
18:05
But but even more commonly, particularly for benefits
18:08
like dental,
18:10
these reductions,
18:11
you know, you know, they may be hard
18:13
to see, but they really take the form
18:14
of the benefits being called out, you know,
18:17
whether it's through network changes and reductions,
18:21
lower total benefit value,
18:23
the removal of certain services, you know,
18:26
for example, implants
18:28
from included coverage. And and across all these
18:31
types of changes, we really view them as
18:33
a as a potential opportunity for the stand
18:35
alone dental market,
18:37
for for NCD and others as well.
18:40
And really the reason is
18:42
as these benefits are pulled back, we believe
18:45
many Medicare Advantage members are gonna reassess their
18:48
dental needs,
18:50
and and what coverage they need and and
18:52
consider adding a stand alone dental plan
18:55
to their coverage separate from their Medicare Advantage
18:57
coverage.
18:58
And
19:00
we believe for a significant segment of Medicare
19:03
Advantage members with these benefit pullbacks,
19:05
there's there's gonna be strong value for them
19:08
to pay, you know, a small premium for
19:10
that additional standalone dental plan,
19:13
rather than having, you know, included but highly
19:16
limited dental coverage,
19:18
as as their only way to access, you
19:20
know, critical dental services.
19:23
And and so we've we view that as
19:25
a a really intriguing, you know, development on
19:27
the horizon for the market. Yeah. Absolutely. So
19:30
it sounds like the time is ripe for
19:32
the growth of stand alone dental plans.
19:34
Anything you'd add there, Sam?
19:36
Yeah. I would say it's an open question
19:38
whether Medicare Advantage Plans should, in fact, cover
19:41
all the supplemental benefits that they have or
19:44
not. You know, it certainly wasn't the original
19:46
intent, and there are trade offs. There's certainly
19:49
a lot of nice things, and they've been
19:50
very effective
19:52
from a marketing standpoint.
19:53
When I think about what policy makers, in
19:56
particular,
19:57
legislators could think about, one interesting idea we
20:00
haven't really seen floated is
20:02
that many,
20:03
many people who receive their supplemental health benefits
20:08
when they're working get to pay for it
20:10
with pretax dollars through a section one twenty
20:12
five plan or because the company pays for
20:15
it. Whereas when you retire, you really can't.
20:17
And so if you're going
20:20
to have the economics of Medicare Advantage make
20:23
it difficult to embed additional supplemental plans,
20:26
then perhaps there could be a tax break
20:28
for those dollars.
20:30
Currently,
20:31
it's only dollars you spend in excess of
20:33
7.5%
20:35
of your modified adjusted gross income that are
20:37
tax deductible.
20:39
So it effectively costs more for those people
20:41
who are not actively in the workforce to
20:44
actually ensure some of those needs.
20:47
Understood. Understood.
20:49
Okay. So we've we've gone through a lot,
20:52
talked a lot about the ACA, talked a
20:53
lot about Medicare Advantage.
20:55
Anything else you both would mention in terms
20:57
of the biggest potential regulatory considerations
21:00
that
21:01
our health plan and hospital system stakeholders
21:05
really need to keep an eye on at
21:06
the federal level.
21:08
Brett, you wanna start us off there?
21:10
Sure. Absolutely. Well,
21:13
I think the the the most interesting potential
21:16
trend is is
21:18
not just the regulations are coming, but
21:21
as the regulations come will be the the
21:23
potential
21:24
change in approach that
21:26
that,
21:28
private market participate
21:30
participants take
21:31
to competing in the Medicare Advantage and ACA
21:34
markets,
21:35
While not knowing, you know, all the ways
21:37
regulations will change, I I think as they
21:40
they come to market, one of the thing
21:42
we're
21:43
likely to see
21:44
is that the general
21:46
approach of
21:47
more benefits, more supplemental benefits equals a better
21:51
strategy actually could could very much change. And
21:54
instead, we might see
21:56
a number of
21:58
ACA
21:59
and Medicare Advantage participants intentionally focus more on
22:04
core medical benefits
22:05
and and really trying to differentiate there rather
22:08
than through, you know, a a broad portfolio
22:11
of supplemental benefits,
22:13
which which has the potential to serve, you
22:16
know, the
22:17
needs of a segment of consumers who are
22:19
looking,
22:20
you know, not for for the buffet plan,
22:22
but who are looking for the best medical
22:24
plan. And then in turn, we'll be looking
22:26
for, you know, alternative standalone options,
22:29
to cover
22:30
their their other health related needs. So that
22:34
that's one really interesting trend,
22:36
on the horizon that that I will be
22:38
looking for.
22:39
And, Sam, how about you? What are you
22:41
keeping an eye on or any other final
22:43
thoughts that you wanna share with our listeners
22:45
today?
22:46
Yeah. I'm certainly keeping an eye on some
22:50
interesting
22:51
ideas that would have been more out of
22:53
the box,
22:54
things like multiyear plans where plans can really
22:57
invest
22:58
in and make commitments to wellness and to
23:02
really bending the cost curve,
23:04
knowing that they will receive some of the
23:06
benefits of the lower utilization
23:09
rather than, you know, than some other insurer
23:12
that people move over to.
23:14
I think it'll also be interesting to see
23:16
whether they take a look at some of
23:17
the MLR regulations
23:20
that, while well meaning, might effectively
23:23
cap margin and therefore drive some of the
23:25
consolidation
23:27
and reduce some of the incentive from plans
23:30
to really drive for better control of health
23:33
care costs.
23:34
So I think it's an exciting time to
23:36
be in health care.
23:37
And then the last thing would be the
23:39
general zeitgeist in health care is that we
23:42
spend too much money on it, and people
23:45
are not very happy with it. And so
23:47
I think, well, a lot of insurers are
23:49
focused on automation and outsourcing and finding ways
23:52
to reduce their costs.
23:54
Sacrificing around member experience,
23:57
does not seem like it's gonna pay dividends.
23:59
And so I would certainly be encouraging
24:01
this topic for another day, but for, smart
24:04
health plans to be very mindful of that.
24:07
Fantastic. Well, I think that's a great place
24:08
to leave things. Sam, Brett, thank you very
24:11
much for taking the time to sit down
24:13
with us and for sharing your insights with
24:15
our listeners. We really appreciate it. Thanks, Jacob.
24:18
Thank you.
24:19
And if you'd like to listen to more
24:21
podcasts from Becker's Healthcare, you can visit beckershospitalreview.com.