Latest / Becker’s Payer Issues Podcast / Ellen Sexton, Executive Vice President and Chief Growth Officer at Blue Shield of California

Transcript

Ellen Sexton, Executive Vice President and Chief Growth Officer at Blue Shield of California · 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 Ellen Sexton,
• 0:06
  who serves as executive vice president and chief
• 0:09
  growth officer at Blue Shield of California.
• 0:12
  Ellen, thank you so much for taking the
• 0:14
  time to be with me on the podcast
• 0:15
  today.
• 0:16
  Hi, Jacob. It's great to be here. I'm
• 0:18
  looking forward to it. Likewise, Ellen. And before
• 0:21
  we dive into everything we wanna talk with
• 0:23
  you about today, can you first tell us
• 0:24
  a little bit more about yourself, your background
• 0:26
  in health care, and what it is that
• 0:28
  you do today at Blue Shield?
• 0:31
  Yes. Absolutely. So,
• 0:33
  Ellen Sexton again, and I'm the executive vice
• 0:36
  president and chief growth officer for Blue Shield
• 0:38
  of California,
• 0:40
  which means I oversee both the commercial and
• 0:42
  the government markets
• 0:44
  for the organization. And we serve 6,000,000 members
• 0:48
  both in and outside California.
• 0:51
  For our employer group, actually, a third of
• 0:53
  our 4,000,000 members are outside of California. California.
• 0:56
  And then in the government program business, we
• 0:59
  serve Covered California, which is the state exchange
• 1:02
  business here. We have Medicare Advantage and MedSup
• 1:06
  plans. And then we also have our Promise
• 1:09
  Blue Shield plan,
• 1:10
  which serves Medicaid beneficiaries
• 1:13
  in Los Angeles and San Diego Counties. So
• 1:16
  it's very diversified,
• 1:18
  high impact,
• 1:19
  and we like to lead with innovation
• 1:22
  in California,
• 1:23
  both I think as a health plan as
• 1:25
  well as a state, and that's really what
• 1:27
  attracted me to to joining Blue Shield of
• 1:29
  California.
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  And my prior experience points to just a
• 1:33
  passion around serving in health care,
• 1:36
  over two decades of experience. It's hard to
• 1:39
  believe when I when I count back the
• 1:41
  years.
• 1:41
  I was at UnitedHealthcare
• 1:43
  for many, many years across all different capacities.
• 1:47
  I ran a Medicaid plan in Wisconsin
• 1:50
  for them. When part d was rolled out.
• 1:53
  I was one of the original pioneers in
• 1:56
  rolling that out.
• 1:57
  I had also the ability to lead their
• 2:00
  group retiree business. So
• 2:02
  I've seen a lot of different capacities and
• 2:04
  coverage areas across the health care landscape.
• 2:07
  I was also at Humana for a while.
• 2:10
  And then more recently,
• 2:11
  before I joined Blue Shield of California,
• 2:14
  I was at a startup called Curative, which
• 2:17
  was based out of Austin, Texas.
• 2:19
  And we were really trying to to revolutionize
• 2:22
  the employer group coverage business. So,
• 2:25
  I have a real passion for health care
• 2:27
  and,
• 2:28
  just enjoyed thinking through, you know, how do
• 2:30
  we improve it
• 2:31
  and how do we improve access as well
• 2:34
  as coverage and affordability.
• 2:36
  Absolutely. So you've been in the industry for
• 2:38
  a long time, Ellen.
• 2:40
  Fair to say that you are an expert
• 2:42
  in your craft. And so
• 2:44
  I I wanted to get us started today
• 2:45
  by talking about,
• 2:47
  some of the legislative shifts we've seen this
• 2:49
  year. It has certainly been something that has
• 2:52
  been top of mind to all the the
• 2:54
  senior leaders we talked to at health plans
• 2:57
  and at hospital systems across the country.
• 3:00
  Specifically,
• 3:01
  the one big beautiful bill,
• 3:03
  HR one,
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  you know, passed this summer,
• 3:07
  and and, you know, I know the bulk
• 3:09
  of a lot of this this legislation and
• 3:11
  the changes that will go into effect don't
• 3:13
  come into fruition,
• 3:14
  for for a little bit more time,
• 3:17
  2027.
• 3:18
  But
• 3:19
  I'd love to hear your immediate
• 3:21
  and and,
• 3:23
  long term thoughts in terms of the impact
• 3:25
  here,
• 3:26
  on on how you're thinking about this specifically
• 3:28
  for the Medicaid population that you serve.
• 3:32
  Sure. It's certainly,
• 3:34
  very impactful, the different changes and the policies
• 3:37
  that are coming down,
• 3:39
  from an implementation
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  side. So first of all, on the Medicaid
• 3:43
  side, there's removal of ex parte or the
• 3:46
  expedited
• 3:47
  renewal process as well as an additional
• 3:50
  semiannual
• 3:51
  renewal requirement for Medicaid beneficiaries, and that just
• 3:55
  creates extra eligibility
• 3:57
  hurdles for them to have to get access
• 3:59
  to care.
• 4:00
  And, you know, from that, we see many
• 4:02
  of those members that that may not go
• 4:04
  through all those, challenging forms, if you will,
• 4:08
  and actually lose coverage.
• 4:10
  There's also the implementation
• 4:12
  of work requirements, and so how we work
• 4:14
  to to streamline that and make the eligibility
• 4:17
  requirements around that
• 4:19
  are type of top of mind. And then
• 4:21
  there's also impacts to members
• 4:24
  with on sack unsatisfactory
• 4:26
  immigration
• 4:27
  status,
• 4:29
  from right now and enrollment freeze for new
• 4:31
  members as well as decreased benefits for for
• 4:35
  members as far as maybe having to have
• 4:37
  co pays or additional premiums,
• 4:40
  which may extend also beyond into the the
• 4:42
  adult,
• 4:43
  expansion.
• 4:45
  And then there's possible nonrenewal
• 4:47
  of what California
• 4:49
  has as far as CalAIM.
• 4:51
  We'll be trying to figure out how to
• 4:53
  cover all of those with these federal cuts.
• 4:57
  And the Cal AIM waivers really looked at
• 5:00
  areas like enhanced care management
• 5:03
  and other flexible community support services like housing
• 5:06
  and nutrition and behavioral health
• 5:08
  that really extended
• 5:10
  in the community and and improved health outcomes.
• 5:13
  So
• 5:14
  all of these are are really big impacts
• 5:16
  to Medicaid. And then I would lift up
• 5:19
  as far as covered California
• 5:21
  the fact that the extension of the enhanced
• 5:24
  tax credits is still,
• 5:26
  being considered, although probably not too likely. It's
• 5:30
  got a real impact across the Medicaid because
• 5:33
  some of those members, of course, flip in
• 5:35
  and out of either the exchange coverage or
• 5:38
  Medicaid. And so, you know, we've had to
• 5:40
  file two rates with the state whether or
• 5:43
  not the tax subsidies
• 5:44
  are approved or not, and it just creates
• 5:47
  a lot of confusion in the system
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  for members as well as as thinking about
• 5:52
  their eligibility.
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  And so, you know, we're really lifting up
• 5:55
  programs that can help people meet these eligibility
• 5:58
  requirements. And so the 28 page Medicaid eligibility
• 6:03
  form,
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  We've thought through, you know, how do we
• 6:05
  apply
• 6:06
  artificial intelligence to try and prepopulate
• 6:10
  parts of it to help identify these members
• 6:13
  sooner.
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  We've also lifted up a GED program to
• 6:17
  help people actually go back and get their,
• 6:21
  high school diploma.
• 6:23
  And and so, you know, the promise Medicaid
• 6:26
  plan that we have within Blue Shield, they're
• 6:28
  just so creative,
• 6:29
  Jacob, and they come up with all these
• 6:31
  different areas to really extend, you know, what
• 6:34
  I would call beyond insurance and help people
• 6:36
  continue their coverage.
• 6:38
  Understood. I mean, there's there's so much going
• 6:41
  on here in terms of what you just
• 6:42
  talked about, Alan, between the work requirements,
• 6:46
  the changes with with CalAIM,
• 6:48
  and then, of course,
• 6:50
  you know, in in extension, all the the
• 6:53
  the changes around the enhanced ACA subsidies,
• 6:56
  and what may or may not happen as
• 6:58
  we go into next year. I know it's
• 7:00
  been, like you mentioned, pretty difficult for insurers
• 7:02
  all over the country, trying to prepare different
• 7:05
  rates, depending on on what happens over these
• 7:08
  next few weeks.
• 7:09
  I I wonder then how does a company
• 7:11
  as large as Blue Shield of California
• 7:13
  respond to these policy changes? How do you
• 7:16
  prepare and prep for,
• 7:19
  uncertain situations that might not even come to
• 7:22
  fruition?
• 7:23
  And, ultimately, what are you doing,
• 7:25
  from where you sit, Ellen, to ensure that
• 7:27
  your members, whether it's,
• 7:29
  currently insured by Medicaid or or ACA,
• 7:33
  or even commercial, that they still receive that
• 7:35
  that quality coverage that you all provide?
• 7:38
  Yes. We I mean, we are preparing for
• 7:40
  implementation
• 7:41
  and interpretation of it on all all fronts.
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  And I think one of the first things
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  is to be
• 7:47
  really close partners with your state agencies and
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  with
• 7:51
  other providers in the community
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  and some of the organizations that help members.
• 7:57
  That goes beyond just the doctor's office, if
• 7:59
  you will. And so a first focus for
• 8:01
  us is gonna be ensuring the access and
• 8:03
  care for our members
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  while ensuring overall population health,
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  emergency
• 8:09
  emergency
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  care, and and continuity of care. And so
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  one of the things we have are community
• 8:15
  resource centers, and they serve everyone in the
• 8:18
  communities, not not just our health plan members.
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  And they provide really high impact services
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  reinforcing
• 8:24
  the benefits of health care coverage and enrollment.
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  And we offer these in partnership with with
• 8:30
  LA care in LA County, and we have
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  14 different community resource centers.
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  And they offer support to people on health
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  care, eligibility,
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  and other social determinants of health. And they're
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  just real difference makers in the lives of
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  many and and just go one step beyond
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  in this situation. So
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  I think you also have to think about
• 8:50
  continuity of care, and that is really top
• 8:53
  of mind for me. So how do you
• 8:55
  ensure that members that might be in the
• 8:57
  middle of oncology treatment for cancer
• 9:01
  or think about an expectant
• 9:04
  mother who is in her last trimester. You
• 9:07
  know, making sure that we identify
• 9:08
  those members
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  and ensure that they're not losing eligibility during
• 9:12
  this time period is just really
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  important.
• 9:15
  And you can imagine if you're somebody in
• 9:17
  that situation,
• 9:18
  you know, losing your your health care coverage
• 9:20
  during those times would be just really stressful.
• 9:23
  So that's one of the things, that we're
• 9:25
  definitely trying to do is ensure continuity of
• 9:28
  care through all of these policy changes.
• 9:30
  Understood. And and and and, to your point,
• 9:33
  I I appreciate the acknowledgment that it is
• 9:35
  a stressful time for a lot of people.
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  It's it's an emotional issue as much as
• 9:39
  it is a a political and a financial
• 9:41
  one. So I I think a really great
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  point there, Helen.
• 9:45
  I do wanna switch gears and ask a
• 9:47
  little bit about some of the trends that
• 9:49
  you're seeing right now in the commercial employer
• 9:52
  market, especially as we go into next year.
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  We we've heard,
• 9:56
  numbers
• 9:57
  from from employer groups all over the country,
• 10:00
  predicting that 2026
• 10:02
  might be one of the largest
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  increases
• 10:04
  in in rates,
• 10:06
  in in the last few years, maybe even
• 10:07
  up to a decade,
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  on average. And and we've heard things, you
• 10:11
  know, increased utilization
• 10:14
  overall, more chronic conditions,
• 10:16
  but then, you know, there's the GLP one
• 10:18
  factor,
• 10:20
  that that's contributing to all of this. And
• 10:22
  we've also we've heard a lot about the
• 10:23
  growth of stop loss insurance,
• 10:26
  in in contextually
• 10:27
  as part of this conversation as well. So
• 10:30
  would would love your take in terms of
• 10:32
  what you're seeing from where you sit.
• 10:34
  Yes. I mean, employers want stability
• 10:37
  and predictability in their solutions. Right? And so
• 10:41
  all of those
• 10:42
  areas that you just mentioned, you know, really
• 10:45
  start to increase what we're seeing, you know,
• 10:48
  a pressured employer group coverage
• 10:50
  marketplace.
• 10:51
  We are seeing that rising utilization that you're
• 10:54
  talking about that's, you know, resulting in these
• 10:57
  double digit,
• 10:59
  increases, and it's happening in both medical and
• 11:02
  pharmacy.
• 11:03
  You mentioned GLP one. So, you know, one
• 11:05
  of the biggest areas is, you know, how
• 11:07
  you decide to cover that with with the
• 11:10
  employer group at hand. And I think you
• 11:12
  also see some of these amazing
• 11:15
  new cell and gene therapies and their tremendous
• 11:18
  innovation and results, but they can also come
• 11:21
  at a cost of 2 to 3,000,000 for
• 11:23
  a treatment. And so how we think about
• 11:25
  making those affordable affordable
• 11:28
  and stratify the financial risk of coverage is
• 11:31
  is really imperative.
• 11:34
  I think many employer groups, you know, as
• 11:36
  they look, they're trying to find solutions
• 11:39
  to still offer their employees
• 11:41
  great access but at an affordable price.
• 11:44
  And many times to do this, I think
• 11:46
  you'll see employers
• 11:48
  and us as health payers
• 11:50
  looking to engage their employees in their own
• 11:52
  health and help them help us select the
• 11:55
  best, highest performing providers. And so how we
• 11:59
  modernize our health plans to give incentives and
• 12:02
  provide the right digital tools
• 12:04
  so that their employees can actually make good
• 12:07
  decisions, and their health care selections is key
• 12:09
  as we go forward.
• 12:11
  The other areas that I see as far
• 12:13
  as programs for employer groups that are really
• 12:16
  picking up in in need is, first of
• 12:19
  all, behavioral health. And I think you see
• 12:23
  workforce stress as well as burnout and people
• 12:26
  just really looking at their own behavioral health
• 12:29
  as far as a big need, but also
• 12:31
  the the employees' children.
• 12:33
  There's more and more access issues as far
• 12:36
  as behavioral health and really trying to help
• 12:39
  employers with this big need in the market.
• 12:42
  And then, one that's near and dear to
• 12:44
  my heart is just solutions around women's health
• 12:47
  and really thinking about some of the specific
• 12:49
  treatment conditions that come through and just haven't
• 12:52
  been as much of a focus sometimes.
• 12:56
  And then overall,
• 12:57
  you know, employers are also looking for convenience
• 13:00
  for their employees. And so whether that's through
• 13:03
  virtual or telehealth,
• 13:06
  or also a solution that we just rolled
• 13:08
  out with Zocdoc, which is online appointment booking.
• 13:11
  And we had over one million hours on
• 13:14
  care able to be booked online. And I
• 13:16
  think consumers
• 13:17
  are just looking for the same way that
• 13:19
  they can go forward and, you know, order
• 13:22
  something,
• 13:23
  a package from Amazon or order their meals.
• 13:25
  They wanna be able to do things online.
• 13:27
  And and so I think how health care
• 13:30
  is delivered in that similar matter is just
• 13:32
  gonna be coming to the forefront. But
• 13:34
  all of these things are gonna get at,
• 13:36
  you know, how do we create some predictability
• 13:38
  and how do we actually get ahead of
• 13:41
  these rising core
• 13:42
  rising costs for employer groups is just gonna
• 13:44
  be really important for the future,
• 13:47
  sustainability of employer group offerings.
• 13:51
  Absolutely. And that and that really does reflect
• 13:53
  what we are hearing from leaders all over
• 13:55
  the country of really trying to support
• 13:57
  their employer clients,
• 13:59
  with stability
• 14:01
  and then, you know, trying to meet that
• 14:02
  demand,
• 14:03
  for behavioral care, for more women's focused health
• 14:06
  care.
• 14:07
  That is has been top of mind from
• 14:09
  what we're hearing as well.
• 14:11
  I wonder if we if we shift towards
• 14:13
  a little bit more, toward your role and
• 14:16
  some of the work you're doing in the
• 14:17
  day to day, Helen.
• 14:19
  What would you say are some of the
• 14:20
  biggest priorities for you right now, for for
• 14:23
  your role specifically,
• 14:24
  for the health plan as a whole in
• 14:26
  the year ahead? I mean, really, what are
• 14:29
  you trying to achieve as chief growth officer
• 14:31
  for Blue Shield of California?
• 14:34
  Yep. One of my biggest priorities is how
• 14:36
  do we not only come up with great
• 14:38
  ideas to innovate, but also implement those ideas?
• 14:42
  I always say to my team, great ideas
• 14:44
  are great, but implemented ideas are are even
• 14:46
  better, and it's what the market's looking for.
• 14:48
  And I think as we come up across
• 14:50
  this year, how we come up with joint
• 14:52
  efforts with providers to actually
• 14:55
  actually good at the cost of of health
• 14:57
  care that's rising,
• 14:58
  but then also create stability for our members
• 15:01
  and employer groups and plan sponsors
• 15:04
  so that we can lead through all of
• 15:06
  these policy changes
• 15:08
  and and really bring the right outcomes to
• 15:11
  the market.
• 15:12
  And to do that, I think you have
• 15:14
  to really instill some resiliency
• 15:16
  in your teams right now because there's many
• 15:18
  challenges
• 15:19
  that they're taking
• 15:21
  taking on and these policy changes,
• 15:24
  a lot of times, are actually in conflict,
• 15:26
  right, with our mission. And our mission has
• 15:28
  been to actually increase care and coverage. And
• 15:31
  so to think about, you know, millions of
• 15:34
  people across the country that may be losing
• 15:36
  coverage is
• 15:38
  is really hard, I think, for sometimes the
• 15:40
  for the teams to fathom.
• 15:42
  And as a nonprofit health plan, we're focused
• 15:45
  on providing more
• 15:46
  comprehensive coverage that's reflective of community needs. So
• 15:50
  so the policy changes can fly in the
• 15:52
  face of that.
• 15:53
  We'll be working really closely, as I said,
• 15:55
  with providers
• 15:56
  to interpret and implement and then ensure that
• 15:59
  continuity of care, that's definitely
• 16:02
  at the forefront.
• 16:03
  And these changes are gonna hit not only
• 16:06
  urban areas, but also rural. And so how
• 16:08
  we support providers is gonna be really important.
• 16:12
  And and for us, you know, we don't
• 16:14
  look
• 16:15
  to change how we show up in the
• 16:16
  market.
• 16:17
  We serve people in every county in California,
• 16:20
  and we were the first to do so
• 16:23
  on the exchange, and and we'll continue to
• 16:25
  be doing that. And I think as we
• 16:27
  all reflect across the system,
• 16:30
  as more and more people become uninsured because
• 16:33
  of these policy implications,
• 16:34
  there's gonna be a ripple effect. And people
• 16:37
  end up in the ER with more pervasive
• 16:39
  conditions, and
• 16:41
  that could really end up stretching the capacity
• 16:44
  in hospitals,
• 16:45
  and the cost then just ends up being
• 16:47
  spread back to employer groups. And so how
• 16:50
  we prevent that is is really at the
• 16:52
  forefront
• 16:53
  of our mission
• 16:54
  and, you know, one that the team and
• 16:56
  I are working really hard on.
• 16:59
  Yeah. And I I think that's such an
• 17:00
  interesting point,
• 17:02
  of what you just said there, Alan, that,
• 17:05
  that health plan leaders all over the country
• 17:07
  typically are in this work because they wanna
• 17:09
  make a difference. And it is tough for
• 17:11
  for many to see some of these some
• 17:13
  of these uninsured rates
• 17:15
  go back up,
• 17:16
  in the face of the work that so
• 17:18
  many do in the day to day. So
• 17:20
  I, you know, I I think that's such
• 17:21
  a interesting point that you made there.
• 17:24
  And in that vein, I I would ask,
• 17:26
  is there anything that you would wanna share
• 17:28
  with the other
• 17:29
  insurance leaders listening in right now from all
• 17:32
  over the country? Any any final thoughts or
• 17:35
  final bits of advice that you would wanna
• 17:37
  share with them as we close out the
• 17:39
  year?
• 17:40
  I think it's gonna take all of our
• 17:42
  collective efforts working together. And I think how
• 17:45
  we put forward solid plans and and consistent
• 17:49
  consistency in those,
• 17:51
  you know, we're doing a lot of scenario
• 17:53
  planning,
• 17:54
  of course, and and that's to bring the
• 17:56
  right kind of stability
• 17:58
  to the market and and also how we
• 18:00
  deliver high quality care with our partners. And
• 18:03
  so you can't stay in a vacuum. You
• 18:05
  really have to get out there
• 18:07
  and work with your local state policymakers
• 18:10
  because,
• 18:10
  you know, as these policy changes come down,
• 18:13
  they're not always all fully vetted. And so
• 18:15
  how we carefully plan, I think, across all
• 18:18
  our different
• 18:19
  partners and providers
• 18:21
  and and even with other health plans is
• 18:23
  gonna be really important. And so, you know,
• 18:25
  I like to think about
• 18:27
  particular how we deliver in the health care
• 18:29
  space as more of a partnership
• 18:31
  that's focused on that and less transactional.
• 18:34
  And being in health care always has its
• 18:37
  challenges. As you referenced, we're we're generally the
• 18:40
  leaders in it, very mission focused. And I
• 18:42
  think if we keep the mission at hand
• 18:46
  first and the forefront,
• 18:48
  we're gonna be successful together.
• 18:50
  And, you know, there's millions of Americans depending
• 18:53
  on us to do that, and
• 18:55
  I sure wanna be be the ones that
• 18:57
  help leave a legacy
• 18:58
  that really help bring,
• 19:01
  the coverage and affordability
• 19:02
  that that's worthy of our friends and families.
• 19:05
  That's our mission here at Blue Shield of
• 19:07
  California, and I know many of my fellow
• 19:09
  leaders across,
• 19:11
  health plans across America feel that same way.
• 19:15
  Wonderful. Well, Ellen, I wanna thank you for
• 19:18
  taking the time to sit down with us
• 19:19
  on the podcast today and for sharing your
• 19:22
  insights with our audience. We really appreciate it.
• 19:25
  Thanks, Jacob. I really enjoyed the conversation.
• 19:28
  Likewise. And to our listeners, if you'd like
• 19:31
  to listen to more podcasts from Becker's Health
• 19:34
  Care, you can visit beckershospitalreview.com.