Latest / Becker’s Payer Issues Podcast / Redefining Payer Strategy: From Benefit Design to Intelligent Care Delivery

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Redefining Payer Strategy: From Benefit Design to Intelligent Care Delivery · Becker’s Payer Issues Podcast

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  Hi, everyone. This is Brian Zimmerman with Becker's
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  HealthCare. For today's podcast,
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  I'm excited to be joined by Nirne Patel,
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  EVP and GM Benefits One, chief digital officer
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  for Simplify Healthcare.
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  Thank you so much for joining us today.
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  Thank you, Brian. Thank you for having having
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  having me here. Alright. Nunez, so let's get
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  started with a simple introduction. Why don't you
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  share a few details about your background and
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  the work you're doing? Yeah. Of course.
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  So I get excited at the intersection of
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  healthcare and technology.
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  I've been in healthcare space for about fifteen
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  years and then in in tech for pretty
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  much all of my career. At Simplify, we
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  are solving two problem areas,
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  benefits the problem of benefits management
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  from an end to end value proposition for
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  payers
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  and the problem of provider data management. So
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  these are the two areas we focus on,
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  and,
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  we have an incredible
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  set of capabilities and customers which,
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  solve these problems across different markets. So we
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  specialize in how do we solve this for
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  Medicare, Medicaid,
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  commercial, and all the markets, involved. Yeah. And
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  that that that data management challenge,
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  I'm sure can create some silos Yeah.
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  From from time to time. So I guess
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  from your point of view, how are payers
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  are doing this really well? How are they
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  breaking down operational silos between the insure between
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  insurance and and and care delivery?
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  Yeah. No. I think I think that's a
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  that's a great question.
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  You know, at at a at a very
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  macro level,
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  the way we see it is there are
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  two aspects of of care. There is there
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  is what I call it design of care,
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  and then there is delivery of care.
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  And I think,
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  where most successful payers and even paywiders, right,
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  are increasingly going towards is how can we
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  bridge that gap? Because at the end of
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  the day, the continuum of care for a
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  member,
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  would require
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  these two areas, right, to be highly integrated.
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  So for example, when you're designing the care,
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  you will be looking for what are some
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  of the shared risk models from a delivery
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  of care you would like to incentivize the
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  member.
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  So designing of the care would mean what
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  are your strategies with respect to your network,
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  are there vertical integration option if you are
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  taking shared risk and capitation models,
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  what kind of member experience you wanna deliver
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  before you onboard the member,
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  and what kind of personalization,
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  right, you want to deliver after you onboard
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  the members,
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  in particular,
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  during their their care delivery process.
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  So when we look at these silos, there
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  are common denominators. Right? Benefits is a common
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  denominator.
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  You would want to know when you're shopping
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  for your insurance plan, how much it's gonna
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  cost.
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  And you would want to know the same
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  question
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  when you're actually in the middle of a
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  care episode.
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  So benefit is one kind of data layer,
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  which we believe is a common denominator, which
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  kinda threads the needle between designing the care
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  and delivery of the care. The last thing
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  you want is to create a fragmented data
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  source for such an important layer, which is
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  where which is the problem we are trying
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  to solve.
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  We enable a source of truth for benefits
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  so that all different stakeholders from actuary
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  to product design development,
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  to your customer service, to your claims team,
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  to the to the care delivery providers who
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  need access to those benefits,
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  they all are essentially getting a consistent view
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  of benefits because it's sourced
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  from the same source of truth. So those
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  are some of the value propositions we bring
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  to the table. And, essentially, you kind of
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  break down the silos by building
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  an integrated layer across the continuum of care.
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  Yeah. And that that that tie in or
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  that bridge, so to speak, is that the
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  benefits
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  information
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  serve serving as, like, sort of that bridge,
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  like you said, between design of care, delivery
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  of care.
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  And, of course, you know, we're we're talking
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  about health care in 2025.
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  So I gotta ask you
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  what role sort of when doing that work
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  with with benefits,
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  and shaping that member experience as you put
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  it, what role is AI and analytics playing
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  in helping make this a connected experience
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  from, you know, benefit navigation to
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  the proactive care that that I believe,
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  you know, all of the the the idea
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  here is to get to a place like
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  that where there's more proactive care? Yeah. Yeah.
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  Yeah. Well, you know, we are in this
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  incredible wave of AI,
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  here at Becker's. Right? It's hard to even
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  walk 10 steps without not hearing AI. True.
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  Yep. So it's it's very exciting.
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  We we have taken
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  the mandate of applied AI
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  at on two fronts. The first one is
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  how can we
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  make
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  access to knowledge
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  easier? And that becomes more along the lines
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  of how can we personalize what's important
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  on the benefits level. So we recently launched,
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  an AI assistant
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  feature to benefits one platform. We call it
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  Benny, which is Benefits Native Intelligence. And, essentially,
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  the the mandate for Benny is
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  how can we make sure that,
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  you have access to all different kinds of
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  benefits information we house within our platform
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  almost in a natural language manner. So things
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  like, hey. I'm gonna go and about to
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  have a broken bone injury.
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  What it might cost me?
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  Now to answer that question, today, you may
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  be on the phone with a customer service
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  rep. Right? And and and and and you
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  will be dealing with calls or multiple,
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  checkpoints where you would try to get that
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  information.
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  Benny would make it easier because we would
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  source it directly from where the care was
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  designed again. So this is a perfect example
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  where the delivery of care and design of
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  care are kinda eating from the same bucket.
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  Mhmm. And that just allows,
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  that removes the human error. It removes the
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  silos. It it takes the friction and the
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  rate limiters away, and it gets you to
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  the source of information and the knowledge as
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  fast as possible, as natural as possible. So
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  that's one use case of AI where we
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  can deliver a lot more personalized
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  experience on the frontline,
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  by just limiting the distance from the source
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  of truth. Yeah. The second one will be
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  on more on the back office side where
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  you would want to do a lot more
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  automation.
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  So, for example, if you would want to
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  match your member benefits, right, with incoming data
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  sources, you would want to automate the end
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  to end workflows
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  using an agentic layer to to take care
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  of your back office functions.
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  As it comes to benefits and provider, those
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  are the areas which we are also looking
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  at. So you can you can you can
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  talk to Benny in future, right, and say,
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  hey. I would like to renew this plan
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  for next plan year.
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  Show me, right, what are some of the
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  plan recommendations I should be making as I
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  look into design of care for next year.
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  Now when you actually have that level of
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  sophistication, you will be able to create and
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  compile and design a plan. So your starting
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  point of taking that process is incredibly sophisticated,
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  and that would mean that you would save
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  a lot of time, cost, and you can
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  spend more time, right, designing the care versus
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  dealing with, a lot more manual processes which
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  exist today.
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  Yeah. When I when I come back to
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  sort of sort of Benny and thinking about
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  that that sort of, that sort of capability,
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  I think it's come up being on-site at
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  at Becker's Parachute's roundtable come up a lot.
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  Like, the the demand for such a tool
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  is high, and the need for it for
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  members is high.
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  When you think about
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  how complex insurance can be to to the
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  average member,
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  being able to cut through the noise, not
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  have to be on hold to have a
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  direct answer. I mean, are am I reading
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  that correctly just from the rooms I've been
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  in during the conference?
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  Yeah. Absolutely. You know, we we have multiple
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  solution options that simplify Benny. It essentially solves
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  the problem of,
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  exposing benefits information
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  to all all of the product
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  design, actuary, right, document management, compliance, a lot
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  of the stakeholders which we have. We also
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  have benefit inquiry solution, which empowers the day
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  in the life of a customer service and
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  the member.
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  So again, it's all the same source of
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  truth information.
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  The demand is high because,
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  as we both know, Brian, it's a it's
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  a team sport. The moment you are about
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  to embark upon an episode of care,
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  you are talking you're you're talking to at
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  least interact with anywhere between 18 to 25
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  people,
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  and that's the simplest form of care. Mhmm.
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  And as you are interacting
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  and as your as your care delivery needs
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  gets more complicated, you will just have more
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  stake
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  Right? You not only have doctors, but you
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  have to you have to schedule appointments. You
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  have to talk to insurance
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  companies on how much you are going to
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  pay for it. If you are prescribed, let's
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  say,
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  you know, pharmacy, now you have pharmacist. So
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  now you will go back to your formularies
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  and understand, hey. What what is this drug
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  type? Tier one, tier two, tier three. So,
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  again, this pendulum kinda keeps swinging between who
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  designed the care, which is more along the
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  lines of payers and who is delivering the
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  care, which is more on the providers and
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  pharmacy.
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  But as a member, I would be talking
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  to both of these because I'm trying to
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  take care of the episode of care, right,
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  for myself.
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  So we see an incredible demand here of
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  kind of bridging this gap because at the
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  end of the day, one common goal across
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  both of these entities is how can we
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  improve the life of a member and how
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  can we make sure that they are delivering
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  and meeting the outcomes, right, the healthy outcomes
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  we all intend for. Yeah. And and speaking
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  about that, I think what you just,
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  what you just shared kinda gets at this,
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  but to zero and even closer, but maybe
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  a a a finer point on it. What
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  are the most important moments that shape a
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  member's perception
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  of of the benefits they're getting of of
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  the value from their plan?
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  Yeah. I think,
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  it's it's almost like the perception of the
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  member is
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  so intertwined with the market or the
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  care access channel, which they're coming from. And
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  what I meant for
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  the moments that matter for a Medicare member
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  will be different
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  than a Medicaid member,
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  which will be different
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  from a commercial member. If you look at
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  Medicare
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  member,
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  for example,
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  every year they have an opportunity to shop.
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  Right.
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  And that would mean that,
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  every year
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  there is just an extremely hyper focus on
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  access to care,
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  experience
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  to care,
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  because you would want,
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  like, anywhere from onboarding and retaining
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  a member
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  all the way to making sure that, you
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  know, their care needs are met.
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  And a Medicare member in an urban Chicago
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  versus Medicare member in a rural Chicago, rural
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  Illinois. Right?
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  Could be very, very different need. Right? So,
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  so I think moments that matter for a
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  Medicare member would be
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  how good is your broker network system, which
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  can educate the member,
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  how aware you are with their current
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  care needs, and how accessible that care is.
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  And the problem for Medicaid would be completely
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  different. What are the social determinants? They are
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  much more amplified, right, for Medicaid.
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  Versus with commercial, you're talking about, hey, what
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  employer are we talking about? What kind of
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  benefits is that employer subscribed to?
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  So I think that the moments that matter
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  for the member are
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  onboarding and educating the member. I think that
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  is a common theme there across all markets.
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  Customer service becomes an important one, and then
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  access to care and provider experience becomes an
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  important one. So across all three markets, those
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  are the common denominators.
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  But there are so many nuances as you
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  can imagine. Onboarding a Medicare member would be
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  very, very different than onboarding a commercial member.
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  So the devil is really in the details.
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  You know, one may think that, yes, these
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  are the areas we want to improve and
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  kinda get more sophisticated on. But the playbook
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  for each one of these market is extremely
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  nuanced and different. And I think those are
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  the areas, right, which we essentially offer a
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  lot more value for our customers.
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  In considering everything we've we've we've talked about
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  so far, Nirneh,
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  what do you believe should be on the
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  top of the innovation
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  agenda this year for payers?
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  Yeah. I think,
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  I think it's it's really enabling
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  more integrated, connected journey for
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  the members
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  and and your internal stakeholders alike.
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  So,
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  personalization
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  of benefits,
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  which allows to meet
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  more competitive needs in the marketplace,
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  much more member facing needs in the marketplace,
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  partnerships with providers and different entities,
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  especially on value based and other shared risk
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  arrangement that kinda start shifting the the output
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  to the outcomes conversation.
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  So we're excited about that trend line. Mhmm.
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  But at a at a macro level,
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  we believe that the more bridging the silos
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  happen between design and the delivery of the
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  care, I think that's kind of the shared
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  space, right, where it's a win win win.
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  And when I say win win win, and
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  there are three stakeholders here, there's member, there
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  is
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  holders here, there's member,
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  there's peer, and provider. So how can we
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  get these three wins?
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  And it's really founded in how well we
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  can integrate
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  the delivery of the care and design of
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  the care.
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  AI is making a lot more
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  lot more of these
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  use cases much more easier, faster, and more
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  accessible.
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  We, we have use cases like how can
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  we do how can we recommend plan for
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  a particular member or a particular market. Right?
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  So
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  your your journey of onboarding a member becomes
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  a lot more smarter
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  knowing what was the delivery of care formula,
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  right, which worked for that member. So with
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  all the data available between peers and provider,
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  some of these use cases on enabling a
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  connected journey becomes much more easier. And those
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  are the value propositions we bring to the
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  table at Simplify.
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  Yeah. And can we talk about I think
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  that's that's,
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  an important point. Maybe we can go even
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  deeper for for our final question here, which
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  is really about,
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  you know, they're either payers are gonna have
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  to partner, obviously, here or they're gonna have
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  to to to build solutions of their own
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  to sort of get to this future state,
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  fill this need that members have, and, you
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  know, the the payers that do this are
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  gonna be the ones that thrive in the
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  future. So I guess the final question is,
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  what should they be looking for in partners,
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  or what kind of capability should be looking
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  for as they go to build their own,
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  so that they can get to this future
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  state of a more connected future for for
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  members? Yeah. No. I think that's a great
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  that that's a great question. So it's almost
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  like, you know,
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  there are two constraints,
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  which which which we see. The the first
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  one is
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  really invest and improve upon
• 14:35
  personalizing your experience for your members.
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  And on the other end, there is an
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  incredible pressure of
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  doing that at scale
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  without adding a lot more cost.
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  And if you look at these two constraints,
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  right, it's inevitable
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  for you to not leverage platforms.
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  And what platforms bring to the table, what
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  platform thinking brings to the table, the technology
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  which comes into picture here is
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  it can kinda allow you to kill both
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  birds with same stone. Right? So on the
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  on the front line and on your digital
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  front doors, it can enable a personalized experience
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  for the member because it's using the data
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  to have a much more integrated
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  story, more accessible story for your members.
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  And, for your back office teams, it brings
• 15:22
  incredible automations. So your manual silos goes away,
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  which is exactly where a lot more admin
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  savings and cost and a lot more exhaustion,
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  frankly speaking, because there
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  are highly regulated environments, which has timelines, which
• 15:37
  are high pressure. And there's just a lot
• 15:39
  of customers try to kinda endure that.
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  So having a platform which allows you to
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  improve,
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  on personalizing for your members at scale,
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  at the same time not adding more cost.
• 15:52
  Like, we have a story with, our customer
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  where they improved their NPS score by 12
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  points without really adding,
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  you know, any person on their employee staff.
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  Now it cannot be possible because as you
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  grow in,
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  in geographically in more markets,
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  as you add on more members,
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  if you're not adding more
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  admin cost,
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  it it's a litmus test, right, on how
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  the degree of automation and sophistication you have
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  in your operating protocols. Those are the areas
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  which we we think are going to be
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  important for,
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  for journey onwards. Yeah. Appreciate that that sort
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  of, it it's very easy to conceptualize the
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  way you put it in terms of this
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  becomes a litmus test in terms of how
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  effective the technology is being.
• 16:39
  And, Nirne, it was a pleasure speaking with
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  you today. Thank you so much for coming
• 16:41
  on the podcast. Yeah. Sounds good. Likewise, thank
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  you so much, and,
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  have a nice day. Yeah. Absolutely.
• 16:48
  I also wanna thank Simplify Healthcare for sponsoring
• 16:50
  today's podcast.
• 16:52
  Invite our listeners to tune in to more
• 16:53
  podcasts from Becker's Healthcare by visiting our podcast
• 16:56
  page at beckershospitalreview.com.
• 16:59
  Hope you all have a wonderful rest of
• 17:00
  your day.