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

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