Latest / Becker’s Payer Issues Podcast / Driving Affordability and Access Through Digital Innovation with Ellen Sexton

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Driving Affordability and Access Through Digital Innovation with Ellen Sexton · Becker’s Payer Issues Podcast

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  Hi, everyone. This is Elizabeth Caslow with the
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  Becker's Payer Issues podcast here at the April
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  2026 Becker's Payer Issues Roundtable.
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  I'm so excited today to be joined by
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  Ellen Sexton, executive vice president and chief growth
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  officer at Blue Shield of California. Ellen, thank
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  you so much for joining us today. Thanks,
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  Elizabeth, for having me. It's great to be
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  here. Yeah. So I would love to hear
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  a bit more about your role at Blue
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  Shield of California and your health care career
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  background, where you're at now.
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  Absolutely.
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  So I am executive vice president and chief
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  growth officer for Blue Shield of California.
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  We cover 6,000,000
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  members,
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  both inside and outside California. We have a
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  million members actually outside of California,
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  and we cover employer group, Medicare,
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  Medicaid,
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  and individual exchange, which is called Covered California.
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  So we have a really diverse group of
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  membership.
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  And
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  I have been in health care what seems
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  like, a long time now and all within
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  health care payers. So I started at UnitedHealthcare
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  and just got to do really fabulous things
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  there,
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  like roll out part d, which was twenty
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  some years ago now. So thinking about, you
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  know, prescription drug coverage for Medicare members.
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  I also was able to run a Medicaid
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  plan for them and really learn about how
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  do you have to deliver for complex members.
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  I also work for Humana, and I ran
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  their specialty and group benefits.
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  And then I also spent,
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  a little bit of time at a startup
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  called Curative out of Austin, Texas.
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  And we were trying to do really innovative
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  things around employer group coverage,
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  getting people in a preventative care by giving
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  them a baseline visit and then zero co
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  pay, zero deductible.
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  And so really great to see sort of
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  the nimbleness of a start up and how
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  you get members actually into care. So,
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  I love the challenges of health care and
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  that's why I think I've just stayed within
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  it for so long, and we've got more
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  to go, and I'm ready to roll up
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  my sleeves and do that. Well, thank you
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  so much for that background, Ellen. And so
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  from your point of view, what is the
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  biggest
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  operational challenge that payers are dealing with right
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  now, and what are you doing to address
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  it?
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  I think from that standpoint for health plans,
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  really getting that affordability
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  and figuring out how do we actually bend
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  that cost curve.
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  And do we do it with providers, but
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  also do it within sort of how do
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  we run our operations more efficiently,
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  whether that's through AI,
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  whether that's through just better process and technology.
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  And we know that health care in America
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  has to change from the trajectory of health
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  care costs. Employer groups can't afford it. Most
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  families are just one health care crisis away
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  from bankruptcy.
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  And to think about that as a charge
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  from a leadership standpoint
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  just is really impactful.
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  And so I think there's a blend of
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  how we work with providers and value based
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  care and bring things to market where we
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  actually
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  help them select the right care for members.
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  We help members engage with providers that deliver
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  high quality
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  as well as how do we make
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  the complexities
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  of health care go away. And that's not
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  an easy thing to do and as a
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  journey we're on and one that I'm proud
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  to be part of.
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  So I wanna talk a little bit more
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  about that cost curve. So there's a real
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  tension between keeping costs down and also
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  ensuring a good member. So
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  that is something that we see a lot
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  of with care coordination, but how is your
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  organization balancing cost containment with improving that experience
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  and also thinking about quality outcomes, and where
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  are you seeing the biggest opportunity for impact?
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  The first thing I would say is that,
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  you know, member experience
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  and making sure that people have access to
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  care, that is table stakes and the first
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  thing that we're always really focused on, and
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  that can't come at the expense of anything
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  else. And so thinking about how do we
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  introduce digital tools that help members access care?
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  How do we think about behind the scenes,
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  like, prior auth tools with providers so that
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  we make care more seamless? And in many
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  cases, when somebody's undergoing treatment, not having to
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  wait for approvals and things like that.
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  And why that matters is is if you
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  get people into care sooner, then their conditions
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  can actually be addressed, and you don't have
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  the same sort of pervasive, like, issues that
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  people end up in the ER with or
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  back with a readmit. And so how we
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  get after that is really important.
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  You know, one of the things that we've
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  have is virtual blue, and that is our
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  online
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  virtual care. And we're in our third year
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  anniversary.
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  We've had a 150,000
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  members access it, and the first thing it
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  brings to the table is the ability to
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  get into an appointment much sooner. So on
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  the primary care and mental health, people are
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  able to access and get into appointment in
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  one day versus ten days. And on the
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  specialty side, within three days versus fifteen. So
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  imagine you're a patient
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  and you have something ailing you. And instead
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  of waiting for a number of days, you
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  can get in much sooner and get whatever
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  it is addressed. And so we've seen that
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  not only improve the experience, but also a
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  lot less ER visits because people don't have
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  to go to the ER.
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  So 10%
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  less ER visits. And so overall,
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  we're seeing a member savings of $468
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  per member, which is huge. Right? So better
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  experience as well as lowering costs at the
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  same time.
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  So my next question was about technology as
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  an AI that you're prioritizing right now,
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  Virtual Blue and what's to come there. So
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  what are you prioritizing within Virtual Blue? What's
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  the next step now that you've had that
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  three year landmark? Yeah. And where are you
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  seeing meaningful ROI and better engagement with members?
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  Definitely. So, again, it's about helping us as
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  members access care, and I think we're all
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  frustrated too. There's lots of experiences we have
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  outside health care that are way more seamless
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  that we're now comparing to, you know, whether
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  it's through an app, whether it's how we,
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  you know, talk to,
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  you know, our doctor. There's a ton of
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  things that people are just waiting for that
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  we can bring to the table. And so
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  continuing to roll out Virtual Blue is a
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  big focus point. Also, online appointments in in
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  just in general. And so we work with
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  Zocdoc to put online appointment capabilities. So just
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  like when you reserve an airline ticket or
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  a hotel, you don't have to make a
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  call. Right? You're able to do it through
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  an app. Same thing for your doctor and
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  just makes it much easier with all of
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  our busy schedules.
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  The other thing that we're rolling out is,
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  check
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  Rx script, and what that allows you to
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  do is when you're in the doctor's office,
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  get the ability to understand,
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  could you have gotten that prescription through a
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  generic or through biosimilar,
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  and have a lot less,
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  cost to your bottom line? And what's important
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  about that is it's not when you're at
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  the pharmacy and can't make a decision. You
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  can talk through with your doctor, like, how
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  could this impact me? And so for instance,
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  maybe you have something,
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  that has a generic, but it could make
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  you drowsy. Your doc can talk that through
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  with you and can say, well, yes. For
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  me, the ability to, like, have to pay
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  less, and I'm okay with maybe that as
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  a side effect, or maybe you're not. But
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  it puts you more in that decision phase
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  and helps you understand what you can do.
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  So all these things are are well underway,
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  and we've just seen great impact. And our
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  members really love it, and we're gonna continue
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  to look for things like this to disrupt
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  the status quo.
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  It's really interesting that you're using new technology
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  and those types of innovations
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  for building agency with the members. Mhmm.
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  But just more broadly speaking, how do you
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  see AI supporting member facing interactions while still
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  maintaining trust and quality, and what advice do
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  you have for other carriers that are looking
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  for advice in that? Yeah. I don't think
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  I go through a day where I don't
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  talk about AI,
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  either internally with teams,
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  with providers,
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  or even with other health plans on how
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  they're using it because it's certainly gonna, like,
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  I think, improve a lot of things. It's
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  gonna bring data to the table,
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  and help with decision points that we never
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  had before and make it much more real
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  time as well. Instead of waiting for claims
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  or waiting for a a phone call,
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  we can use AI.
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  With all of that, though, you're right. You
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  have to build the trust and the guardrails
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  around it to make sure that it's gonna
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  help improve the experience
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  as well as make sure sure that it's
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  gonna be accurate and help really that member
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  and provider. And so those are the layers
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  that we're instituting
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  over it and within it to make sure
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  that we can get sure make sure that
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  that's, the right way to handle it. And
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  I think as we think about it, it's
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  just gonna grow more and more, and it
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  is gonna be able to cut out a
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  lot of costs, which then means we can
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  invest that in the benefits
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  and the things that really improve health care
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  overall.
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  Well, Ellen, any last thoughts as we wrap
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  up our conversation today?
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  It's been just so delightful to talk with
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  you. I'm really excited about this entire conference
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  because I think, again, it brings ideas to
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  the table, and no one organization is gonna
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  be able to solve this alone. So how
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  we work together and solve health care challenges
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  is what these kinds of venues help us
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  do. That's great to hear. We're so happy
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  to have you here with us at the
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  event.
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  And to our listeners, if you wanna listen
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  to more podcasts from Becker's, you can go
• 9:57
  to beckershospitalreview.com.
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  Thank you.