Latest / Becker’s Payer Issues Podcast / How Payers are Preparing for 2026 and Beyond

Transcript

How Payers are Preparing for 2026 and Beyond · Becker’s Payer Issues Podcast

• 0:00
  Hi, everyone. This is Erica Spicer Mason with
• 0:02
  Becker's Healthcare. Thank you so much for tuning
• 0:04
  in to the Becker's Healthcare podcast series today.
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  So today, we're going to talk about how
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  payers are preparing for 2026.
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  And joining me for this conversation, we have
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  Bob Tavernier,
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  the sales solution executive at Quest Analytics,
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  and Rick Harbitt, senior manager of provider network
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  programs and strategy at Blue Cross Blue Shield
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  of North Carolina.
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  Bob, Rick, welcome to the podcast. Thanks for
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  joining me today. Thank you, Erica. Thanks. Yeah.
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  Great to have you both here today.
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  Before we get into the discussion, I wanted
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  to see if you both like to share
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  just a little bit more about yourselves, your
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  organizations, whatever you think is helpful for listeners
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  to know going into the conversation today. Rick,
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  do you wanna kick us off? Sure. Sure.
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  So, happy to be here, Erica, once again.
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  And, yeah. So I've been with Blue Cross
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  Blue Shield now for, a little over half
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  a decade.
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  And prior to that, I was with the
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  health care delivery organizations,
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  in the Southeast, couple of them. So about
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  twelve years, in the industry on both sides
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  of of the aisle.
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  Excellent. Great to have you with us, Rick.
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  And, Bob? Well, Rick, the the blues are
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  very familiar with, myself.
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  I was actually at health care service corporation
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  for
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  twenty six years. I was born there. So
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  I guess you could say I'm blue blooded,
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  but, you know, focused predominantly not only on
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  internal operations,
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  with product development, claims customer service, IT, as
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  well as external operations, national accounts.
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  Also focusing on government networks as well as
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  government clinical operations. Nice to be here today.
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  Oh, great to have you both with us.
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  And, you know, we're recording here today at
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  the Parachute's roundtable at Becker's CEO CFO conference.
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  So throughout these next few days, I know
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  we're going to hear a lot about these
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  growing financial and regulatory pressures that plans are
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  facing as they head into 2026.
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  So, Rick, I wanted to start with you
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  in getting your perspective.
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  How are some of these forces reshaping priorities
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  around provider network design? Yeah. So, Eric, as
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  you know, it's
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  was never projected to be a great year
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  for payers, in 2025, and I think, it's
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  even been more challenging than what many of
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  them were expecting. And, you know, we're, no
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  stranger to that, unfortunately. And so,
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  ultimately, it it comes down to what can
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  we prioritize and what can we deprioritize.
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  We have to be smarter with the approach
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  that we take in many cases.
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  It's not always the the first thing that
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  comes to mind that we can do. It,
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  really needs to be buttoned up when it
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  comes to our business case. So,
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  CapEx is is,
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  nearly nonexistent
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  in many cases,
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  at least through 2025.
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  And so we really have to look at
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  the future both from a three year and
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  five year perspective rather than the short term.
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  Yeah. I really appreciate how you're emphasizing prioritization,
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  staying really disciplined.
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  Appreciate that, Rick. And, Bob, I know you
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  you're having conversations with payers on a national
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  scale in your work with Quest Analytics.
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  So So what trends are you seeing in
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  how organizations are balancing compliance,
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  performance goals, some of the areas that Rick
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  touched on as well? Rick, I can't agree
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  enough in terms of prioritization and discipline. You
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  know, from a national landscape, we're seeing
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  a huge shift in diversification of lines of
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  business, you know, plans that are getting out
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  of certain lines of business,
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  investing more in other lines of business.
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  We're seeing doubling down around, the areas of
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  profitability
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  and less around
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  service air expansions and pure growth, as its
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  own.
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  From a compliance perspective,
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  compliance is is absolutely key, you know, whether
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  it's, you know, state based or federal based.
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  And it's really being able to meet the
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  baseline requirements of compliance,
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  but also be able to have a good
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  management and monitoring strategy overall that you're continuing
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  to invest in,
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  your practices operationally
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  to remain compliant,
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  and then balancing that with areas in terms
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  of performance,
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  and being able to utilize data as your
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  key. So data and analytics is really golden,
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  to really find those nuggets
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  of how do you truly focus around things
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  like profitability,
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  thinking about things like,
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  PMPM,
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  MLR,
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  thinking about areas, from a claims perspective.
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  How do you truly leverage that and look
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  deeper into your network and be able to
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  make investments incrementally?
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  But back to Rick's point, in terms of
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  that long term plan, so the three to
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  five year
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  taking steps now, it takes time, to be
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  able to establish discipline,
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  establish governance, and be able to, eventually roll
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  that out, to match the plans that,
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  the not only the national players are expecting,
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  but also the regional players as well.
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  Yeah, Bob. And I noticed in your response,
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  you touched on the network. And so I
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  wanna go a little bit deeper and talk
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  about network adequacy.
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  We're seeing plans move past those traditional time
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  and distance standards, and they're taking a more
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  holistic view of what network adequacy really means.
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  So I'd love to hear from you both
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  on this. What does that evolution really look
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  like in practice, and how does it translate
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  into real access and member satisfaction?
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  Yeah. Erica, in on the North Carolina side,
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  I can tell you network adequacy two point
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  o is really moving from what we have
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  to do to what we should
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  do it's not about necessarily checking that proverbial
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  box for regulator although that does have to
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  be done it's looking at our membership and
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  what they need so it's it's moving beyond
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  the regulatory piece to do we have enough
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  members even beyond the minimum required amount? Do
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  we have enough providers to meet the need?
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  Do we have the right type of providers?
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  Are they the highest quality that we can
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  can offer? And
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  are they coming at a in at a
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  competitive rate when it comes to the cost?
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  So
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  that's really what two point o is for
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  us, and that as Bob mentioned, that's really
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  all centered around
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  data and intelligence, right, and how we apply
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  that to our network adequacy.
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  There's a lot of meat on the bone
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  for that, and that's really what two point
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  o does. Thanks, Rick. And what would you
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  add, Bob? Yeah. Rick, really appreciate your response
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  and, you know, the direction where where you're
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  headed with two point o. I mean, two
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  point o has really blossomed,
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  over the last few years. You're hearing not
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  only the things, you know, that have to
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  be applied, like the price transparency act, but,
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  you know, also,
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  access to care,
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  appointment wait times.
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  Truly, and to Rick's point, right, really making
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  sure that you have strong bench strength when
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  it comes to your networks, your providers,
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  where are your members concentrated at, what comorbidities
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  do they have, do you have the right
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  providers in place to support the member populations
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  in the local communities that they reside in?
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  And then even, you know, on the broader
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  landscape going beyond urban, suburban and thinking about
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  rural and scenic areas, how do you true
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  truly have an omnichannel or a multichannel approach
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  when you're thinking about access to care and
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  you're thinking about servicing those members, not only
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  from a brick and mortar perspective, but also
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  from a telehealth perspective? So access two point
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  o or network adequacy two point o is
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  really going above and beyond the standard to
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  truly focus on
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  getting the member to the not only the
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  right level of care, but at the right
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  time, in the right place to truly help,
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  manage the overall toast total cost of care.
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  Yeah. Thank you both. And I can see
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  in taking this holistic stance that plans
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  are starting to embrace more and more the
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  the key role that advanced analytics or or
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  technology would play in helping to understand these
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  many factors that that play into network adequacy.
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  And I wanna go back to something that
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  we also touched on earlier. You know, we
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  talked about kind of this perfect storm of
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  cost, competition, regulatory change that payers are facing
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  right now. And, Rick, you touched on prioritization
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  and the role that that's playing at Blue
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  Cross Blue Shield of North Carolina.
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  So how are you prioritizing initiatives when budgets
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  are so tight and ROI expectations are higher
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  than they've been before? Yeah. So, Eric, I
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  think that the key takeaway there is higher
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  than they've been before. They've always been you
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  know, competing priorities have always been a thing.
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  To your point, though, you know, budgets are
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  tighter than what we were expecting, what we'd
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  like to see, and so prioritization is key,
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  and deprioritization
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  is key. And so how we're doing that
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  is, certainly,
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  we need to focus on the things that
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  mean the most to the plan overall in
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  the enterprise.
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  There's things we'd like to do with the
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  departmental and divisional levels that, just really aren't
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  there
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  at least for 2025.
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  And so we're that's why we're looking at
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  the our three and five year plan. So
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  our shift is
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  more
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  focused on what can we do to be
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  in a better place in 2030
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  than what can we do to be in
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  a better place in 2025 and 2026 because
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  it's simply not gonna gonna matter,
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  in the short term. So,
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  you know, I'll I'll wrap all that up
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  to say
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  that, really, what we need to do is
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  just focus on the long term versus the
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  short term and what we can do to
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  to support those goals. Yeah. Rick, thank you
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  for that perspective.
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  And, Bob, I know you we've already touched
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  on kind of the role that analytics can
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  play in this space, the importance of data
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  in achieving some of these aims and prioritization
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  to Rick's point. So can you shed a
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  little bit more light on how payers can
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  use
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  data and market insights to really focus their
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  limited resources on where it will have the
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  greatest impact? Absolutely, Erica. You know, when we
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  think about data and analytics and
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  thinking about some of the levers such as
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  cost,
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  such as quality. You know, a lot of
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  that is focused around,
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  truly being able to look at the the
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  macro level, you know, not only across the
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  service areas that you are serving,
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  but also, the different product and benefit designs
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  that you have,
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  the different, providers,
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  as well as facilities that you have lined
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  up to support specific
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  benefit and network designs.
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  When you think about cost and quality,
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  the name of the game is utilization.
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  Right? And I don't care if you're a
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  regional or a national,
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  payer.
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  You know, you really wanna focus in around
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  managing that medical expense.
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  And, you know, it's again, to Rick's point,
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  you're in it for the long game. Right?
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  And you wanna be able to build up
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  your reserves. You wanna be able to service
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  your members.
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  But being able to look at opportunities where
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  you see
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  high cost opportunities and being able to negotiate
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  down or be able to provide further
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  direction, to, members
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  on, you know, the best choice of care,
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  being high quality, low cost,
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  to truly help that man member manage their
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  condition.
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  But then also being able to, you know,
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  stay up to date with things like provider
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  directories, which we know churn at
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  a 60 to 70% rate.
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  What are you doing as a payer organization
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  to truly help to enable
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  a high performing network with a network that
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  is truly accurate. So when a members are
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  shopping for insurance, they look at those online
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  provider finders, they look at the directories,
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  and they know that the PCP or specialist
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  that they're signing up for is gonna be
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  there,
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  when they sign up. So there's a lot
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  of different things to factor in,
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  When you think about the perfect storm, you
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  think about cost, and quality and just using
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  data overall, to make informed decisions. Yeah. Yeah.
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  Thank you so much.
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  And as we look ahead,
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  you know, when when we consider this concept
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  of network adequacy two point o and and
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  where the market is headed, what advice would
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  you both offer to leaders who are just
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  starting to evolve toward that two point o
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  mindset or even rethink their network performance strategy
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  overall?
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  Yeah. Erica, that's a great question because, you
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  know, ultimately, I I think I would say
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  that what the plan has to do is
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  understand where their specific goals are,
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  and understand current state because, you know, one
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  of the things that we've talked about, you
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  know, really has been multifaceted.
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  There's multiple
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  components to this problem, and no single plan
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  is gonna have every one of those same
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  things happening to them as what's happening on
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  the North Carolina side or or others. And
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  so understanding where you're at, where you wanna
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  go,
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  and then being open to alternative ways to
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  get there. Right? So building it yourself is
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  not always the best case. I can tell
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  you on the North Carolina side, we evaluated
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  multiple options, and one of which were were
• 12:13
  internal solutions.
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  We ultimately ended up finding a partner to
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  go with, because just their their time to
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  scale and time to market was just so
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  much better,
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  and the value prop they offered was was
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  much better. And so I think being open
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  to partnerships such as that would be in
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  everyone's best interest. Yeah. It's great takeaway. And,
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  Bob, what would you say? You know, it's
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  it is a state of evolution. You know,
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  Rick, you bring up a really good point
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  in terms of the North Carolina market and
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  things that are in integral to your, your
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  communities and your markets.
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  But the communities vary right across The United
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  States and just, you know, there's different shifts
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  in terms of our overall strategies,
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  really being able to, you know, to take,
• 12:53
  you know, incremental steps towards the goal. If
• 12:55
  you have long term goals, three to five
• 12:57
  year plans,
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  if you're really focusing
• 12:59
  in on a a diversification
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  and looking at,
• 13:03
  different lines of business, being able to truly
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  think about how do you take steps incrementally
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  to get there, how do you measure success,
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  You know, thinking about workflow optimization, thinking about
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  ways to use data, ways to use technology
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  to help you,
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  not only from a staffing perspective, but truly
• 13:21
  from a a functional and an output perspective
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  to help you achieve the outcomes that you're
• 13:27
  expecting to achieve.
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  There's so many different things going on right
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  now, you know, buzzwords like AI.
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  But AI only means something if you're able
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  to truly apply it within the application,
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  of your your standard business practices,
• 13:42
  your operations.
• 13:43
  So truly being able to utilize data and
• 13:46
  utilize technology in a way that can be
• 13:48
  effective
• 13:49
  and make incremental steps towards the goal annually
• 13:51
  and ultimately in support of your long term
• 13:54
  goals.
• 13:55
  Fantastic.
• 13:56
  If I have a takeaway from this conversation,
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  it's that network adequacy two point o is
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  really the long game. It's something that organizations
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  have to have a really holistic approach behind
• 14:05
  and one that's fueled by technology and analytics
• 14:08
  as possible in meaningful ways to your point,
• 14:10
  Bob.
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  This has been a great conversation. Before we
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  close, is there anything else that you'd like
• 14:14
  to add or maybe something we glossed over
• 14:16
  too quickly?
• 14:18
  Eric, I would just say thank you very
• 14:19
  much for Becker's Healthcare and your partnership and
• 14:22
  everything that you are, offering for us today.
• 14:25
  We appreciate it. Thanks, Paul. I agree. Oh.
• 14:27
  I agree. That's great. Thank you. Thank you
• 14:29
  both. It's been a great conversation. And, of
• 14:31
  course, we'd like to also thank the podcast
• 14:33
  sponsor for today, Quest Analytics.
• 14:35
  Listeners, please tune in to more Becker's podcasts
• 14:37
  by joining our podcast page at beckershospitalreview.com.