Latest / Becker’s Payer Issues Podcast / Driving Value and Innovation in Health Plan Operations with Gretchen Wagner

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Driving Value and Innovation in Health Plan Operations with Gretchen Wagner · Becker’s Payer Issues Podcast

0:00
Hello, everyone, and welcome to Becker's Healthcare Podcast.
0:02
I'm Scott King. Thrilled today to be joined
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by a very special guest, Gretchen Wagner, associate
0:07
vice president, risk management with Humana. Gretchen, how
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are you doing? Thanks so much for joining
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us. Sure. Thanks for having me, Scott.
0:14
Yeah. You know, we have a lot of
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big topics to get to here, you know,
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on the podcast in in health care and
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with health plans, and we're we're definitely looking
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forward to having you speak with us at
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our spring payer issues roundtable.
0:25
But before we, before we get to that,
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I was wondering if you could just tell
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us a little bit about your background and
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your career.
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Sure. So I actually started out in education,
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a little bit nontraditional to get into health
0:37
care, but then made my shift into internal
0:40
audit. And that is how I ended up
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making my way into health care coming in
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from an internal audit perspective,
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and found that was a great way to
0:49
really learn a company as a new associate
0:52
and a young employee at that point in
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time because it gave me exposure to a
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lot of different parts of
0:58
a company. Right? I got to learn different
1:00
parts and pieces and how they work and
1:02
meet leadership.
1:03
And from there,
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I really moved up and found my niche
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from a clinical perspective,
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at Humana and have been with the the
1:13
organization now for over fourteen years
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and lead our SNP governance.
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So work closely with our SNP models of
1:20
care, serve as a first line risk and
1:22
compliance partner,
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support a lot of our quality governance components.
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Doing a lot right now with our integrated
1:29
D SNPs as we're seeing our Medicaid and
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Medicare programs come more closely together
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across that D SNP landscape,
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and also work very closely with our clinical
1:39
operations team. So,
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excited to be here and,
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excited to talk about really kind of the
1:45
the things we're seeing from a health care
1:47
perspective,
1:48
right now in the state of our our
1:50
health players.
1:52
Well, appreciate you sharing that background info there,
1:54
Gretchen. And, you know, the first kind of
1:55
big topic I wanted to get to
1:57
is how are your relationships with providers changing
2:00
as both sides face cost pressure and workforce
2:02
shortages?
2:04
Sure. So I would say
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we are seeing very significant changes in the
2:09
last few years.
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Right? We're starting to see
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unprecedented
2:15
cost pressures
2:16
that are only continuing
2:18
from especially an MA perspective and a Medicaid
2:21
perspective as well as workforce shortages.
2:24
You know, when we think about historically what
2:27
relationships look like between payers and providers, we
2:30
always had very transactional
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based
2:34
relationships that were very fee for service type
2:36
payments where providers were reimbursed for individual services
2:41
or procedures,
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and payers really focused on that claims processing
2:44
and cost containment.
2:46
And we found that model created silos and
2:49
at times really misaligned
2:50
incentives. So one of the things we're really
2:53
doing at Humana today is seeing a shift
2:55
towards a much more collaborative approach
2:58
where we think about partnership and accountability
3:01
with a value based model.
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So in those arrangements, we're really incentivizing
3:06
our providers to not just think about the
3:08
volume of care, but really how are we
3:11
delivering on quality
3:13
and achieving outcomes.
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And it really is thinking about how can
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we align our goals together
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so that we can see our patients get
3:22
healthier,
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avoid unnecessary
3:25
hospitalizations,
3:26
and, ultimately, we really wanna make sure our
3:29
members are receiving care
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at the right time.
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We've also found, I think, through that as
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we think about that value based care model,
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that it allows more innovation and care delivery,
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and it really allows us to think about
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recognizing
3:44
and rewarding
3:46
our payers,
3:48
when they have better coordination,
3:51
fewer gaps in care, and a much more
3:53
personalized approach. So really thinking about a much
3:56
more holistic and streamlined experience. So
3:59
as we think about
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how things have changed with this cost pressure,
4:05
the workforce shortages that we're having,
4:08
we've really got to rethink how we incentivize
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our payers and how we incentivize
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those relationships.
4:15
So it's definitely been a shift as we
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make that shift and that change towards those
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value based
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care arrangements.
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But we are finding
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it truly is
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allowing us to be more effective and efficient
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and also make sure we've got better
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partnerships
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across our our payers,
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but also allowing to make sure that,
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we can put the member first
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when it comes to their health and their
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outcomes as well when we take that approach.
4:47
Yeah. Absolutely. And I love the idea of
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of focusing on quality there. It's something to
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kind of put in the middle of that
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payer provider relationship to kind of get both
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sides to come to the table. I I
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think that's great. And I also wanna ask,
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where do you see the biggest
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gap today between
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payer strategy and operational execution?
5:03
Yeah.
5:04
So
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I honestly think the biggest bur
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burden that we see
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is how do we take that long term
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vision
5:13
that we have as leaders
5:15
and translate that into day to day operations.
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Right? Oftentimes, we have
5:21
big big rocks that we all are working
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towards from a health care perspective as we
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think about innovation and quality,
5:28
even think about things like utilization of AI
5:31
from a strategy perspective.
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And it's how can we take that and
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realize that
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in the daily work of our frontline teams.
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That's something that is not a unique gap
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to Humana by any means.
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It's something that the entire industry is facing,
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particularly with this current pace of change.
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One of my favorite sayings that I continue
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to hear, both internal to Humana
5:59
but external in the environment we're living in,
6:03
is that the pace of change today
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is as slow as it will ever be.
6:09
And that's kind of hard to take in
6:11
because we are facing a rapid pace of
6:14
change
6:15
from a technology
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perspective,
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from a structure and infrastructure
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perspective,
6:21
from a way in which we live perspective,
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from a,
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you know, a day to day function perspective.
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There is so much that is happening
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rapidly,
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and we are only gonna continue to see
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that progress.
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And that can be hard for a lot
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of our frontline associates,
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to adapt to
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as well as our members
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and our patients to adapt to,
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as we go through this this change acceleration.
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So with me saying that, right, of how
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do we take this
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strategic vision
6:55
where we want to innovate, where we wanna
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drive quality,
6:59
and make a better experience for our members
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is
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now how do we how do we go
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about doing that and doing that in the
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right way
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in this time of of growth and technology?
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So I think one is, like, how do
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we start thinking about digital innovation?
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Because our our senior population
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is no longer
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a population that is just working on
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on telephone calls and and letters in front
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of them.
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They are someone who have started to adapt
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things like
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cell phones, mobile apps, online platforms. They want
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virtual care options. They want telehealth options. And
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so we've gotta find
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coordinated ways
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to bring multiple teams together
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across not only our operational teams, but our
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clinical teams and our provider functions
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to make sure that we're doing this and
7:53
doing it appropriately.
7:55
So I think that's one of the things
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that we really gotta find is how can
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we find ways as organizations
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to create cross functional implementation
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that includes
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feedback loops from providers,
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from members,
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and things like I think we've got some
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really good platforms at Humana
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that are,
8:16
in many ways, regulatory
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requirements for us and things like our D
8:21
SNP and our Medicaid
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enrollee advisory committees where we can seek out
8:26
member feedback
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and try out some of our our new
8:29
technology with them. But it's also making sure
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we're getting the feedback from associates and from
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our frontline teams
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to make sure that they are front and
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center
8:39
when it comes to
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the execution
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and how they can execute on that strategy
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at a day to day level. So it's
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really bringing everyone to the to the table,
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closing that gap, and making sure that we're
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building systems and processes
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that consider continuous improvement
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and collaboration and communication.
9:01
Yeah. And I like what you said about
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change. And, you know, it's kind of a
9:04
it's kind of a bit jarring, isn't it,
9:05
too? Like It is. Like emerging tech, and
9:07
is it if this is not gonna slow
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down, so you No. You have to jump
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on board right now.
9:12
Yeah. It it really is. Like,
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it's one of those that I feel like
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we are in such a time of transformation,
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both as a society, but for us in
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health care. This is our time to
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challenge what we have been doing
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and really think about the utilization of technology
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in new ways. Right. Because there are other
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industries
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who are doing things differently
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to think about that member experience in a
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unique way
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that we haven't yet executed on in the
9:45
in the health care industry.
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And so I think this is this is
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really our opportunity
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as we are seeing
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technology advance
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advancement and just the changes that are happening
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from a regulatory perspective
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as well as a societal perspective, right, and
10:01
the adoption of
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more people being open to the utilization of
10:05
technology and those digital platforms
10:08
coming together.
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No. I I agree. I think you're you're
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right 100%.
10:12
I also wanna ask what's one investment or
10:15
initiative you believe will most reshape how health
10:18
plans operate over the next two to three
10:20
years? Yeah. Honestly, it goes back as what
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we've been talking about, and that's that's digital
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it's digital analytics.
10:27
And getting even more specific, I think it's
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the analytics
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and the interoperability, but it's across the health
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care ecosystem.
10:35
Right? Right now,
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there is a lot of data,
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and there is a lot
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of information
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that we have
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across health plans,
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across health systems,
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but it's fragmented.
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And when it's fragmented,
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we aren't seeing a holistic view of a
10:54
patient's health journey or a member's health journey.
10:58
And so one of the things that I
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think we need to invest in and one
11:02
of the things we're focusing on at Humana
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is investing heavily in data infrastructure
11:07
and advancing analytics
11:08
so that we can really bring all of
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that information together from multiple sources.
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So So think about things like
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clinical records,
11:17
pharmacy data, member interactions. So when did we
11:20
call a member? Who called a member? When
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did they pick up the phone? And even
11:25
things we might know about them,
11:27
such as social determinants of health,
11:29
right, based upon
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maybe they have food insecurity,
11:34
maybe they have a transportation need. So it's
11:37
really how can we build comprehensive
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views
11:41
of our membership
11:42
to know
11:44
how to be more pro proactive
11:46
in outreaching members and especially outreaching members
11:50
at the right time.
11:52
Right? We've gotta make sure that we can
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take data
11:56
and utilize it for good
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and not just take data
12:00
to have data
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and report on data.
12:04
We've gotta make sure we're using data
12:07
in the right way and pulling it together
12:09
through analytics,
12:10
through interoperability,
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sharing that data
12:14
to make sure we're really tailoring it to
12:16
drive efficiency
12:18
in the payer system, but across the broader
12:21
health care system and really focusing on that
12:23
member experience through it.
12:26
If you could change
12:27
one regulatory or industry practice tomorrow to improve
12:30
affordability and access, what would it be and
12:33
why? Sure.
12:35
Well, I feel like I'm I keep talking
12:37
about the same thing a little bit, but
12:39
I I think it also shows how important
12:41
out it is, and that's interoperability.
12:43
Right? And that is something we have got
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to change and speed up even
12:48
more so than we have today.
12:50
We have got to
12:53
I think about this from my own perspective
12:55
frequently
12:56
both as
12:58
a a patient and as a caregiver,
13:02
for my mother who has complex conditions and
13:05
sees a number of specialists and doctors across
13:07
networks and networks and provider groups, and how
13:11
frequently
13:12
we don't see the full picture of a
13:14
member because we don't have that information,
13:17
and how frequently we we have inefficiency
13:22
in the work that we do.
13:24
How often do we create duplicate tests? How
13:28
often do we miss something?
13:30
How often do we have the chance to
13:32
take action we can't because we don't have
13:35
the right information,
13:36
but it's sitting in another payer's health system,
13:39
or it's sitting in another
13:41
health system system at a hospital or at
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a doctor's office.
13:46
Think about how how many hours just we
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as
13:50
patients would say if we didn't have to
13:52
fill out the same form every time we
13:54
went to the doctor's office because that information
13:57
was up to date and timely.
14:00
We could save ourselves, could save hours
14:03
over the course of years in doing that.
14:05
And so we really have a chance to
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rethink about data
14:10
and bringing that together
14:12
to create
14:14
a better member experience,
14:16
but truly
14:18
having the chance
14:19
to create
14:20
a more complete picture for our providers, for
14:23
them to make better decisions
14:25
and create a better treatment plan.
14:27
And for health plans, it's gonna mean that
14:30
we can improve the accuracy of what we
14:32
do
14:33
and make sure we're supporting,
14:36
our populations in a more effective manner. And
14:39
so going back to where we started,
14:42
talking about some of the cost pressures we're
14:44
feeling.
14:45
The more that we can streamline data and
14:47
have the right data, that's only going to
14:50
help us as health plans
14:52
in a time where we're facing more from
14:54
a a margins perspective
14:57
and and the cost pressure from a regulatory
14:59
aspect that we're seeing right now. So this
15:01
is definitely a place where
15:04
while
15:05
a lot is moving quickly
15:07
from a regulatory aspect for us to get
15:09
there from an interop aspect,
15:11
there's an opportunity for us to move even
15:14
quicker here.
15:15
And that kinda ties into the last thing
15:17
I wanted to ask you, Gretchen, along the
15:18
lines of margins. And you you might have
15:20
touched on this already, but what issue do
15:22
you think is putting the most pressure on
15:23
health plan margins right now, and how how
15:26
are you responding differently in 2026?
15:29
Yeah. It's it's interesting. I feel like it's
15:31
such a timely question as we've been seeing
15:35
all of the,
15:37
the end of year
15:39
financial
15:40
reports come out from the large health plans
15:43
and just how
15:44
things from the industry perspective that are coming
15:46
out right right now about what is happening
15:49
in the health care industry. So it's an
15:51
interesting time for us.
15:53
And there definitely is pressure that we have
15:56
not seen,
15:58
especially in the MA space or the Medicaid
16:00
space.
16:01
And I don't think it's gonna slow down.
16:03
And I think there are really
16:04
three large contributors
16:06
to that. So one is just rising health
16:08
care cost.
16:11
Primarily,
16:12
we're seeing that through the price of specialty
16:14
medications and advanced treatments.
16:17
But in general, we're just seeing the cost
16:19
of health care go up. Everything from a
16:21
cost perspective is rising.
16:23
Two, I think we're seeing greater utilization.
16:26
Our boomer population is aging.
16:29
We're seeing chronic conditions become more prevalent.
16:32
But I also think we've created
16:34
where people are becoming more proactive
16:38
and seeking
16:39
care, which is positive, but that drives up
16:42
that utilization.
16:44
And then really the last piece is just
16:45
the administrative costs, so the cost to do
16:48
business is going up everywhere.
16:50
That doesn't matter what industry you're in. That's
16:53
not unique to health care, but it's something
16:55
we're seeing across industries.
16:57
And I think the last piece, as we
16:58
know, is the regulatory
17:00
requirements. Right? We've seen cuts in Medicaid.
17:03
We have
17:04
the proposed
17:06
you know, payment that came out on the
17:08
MA space with the reimbursement rate standing pretty
17:12
flat with a slight increase,
17:15
that's been a lot of the stocks dropping
17:17
massively last week.
17:19
So
17:20
this is not something
17:21
that's gonna go away for sure. And so
17:24
I think,
17:25
you know, when we think about this, we
17:27
have to definitely think from a health plan
17:29
perspective.
17:30
We've got to be
17:33
thinking
17:34
about efficiency,
17:36
innovation, and value.
17:39
And this really is our chance to think
17:41
differently
17:43
about how we show up,
17:46
who we are as a company,
17:48
and how we're gonna serve our members. It
17:50
really is our chance to distinguish ourselves from
17:53
each other
17:54
and really think about that member experience
17:57
if we ground ourselves in the efficiency, innovation,
18:00
and value,
18:02
from an organization
18:03
perspective. And that's something we're really focused on
18:05
here at Humana.
18:07
So
18:08
I I would say when I think about
18:09
this
18:10
operational efficiency,
18:12
we've all gotta think about leveraging automation
18:15
right now, process optimization.
18:18
How can we reduce administrative
18:20
cost?
18:20
Right? We've gotta think about things like
18:23
automated claims processing,
18:25
analytics. This is a place where I think
18:27
we have a chance to think about AI
18:29
and how we can utilize
18:31
that in the right way to support
18:34
some efficiency in our especially in our administrative
18:36
processes.
18:38
And then I think innovation is something that's
18:40
really exciting.
18:41
I talked about this is a chance to
18:42
do things differently.
18:44
How can we think about
18:46
things like virtual care,
18:48
remote monitoring,
18:50
new care management practices?
18:53
How can we think
18:55
about improving outcomes differently than we have in
18:58
the past. So I think the more that
18:59
we can think about cost containment over time
19:02
by improving health outcomes,
19:04
that's gonna help us from an innovation perspective,
19:08
but also from a member perspective.
19:10
And then the last piece I would ask
19:11
is just that value based partnership piece. You
19:14
know, the more we can incentivize our providers
19:17
with quality,
19:18
partnership,
19:19
efficiency,
19:21
that's gonna help all of us as we
19:23
we work through these cost pressures.
19:25
But it definitely is gonna be something that
19:28
we see and continue to have as payers
19:32
going into 2026.
19:34
I don't see that something that is going
19:36
to change, And so we've all really gotta
19:38
think about how we can focus
19:40
on member engagement.
19:41
Like I said, going back to how do
19:43
we think about
19:45
efficiency, innovation, and really driving that value
19:48
both for
19:49
our members,
19:51
our payers, and our providers that we work
19:52
with.
19:54
Well, Gretchen, thanks so much for a great
19:55
conversation and for joining the podcast, and I'm
19:58
looking forward to you speaking with us in
19:59
April.
20:00
Absolutely. Thank you so much, Scott.