Latest / Becker’s Payer Issues Podcast / Payer Innovation, Venture Investment, and Managing Rising Care Costs with Emily Durfee

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Payer Innovation, Venture Investment, and Managing Rising Care Costs with Emily Durfee · Becker’s Payer Issues Podcast

• 0:02
  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
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  payer and health plan executives and more than
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  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. Welcome to Becker's Healthcare Podcast. I'm
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  Scott King. Thrilled today to be joined by
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  very special guest, Emily Durfee, partner, corporate venture
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  capital
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  with HealthWorks. Emily Hardy, thanks so much for
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  joining the podcast.
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  Thank you so much for having me. I'm
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  doing really well. How are you doing today?
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  I'm doing great. We were just talking before.
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  You know, it's getting, like, a little bit
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  warmer in Chicago, which is, like, 25 degrees.
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  So, you know, getting those sunglasses ready. But,
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  no, we thanks so much for joining. We
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  have a lot to to get to, a
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  lot of kind of big topics in in
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  health care and and with health plans as
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  always. But, before we do that, Emily, I
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  was wondering if you could just share a
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  little about your background and your, career in
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  health care.
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  Absolutely. So I have one of those quote,
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  unquote, nontraditional
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  backgrounds, which is either a good thing or
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  a bad thing depending on your perspective. Obviously,
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  I think it's a good thing. But I
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  spent most of my career in startups and
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  venture capital. So actually started my career in
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  Nairobi, Kenya, worked for a startup in Sub
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  Saharan Africa for about five years,
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  did impact investing into health care and education
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  over there, and then moved more into The
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  US focused world. So, worked for, at that
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  point, a Neo, insurance company called Clover Health
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  from 2015 to 2017 out in San Francisco,
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  and joined this company about five years ago.
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  So since then, have been working, HealthWorks as
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  the innovation investment arm of CareFirst BlueCross BlueShield,
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  and have been focused on how can we
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  drive innovation in health care as well as,
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  you know, meet the needs of the strategics
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  in health care, like the big payers and
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  providers,
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  in order to marry the the traditional,
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  reach and value of, health care players, and
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  the innovation of some of the folks coming
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  out of whether it's San Francisco, New York,
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  or whatever small town you're part of.
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  Well, I think sometimes, you know, it gives
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  you a really unique perspective to be outside
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  of that, you know, traditional
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  landscape of of health care and, you know,
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  a career trajectory. So I think you bring
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  a really unique perspective, and thanks so much
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  for sharing all that. Absolutely. I'm excited to
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  share what I can and, obviously, just really
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  grateful for the opportunities that I've gotten through
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  the course of my career.
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  Excellent. And, you know, the first thing I
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  wanted to ask you about, Emily, is how
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  are your relationships with providers changing as both
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  sides face, you know, all kinds of regulatory
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  pressures, but specifically cost pressure
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  and workforce shortages?
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  Yeah. Absolutely. I mean, I I would say
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  that I don't think that this is new.
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  Right? We've been seeing the writing on the
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  wall for these pressures, these cost pressures, these
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  employment pressures for a really long time. And
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  so I would say that our strategies haven't
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  changed significantly. They're just accelerating. Right? And so
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  we're really focused on how can we continue
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  to work collaboratively
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  with providers. How can we identify
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  win wins for both of us. Right? So
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  whether that's certain types of contract types, value
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  based care arrangements, shared savings contracts, if that's
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  different types of referral systems.
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  And then also, right, we're looking at how
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  do we partner with new types of providers,
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  whether that's different types of nationalized telemedicine providers
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  or local providers,
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  that cover some of the gaps that our
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  members are experiencing. And so how can we
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  continue to both work creatively with our current
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  provider partners and add additional provider partners in
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  to ensure that we are, you know, working
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  across the board to serve our members?
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  But the reality is I don't think there's
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  a silver bullet in this one, and we
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  need to continue to be collaborative and thoughtful
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  in how we approach each other to solve
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  these problems together.
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  You know, some people I've talked to on
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  the health plan side feel like there is
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  more of a kind of collaboration.
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  You know, I don't wanna say it's easier
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  and working easier right now, but it's there
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  it seems more collaborative, I guess, because both
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  payers and providers are both up against, you
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  know, all kinds of specifically regulatory pressures. Is
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  that is that what you find? Like, people
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  are both sides just kinda wanna get things
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  done, so maybe there is a little more
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  collaboration right now than than normally?
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  Yeah. I would say I at least from
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  my perspective, we haven't had bad collaboration in
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  the past. I think, you know, we're really
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  lucky as a regional blues plan. We're really
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  much more focused on, you know, building deep
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  relationships in our geographic region. And so, you
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  know, I think compared to some of the
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  maybe larger and more national players, we already
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  have a lot of that collaboration and that
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  goodwill between us. But, yes, of course. Right?
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  Like, the reality is that we we both
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  know that we can't function without each other.
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  And given all of the the movements that
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  are happening in the payer and the provider
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  space. Right? If you're thinking about roll ups,
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  if you're thinking about, certain types of especially
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  government programs, payer, per like, state shutting down.
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  There's just so much that's going on that's
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  making us turn towards each other as opposed
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  to away from each other even more right
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  now.
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  Absolutely.
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  And where do you see the biggest gap
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  today between payer strategy and operational execution?
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  You know, obviously, I'm a little biased because
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  I sit on the kind of innovation and
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  investment perspective. But from my perspective, it's really
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  the speed of adoption around new technologies for
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  payers. Right?
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  This isn't really new.
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  I feel like one of my favorite facts
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  or or jokes to make around this is,
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  you know, email has existed for decades at
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  this point. Right? And yet still health care
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  depends significantly on faxes
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  as a form of communication, which seems slightly
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  suboptimal.
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  But especially right now as we're seeing the
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  rise in artificial intelligence,
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  and other types of technological advancements, and as
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  we're seeing these rising costs and especially these
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  burdens, both for payers and providers, you know,
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  it's, I think, even more critical that we're
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  able to quickly adopt some of these new
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  technologies.
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  And to be clear, I understand why that's
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  not happening. Right? It's not all AI has
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  been fully vetted for the really sensitive business
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  of health care. There's a lot of risk
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  for us in adopting new technologies for some
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  of our core programs because no one likes
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  it if you have a technological
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  issue and then suddenly a claim isn't paid.
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  Right? And so I think that there are
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  a lot of, reasons that that adoption hasn't
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  happened quickly. But I do think that that
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  is the biggest gap right now and the
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  thing that I'm most excited to try to
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  work to solve, which is how can we
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  do this in ways that are lower risk
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  for providers, for patients, for,
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  individuals on the payer side, etcetera, but is
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  actually accelerating
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  us towards a better and more streamlined future,
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  because I think we have to in order
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  to stay sustainable as a business.
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  Is there a new tech or
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  or perhaps an AI rollout that was easy
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  for you or
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  or HealthWorks to adopt to recently?
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  You know, I think the easiest options when
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  it comes to these rollouts are,
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  niche products. Right? So they're the things that
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  are very specifically
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  working with one type of provider, right, or
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  one type of patient or are part of
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  one small element of a member's journey through
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  our system, etcetera.
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  I think that those are important and they're
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  really, really good experiments. And the good news
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  about those is they do, in fact, affect
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  the outcomes of our members and our providers
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  and us,
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  but aren't super, super high risk. If something
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  doesn't go well, right, if there's a glitch
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  in the system, if someone can't get to
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  a web page for a little while, obviously,
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  that's not something we want, but it's not
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  going to be, you know, detrimental to the
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  entire system.
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  Unfortunately, those are the things that aren't going
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  to have as much lift. Right? If you
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  start to talk about, you know, overall claims
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  processing,
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  prior authorization,
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  etcetera. Right? That's where the biggest opportunity set
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  is, and that's also where the biggest risk
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  is. And so I think we're still figuring
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  out exactly how we can continue to to
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  test
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  and manage, those types of rollouts effectively.
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  If you could change one regulatory or industry
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  practice tomorrow to improve affordability and access,
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  what would it be and why?
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  Yeah. You know, I was thinking about this,
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  and I, like, I have two answers for
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  you.
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  The first is maybe table stakes, but I
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  do think it's important. Like, realistically, on the
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  regulatory side, I feel like the most important
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  thing that we would have
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  is clarity.
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  Right? And it's not a specific regulatory initiative
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  that I'm arguing for. It's mostly that, you
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  know, over the last few years, I think
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  there's been a lot of swings around, what
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  to expect on the Medicare side, on the
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  Medicaid side, on, certain types of states funding,
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  etcetera.
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  And I think that's made it really difficult
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  for payers certainly, I imagine providers too to
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  make effective decisions and to be able to
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  stand by those strategic decisions and see through
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  kind of the long arcs of implementation
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  and change
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  that often come with really established systems.
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  And I think just the the amount of
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  difference and some some amount of even chaos.
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  Right? If you even look at kind of,
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  the number of, debates and shutdowns that the
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  federal government has had around,
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  certain types of funding makes it really difficult
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  for those changes to be implemented in strategic
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  ways. And so I think at the very
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  least some amount of,
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  you know, kind of clarity and stability in
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  regulation, I think is actually going to be
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  the biggest and most important driver in the
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  health care space. At the same time, I
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  would be remiss if I didn't mention the
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  fact that, like, the speed of review and
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  approval around new health care solutions
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  does make it harder to bring new innovations
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  to the table. And so I do think
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  that there's also certain types of regulations that
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  I would love to see around, you know,
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  how we can very quickly understand and measure,
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  whether or not these new innovations work. And
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  if they are working, bring them to market
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  more quickly. So I do think that there's
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  opportunity there as well.
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  What what do you think is is maybe
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  one big step that that needs to be
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  taken to work towards that clarity and stabilization
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  you were talking about?
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  Oh, you know, honestly, I think that's outside
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  of my pay grade, right, in the sense
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  of I think that there's a lot of
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  dynamics right now in the health, sorry, in
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  the American political landscape
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  Sure. That are incredibly polarized,
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  that I think are at the root of
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  a lot of this. Right? But at the
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  very least, you know, having ways of thinking
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  through longer term budgeting processes, ideally trying to
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  have folks who are working,
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  across the aisle more effectively to come up
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  with a situation in which we're not kind
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  of so polarized in what we expect generally
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  and in health care policy. And, therefore, depending
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  on who is in power, we're swinging pretty
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  rapidly between those two pieces.
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  Yeah. Absolutely. I mean, there's there's there's so
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  many different things going on. It's hard to
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  anticipate, so you kinda just have to be
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  able to pivot and and, you know, have
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  an awareness there of what you can do
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  differently.
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  I think that's a great point. Yeah. And
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  there's conflict right now even between federal governments
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  and state governments. Right? And so I think
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  that's just oh, and and to be clear.
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  Right? Like, I I think that that is
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  it's just difficult for us to plan around
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  and manage.
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  I think that there are lots of opportunities
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  for us to build and be successful,
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  but it is hard when you have such
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  large organizations to pivot as quickly as our
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  regulation is changing. Of course. I think everyone
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  a lot of people can identify with that
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  a 100%.
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  And, Emily, what issue do you think is
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  putting the most pressure on health plan margins
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  right now,
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  and
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  how are you responding differently to that in
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  2026?
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  Yeah. Absolutely. I mean, from our perspective, the
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  rising cost of care is by far the
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  biggest pressure for us. Right?
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  There are so many different things that are
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  actually driving that. There's chronic conditions. There's specialty
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  pharmaceuticals. There's rising diagnoses of things around behavioral
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  health, etcetera. Right? There's there's so many different
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  pieces that are driving that rising cost of
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  care. But I think that that is and
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  has been one of the biggest pressures for
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  us.
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  To be honest, I'm not sure that we're
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  changing something super
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  large in 2026 as much as we're continuing
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  to accelerate that work. Right? We've always been
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  in a space where we are trying to
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  quantify,
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  you know, where our costs rising and where
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  our costs rising significantly more than outcomes are
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  benefiting for our members,
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  and then figure out solutions that we can
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  find that will actually improve the ROI on
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  that care. Right? So improve the outcomes that
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  our members are experiencing while ideally decreasing the
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  cost,
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  of those outcomes.
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  I think that that work has been true
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  for the last five years since I've been
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  part of this organization.
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  At the same time, I also think that,
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  like, this is something that we are continuing
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  to hire more folks and accelerate of, like,
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  how can we continue to drive better and
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  better, data analysis on what we need to
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  target. And then how do we get even
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  more creative about the different steps that we
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  can take to solve those problems. And both
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  thinking about solutions internally of, you know, where
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  can we
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  reach out with a care manager or have
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  a different, data flow or have a different
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  alert for someone. Right?
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  And also the external side of, you know,
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  are there solutions that are moving the needle
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  here?
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  And can we bring those into part of
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  that, you know, workflow for us? And so
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  I think fundamentally just continuing to try to
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  figure out how we can manage those rising
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  cost of care is a top priority for
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  us in 2026
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  or the top priority in 2026.
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  Well, Emily, thank you for joining us on
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  a podcast and for a great conversation. We're
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  look we're really looking forward to having you
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  speak at our spring payer issues roundtable. So
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  thanks so much. Awesome. Thank you so much,
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  Scott, for having me.