Latest / Becker’s Healthcare Podcast / Simplifying Payer Operations and Strengthening Provider Relationships

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Simplifying Payer Operations and Strengthening Provider Relationships · Becker’s Healthcare Podcast

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  This is where health care leadership comes together.
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  Becker's sixteenth annual meeting brings more than 3,500
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  hospital and health system executives and nearly 800
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  speakers to Chicago April.
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  This series event includes keynote conversations with Dallas
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  Cowboys legend Troy Aikman and former president George
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  W. Bush. For the 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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  in Chicago.
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  Hello, everyone, and welcome to Becker's Healthcare podcast.
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  I'm Scott King. Thrilled today to be joined
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  by a very special guest, Sharon Williams, chief
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  executive officer of University of Michigan Health Plan,
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  who also is a consultant to payers and
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  providers. Sharon, how are you today? Thanks so
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  much for joining us. Hey, Scott. Thanks for
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  having me, and I'm doing fabulous.
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  Excellent. Yeah. We have a lot of, you
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  know, big health plan topics and and questions
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  for you to get to. But before we
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  dive in there, I just wondering if you
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  could please share a little bit about your
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  background and your career journey.
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  Thanks, Scott. You know, I I've been in
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  healthcare industry about thirty years
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  and, you know, I started off my career
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  with the blues and worked with with a
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  number of health plans and then became a
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  consultant
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  where, I worked with both payers and providers
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  and even state and federal governments.
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  And I'm currently advising digital health companies. So
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  I feel like I've touched almost every facet,
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  of the health care industry in The US.
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  Yeah. Absolutely. That really ties into our our
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  first question, your experience does, Sharon, as you've
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  dealt on kind of both sides. How are
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  your relationships with providers changing
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  as both sides face cost pressure and workforce
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  shortages?
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  So, Skye, that's that's a great question. And,
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  you know,
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  for the University of Michigan specifically, we really
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  pride ourselves on being very member
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  and provider focused.
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  And so, while we're going through,
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  some early tough times, we're making it a
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  point to over communicate with our providers, be
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  proactive.
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  If there's certain things that are happening, we're
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  not just sending out emails
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  or broadcast. We're calling to speak with office
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  managers.
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  We're intensifying
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  the quality of the conversation we're having with
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  some of our large health systems throughout the
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  state.
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  But I can also just share with you
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  having seen both sides,
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  being
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  a payer and a provider.
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  Some of these conversations can get a little
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  contentious.
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  And, we're working specifically,
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  to keep it civil,
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  keep it respectful,
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  and understand,
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  you know, that big beautiful bill and our
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  workforce shortages
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  are challenging for, for both sides. And it's,
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  it's difficult to find quality people,
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  but we know that,
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  our health systems
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  and our providers do not work for free.
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  Everybody,
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  has to really cover their expenses.
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  So it's really having quality conversations. And I
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  would just also say the other thing we're
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  seeing is a lot of creativity.
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  So are there other paths,
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  to
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  professionalism
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  to address those workforce shortages?
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  And I can see that, you know, as
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  a board member for a mental health organization
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  I work for,
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  or they're actually training.
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  They have their own internships and their own
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  fellowships
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  within their organization
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  to help build, a better pipeline for candidates.
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  So, yep, while there's cost pressures and workforce
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  shortages,
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  it's pushing a level of creativity that I
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  think is unparalleled.
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  I I think it's a great perspective to
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  have share, especially with everything going on in
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  in health care now to, you know, kind
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  of zero in on being professional and and
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  that mutual respect. You know, I as the
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  old saying goes, you catch more flies with
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  honey. So I I I think that's fantastic.
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  And where do you see the biggest gap
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  today between payer strategy
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  and operational execution?
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  Yeah. So one of my tags in in
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  my consulting practice is executing value,
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  because, you know, a lot of the payer
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  strategy is still pretty manual.
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  My god. Do we love a spreadsheet and
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  a fax machine?
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  And and so,
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  you know, when I talk to people,
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  who are in tech or in banking,
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  they continue to be surprised by how manual,
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  our operational
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  execution is in health care.
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  We are lagging behind
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  many other industries, and there's
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  extraordinary
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  opportunity. And I and I know the buzzword
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  is AI. Right? So it's like, how long
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  did I go before I mentioned AI? But
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  we are an industry in needed AI. And
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  so while there are some sophisticated
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  players who are using AI tools,
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  especially in the rev cycle area,
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  specifically in pair strategy,
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  there there are so much data,
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  at our disposal,
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  but we don't have the right tools to
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  really be able, to execute on that. And
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  I think the other things that are really
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  simple and I call it being brilliant at
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  the basics,
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  but our contracting,
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  sometimes our contracting is over overly complicated,
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  and it doesn't need to be that complicated.
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  So while the payer strategy
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  may be, you know, we need to keep
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  our,
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  contracts at a particular percent,
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  of payment within a specific market.
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  The ability to do that and to be
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  able to execute more value based contracts,
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  is a lot more complicated,
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  than we've actually been able to deliver on.
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  I wanna ask you, what do you think
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  one investment or initiative you believe will most
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  reshape,
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  how health plans operate, you know, over the
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  next two to three years? And does that
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  have to do with AI? Is there is
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  there a way AI can better serve in
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  the payer space? Yeah. I feel like so,
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  Scott, you know, I listen to Becker's payer,
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  podcast
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  That's great. When I'm when I'm brushing my
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  teeth every morning. So
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  so I, you know, I think one thing
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  everybody's talked about, the role AI is gonna
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  play. Right?
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  Right. AI will not be effective
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  unless we improve our processes,
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  and we need to simplify.
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  So while we're investing in AI
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  and, a lot of the tools that are
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  out there, they can't be single solutions. We
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  really need to think about end to end.
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  And the consumers we need to think about
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  most,
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  in this conversation
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  are are the providers
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  and the members and how we can make
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  it, more simple for them.
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  So there are AI tools that are now,
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  really taking the consumer into account.
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  And whether it's,
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  creating,
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  interoperability
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  among the hospital,
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  post acute home health,
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  in the case of, like, dementia, some of
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  our seniors,
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  bringing the families in. And there are some
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  wonderful AI tools
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  that are,
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  giving all all stakeholders
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  access to the same data. So that's creating
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  transparency.
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  It's creating levels of accountability
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  and communication.
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  That's really exciting. So I think that's,
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  part of the investment that needs to happen.
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  And
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  both payers and providers need to look at
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  their processes
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  to see, you know, are we being a
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  little pedantic here or can we get rid
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  of some of the sludge that's in the
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  system that we really,
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  don't need?
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  So, Sharon, do you think the best way
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  to kind of simplify those processes on both
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  sides is just to kind of
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  focus in on what consumers need most or
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  what patients need the most. Is that the
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  way to kinda streamline everything? Yes, Scott. But
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  I I wanna be careful as we say
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  that because I I think it's spot on.
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  But everybody gives lip service to that. Yeah.
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  Right? So if we really cared about
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  our patients
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  and our members,
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  would our deductibles be that high?
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  Would we have coinsurance?
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  Would we have,
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  ChargeMaster?
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  Consumers don't understand this stuff. So if we're
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  talking about transparency on one end,
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  but we have
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  payment tools and pricing tools that nobody understands
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  or you've gotta have a PhD in economics
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  to understand,
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  then we're really not being consumer friendly.
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  Yeah. Absolutely.
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  Let me ask you this, Sharon. If you
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  could change
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  one regulatory or industry practice tomorrow
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  to improve affordability and access,
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  what would it be and why?
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  Okay. Scott, I'm gonna ask you if I
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  can have two.
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  Jeez. That's a
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  Okay.
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  So the first is is regulatory.
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  In this country, we really need
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  universal health care, cradle to grave coverage.
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  I'm not saying single payer. I wanna be
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  really clear. Single payer is is a dream.
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  We don't have the infrastructure for it, but
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  we can do,
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  universal, whether you call it Medicare for all,
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  whether you call it, Susie, I don't care.
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  We need cradle to grave. What I'm seeing,
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  is people coming on and off insurance, whether
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  because they lost their job, whether it's because
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  they're in the gig economy.
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  And what they're doing is they're trying to
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  figure out, can I pay rent? Can I
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  pay for food? Or can I pay for
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  health insurance? And what I'm literally seeing is
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  people who become effective with their insurance, let's
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  call it January 1,
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  Then January 3, they have major surgery,
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  scheduled.
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  And so what was this person doing,
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  at this time? And then when you look
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  at Medicare, people who become Medicare eligible
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  at 65 and they are chronically ill and
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  they need a host of services
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  as soon as they come on, to Medicare.
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  So we really need to address insurance coverage
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  because
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  insurance coverage is becoming
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  reflective of of the health of our org
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  of our country.
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  And right now, Americans are sick, and we're
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  seeing it in utilization,
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  across all products.
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  So that's that's one regulatory change.
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  The other industry practice,
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  that I would get rid of,
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  for the most part, are prior authorizations.
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  They're sludged.
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  They create,
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  a level of of animosity between both payers
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  and providers, and I would throw in consumers
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  too.
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  And what I would love to see is
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  more kind of retroactive work being done,
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  conversations around quality and outcomes that aren't punitive,
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  because what prior authorizations have come to represent
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  is the sludge in the system
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  in a form of cash flow management.
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  And I have a number of friends who
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  hate me when I say this,
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  but I wanna plant those seeds.
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  And and if maybe a third is getting
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  rid of, like, the high deductibles,
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  the coinsurance.
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  Again, tools that consumers,
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  don't understand that also become another tax
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  to our providers in the system and really
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  just trying to simplify things. That's gonna be
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  my mantra,
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  from both a payer and a provider perspective
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  going forward.
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  Let's get back to simplicity,
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  and let's make, health insurance tools that are
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  more consumer friendly.
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  But I know there'd be a lot of
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  there is a lot of payer leaders who
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  share your sentiments there, especially with prior authorization.
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  I I I remember some people talking about
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  it at length at our our November
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  conference.
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  In your mind, Sharon, what are what are
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  the issues
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  standing in a way of either
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  improving it or or doing away with it?
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  Well, politics,
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  first,
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  and we are the land of steady habits.
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  Right? So people have gotten used to
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  prior authorizations. And then the just the logic
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  around it, we've convinced ourselves
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  that we are somehow
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  adding value. But if you look at most
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  organizations,
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  the net net, and I'm not talking about
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  the initial prior authorization, but once you get
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  done,
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  looking at medical documentation,
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  peer review,
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  the the the net of actual,
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  denied care is somewhere between two to five
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  percent.
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  So,
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  I I think we need to address,
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  the the culture change, change management,
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  and have conversations around that.
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  And I love what one of our health
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  plan leaders, says,
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  the CEO of SCAN. He talks about the
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  need for leadership,
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  and people being more brave and outspoken.
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  And I think he's absolutely right.
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  And I like to consider myself a change
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  agent and liking to work with people who
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  are mission driven and want to improve,
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  The US healthcare system.
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  Certainly. Right leadership can always make the, the
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  biggest change and the, and the necessary change.
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  Last question I wanna ask you, Sharon,
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  what issue is putting the most pressure on
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  health plan margins right now,
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  and how will you respond differently to that
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  in 2026?
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  Yeah. So it's utilization trend.
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  And it's it's,
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  not just the GLP ones in drugs.
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  It's it's utilization just across the board, across
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  all products.
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  And,
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  you know, what we can do is is
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  try to
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  create cost effective insurance that
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  patients are attracted to.
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  And we try to do that, at the
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  university of Michigan. You know, this, this last
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  year, we were the lowest priced,
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  cost product, especially in ACA.
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  The other, that that's putting pressure on health
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  plans
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  is is our drug pricing.
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  Again, it's not unique to to Michigan. It's
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  a US
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  thing where The United States is subsidizing drug
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  and pharmacy costs,
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  for the world.
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  And we need to a drop
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  adopt,
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  global pricing.
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  And, again, I'm I'm seeing AI tools out
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  there. I'm actually working with,
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  a a consultant right now, and he has
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  a pharmacy pricing tool that looks at global
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  pricing for each drug
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  and can come up with the best price,
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  whether it's in Israel, Switzerland,
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  Canada.
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  And we need to start using these global
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  pricing tools
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  to drive the price of of drugs down.
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  Sharon, thank you so much for joining us
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  on the podcast and sharing all your, you
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  know, incredible thoughts with great perspective. Really appreciate
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  your time, and I look forward to working
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  with you again soon. Thanks, Scott, and we'll
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  see you in April.