Speaker 0: This is where health insurance leadership comes together. Becker's fourth annual spring payer issues roundtable brings together over 400 payer and health plan executives and more than 100 speakers to Chicago April. This year's event includes keynote conversations with the industry's top leaders and former president George w Bush. For the full agenda and event details, visit beckershospitalreview.com and click on the events tab in the upper right. We're looking forward to hosting you here in Chicago.

Speaker 1: Hello, everyone, and welcome to Becker's Healthcare podcast. I'm Scott King. Thrilled today to be joined by a very special guest, Dawn Maroney, president, Alignment Health and CEO of Alignment Health Plan. Dawn, how are you doing? Thanks so much for joining us.

Appreciate it.

Speaker 2: I'm doing wonderful. Thank you for asking.

Speaker 1: Of course. No. So great to have you. We're gonna dive into a lot of big payer topics that that I know we're gonna lean on your your expertise for. But before we do that, I was wondering if you could please just kinda share a little bit about your background and your journey in in health care with health plans.

Speaker 2: Well, thank you for asking. I actually have been with Alignment going on twelve years and, you know, lead the health plan for all of our contracts and, the company for other, areas. And, I've been in the Medicare space for going on thirty gosh, it'll be thirty nine well, thirty eight years. I'll I'll give it that that number. And I just have always loved working with seniors.

I've worked for larger companies and a couple of smaller companies. In fact, the smaller company that when we first originally started out to kind of grow it was a company called CareMore. And, you know, so either way, you know, we've tried to do something unique here at Alignment, and we've just, have done exceptional and very excited about seeing how alignment is just blooming, to be able to support as many, seniors in the country as possible.

Speaker 1: That's great to hear, Don. And not just about all your experience, you know, twelve years, I'm sure you've seen a lot and and a lot of things evolve. But, you know, with seniors, it's just to follow that up, it's it's really interesting that, you know, at our conferences, especially, you hear about I guess people are surprised how much seniors are able to adapt to, like, technology. Have you found that too? Just kind of being able to do things with with their accounts and their own plans digitally?

Speaker 2: Yeah. Yes. I you know, it's it's interesting. Although it is improving. So I've seen a big difference,

Speaker 1: in the

Speaker 2: last several years. Prior, it was much more difficult. And and the other piece is, you know, you know, this audience, you know, they don't trust the system and there's so much fraud or spam or other things that are going around. So they're very wise in the sense of, you know, what do I click on, what do I use. And so there's a lot of, extra effort to make sure that they know if we're doing something digitally as an organization or asking them to utilize technology more to to go through the process and educating them on why they can trust us.

Speaker 1: Absolutely. And, you know, one of the topics I wanted to get your expertise on, Don, was just that payer provider relationship and how it obviously changes and especially changed lately. But how are how are you seeing that relationship change as both sides face cost pressure and and workforce shortages in particular?

Speaker 2: Well, what's interesting to me I mean, depending on the areas, you know, the payer can be a number of areas. Right? So it can be the provider well, the health care company, the health insurance company, as well as you can even look at original Medicare as the payer. So you got Medicare Advantage, the original payer. You've got, you know, primarily in the insurance, organizations.

And then you've got the provider, system, which we play literally both sides in the sense of how do you support the provider through our clinicians who work for us. But the providers, you know, are, you know, the ones that are closest to the individual on providing actual care. That is, primary care specialist, hospital, post acute facility, SNF, home health, ancillary service, a number of things. So the hybrid between both, there's a lot of changes from a regulatory standpoint going on. And it's it's it's really, you know, it becomes challenging, you know, for both sides.

But I believe the payer actually gets, you know, kind of more, immediacy tied to what's going to change or more involved in the policy, than you'll see even on the provider side other than the providers, or the hospital systems that you'll see across the board.

Speaker 1: Right. Where do you see the biggest gap today between payer strategy and operational execution?

Speaker 2: Well, it's it's data. And so how do you make sure that you're getting data real time, specifically, no matter who's, you know, who's involved in caring for your members and or your patients? And it can't just be claims based data. So, you know, the more you know about a consumer or a patient, the more you can be proactive in integrating care. And so it's not at the level that you're getting it as close as possible.

So we really work hard at alignment through our technology platform is to try to get that data sooner than later, whether it's lab, pharma, or a hospital, you know, even the census primarily from directly from CMS. So, you know, it's just a it's, you know, it's a process. But it, the closer you can get to that data to understand, individuals about that individuals, you can actually be better at providing care and more in a timely and accessible way that this consumer really deserves.

Speaker 1: What do you think some of the hang ups are? And, you know, people talk about clean data. What do you think some of the hang ups are in getting clean data and having it, you know, readily available like you were saying? I mean, it's, you know, 2026 and with with all the emerging technology we've seen in in health care and with health plans, what what do you think the issue is there?

Speaker 2: You still see the same things. You know, I mean, it would be great to get to a point where you can actually pay a claim, you know, immediately at the the time of service, specifically, to where it's super clean. But you're you need to integrate more. But we're still using we're still pulling out our cards when we're going into doctor's offices. Right.

Even though you're filling out a form electronically or you're doing it through a chart, you know, portal, you're doing all the information, uploading, scanning, whatever you need to do, but you're still showing up to the practice and you're still pulling out that card and your ID and, you know, it and even if there's a barcode or you know, it's it's it's still not at the level that it needs to be. So having that ingestion of data where everybody's aligned, to make sure that we're all working together to share that information as much as possible. I think what you will see, Scott, with this administration is you're gonna see probably more forward looking, opportunities because we've got a pretty sophisticated educated, group. And what I mean educated through the like, the value of technology with our current administration. I'm quite impressed.

And I think if there's gonna be movement, you know, to similar to what we're doing here at alignment, we're gonna see that, at, CMS trying to push and drive that with this team.

Speaker 1: If you could change one regulatory or industry practice tomorrow to improve affordability and access, what would it be and why?

Speaker 2: Well, immediately, I would make sure if a hospital system accepts Medicare today in a fee for service or original Medicare status, Medicare sub not supplemental insurance, but Medicare, then I would make that hospital available even at the same rates as Medicare is paying, 100% of Medicare if you don't have a contract, have a requirement that that hospital would need to be contracted with a Medicare Advantage plan or frankly, any participating Medicare Advantage or Medicare, program. And I think that policy needs to drive that. This would would push more organizations to be in rural areas where, you know, local, state, or government officials as well as at the federal level would like to see us. But you can't get there without that hospital saying, no. I don't wanna contract with you, or I wanna charge a 150 or maybe even 200% of Medicare, some crazy number where it prevents organizations from contracting.

Speaker 1: And then the last thing I wanna ask you, Dawn. What issue do you think is putting the most pressure on health plan margins right now, and and how are you responding differently in in 2026 so far with it?

Speaker 2: It's a great question on, margins. You know, there's a lot of changes. There's a lot of headwinds coming in, hitting the industry as a whole provider and, insurer. And, you know, and it's as well as, you know, the cost continue to increase when it comes to health care expenses, especially in the, when when you think of the acute or institutional cost. And it's not going away.

And as well as if you think of the, inflation reduction act as tied to pharma, you know, these costs, the the liabilities hitting more on the payer side, specifically. So you've gotta really you gotta do it right, and you gotta have discipline. And it can't be just looking at it, three months ago or six months back. You have to have discipline in this business to prepare for the regulatory environment as well as the discipline when it comes to how you manage care. And for alignment, you know, because we're really you know, we're one of few plans, that are focused primarily on seniors, but let alone, we have a very rigorous discipline on how we look at this business.

And we know we still need to improve, but it's helped us when these headwinds have come to be able to to kind of, you know, surpass the storm unlike, what we're seeing of others. But I want our other competitive partners out there to succeed because, you know, we still need competition. Competition is extremely important for this consumer. I want these, members or seniors who are eligible for these types of products to have choice. And you need to have a couple of plans, more than a couple plans, usually in a county, to have where you're kind of pushing and forcing each of those plans to perform.

Because if you only have one org one plan, there's nothing there to force that plan to perform. And so it's really, really important that we still have competition and we have performance across these organizations. But if they're gonna be in it, they're gonna have to do Medicare Advantage done right.

Speaker 1: Dawn, thank you so much for a great conversation and for joining the podcast. We're really looking forward to having you speak with us at the Spring Payor Issues Roundtable as well. But, thank you so much, Dawn.

Speaker 2: You're welcome.

Speaker 1: Thank you.