Hi, everyone. This is Erica Spicer Mason with
Becker's Healthcare. Thank you all so much for
tuning into the Becker's Healthcare podcast series. So
today we're going to talk about how innovative
tech can connect payers, providers, and patients to
improve outcomes and quality.
And joining me for this conversation are two
leaders from Veradigm.
We have with us Courtney Yackel, Chief Product
Officer, and Michael Moore, Chief Revenue Officer. Courtney
and Michael, welcome to the podcast.
Thank you. Thank you. We're so glad to
have you both with us. But before we
get into the questions, I wanted to see
if you'd like to share just a little
bit more about yourselves, your organization, whatever feels
top of mind. Absolutely. Thank you so much,
Erica.
So I'm Courtney Yackel, chief product officer with
Veradigm, and I started out my healthcare journey
on the payer health plan side of the
house,
for about ten years. So everything from risk
adjustment, quality analytics, strategic business unit,
primarily focused on government programs. So whether that
be Medicare advantage,
Affordable Care Act, or the state specific Medicaid
lines of business. So again, everything from analytics
and financial reporting,
to the lovely data submissions, and then of
course, keeping up with the multiple CMS regulatory,
guidance that, we all know and love. Yeah.
You know payers inside and out. Absolutely. And
then jumped over, to start up mode and
have been, a part of the Veradigm family
for about ten years now. So very much
looking forward to the payer issues roundtable this
week along my esteemed colleague here, Michael.
So hi, everyone. This is Michael Moore. I
am, the chief revenue officer for Veradigm Payer.
And we were talking last night and getting
ready for this that I can't believe it's
been thirty five years since,
I got into the,
technology space and and health plans and,
providers. So I've spent a career
working in health care technology, helping
get to that triple aim
and connecting
providers
and
payers so that we have the outcomes that
we all seek, and that's healthier patients. So
we're really glad to be here. This has
been a great conference so far. See a
lot of old colleagues and,
new people getting into the industry, and we're
just really excited to be a part of
this podcast.
Oh, I'm thrilled to have you both on
the podcast with us today, and I love
that we're addressing
what's going to benefit both payers and providers.
You know, so often the conversation is kind
of siloed, who's doing what, but I appreciate
that this we have this perspective on the
line of, alright, how are these groups working
together to get the patient outcomes and quality
outcomes that they wanna see.
So as payer and provider partnerships evolve and
we are seeing a more kind of conscious
effort among these entities to collaborate and work
together,
what strategies have you both seen successfully reduce
administrative complexity,
especially
doing so while being able to improve patient
outcomes. Can you share us through any examples
of that?
Certainly. Thank you. It's
it's really interesting when you look at,
how these organizations, provider organizations and payer organizations,
addressing the market and creating their strategies. Number
one, you should keep in mind that
all the government sponsored programs, these are the
Affordable Care Act or Edge,
Medicaid, and Medicare Advantage,
are all becoming more and more complex.
They are all focused on how to document
your achievements
as a provider or as a payer. And
so our our first focus from a strategy
standpoint is that
an early adopter
needs to
learn
what their organization needs to be compliant with
the government as a payer or a provider
for quality initiatives, etcetera. So they have to
learn and be educated, educate themselves,
and, they have to, number two, talk with
their
payer organizations. They have to understand
what that payer organization is trying to accomplish,
and then they have to
execute. They have to get involved with that
payer and collaborate with that payer.
For a long time, there's always been
a certain amount of animosity or adversity between
payers and providers,
and
both parties should understand that we are here
to solve both of their problems. And
not engaging and not collaborating
is just going to extend the problems further.
Well signed, Michael.
I think in terms of leveraging technology, so
both Michael and I have been in the
the health plan payer space for quite a
long time. And working together at Veradigm, we're
able to capitalize upon the technology,
components from the large and growing provider network.
So when you bring together some of those
those objectives
that both payers and providers are diligently working
to strive to solve for, there's a couple
of of key themes that you see fragmented
data, right, in terms of how they interpret
the data. Michael talks about establishing that dialogue
together. Well, at first, we need to make
sure that we're speaking the same language
in terms of any datasets that we're looking
at, benchmark reporting, financial reporting. The ways that
payers are reimbursed is completely different than how
our physicians are reimbursed. However,
we are all striving to move towards more
value based care arrangements, and that's really where
you bring in the beauty of both risk
adjustment and quality initiatives,
leveraging that technology. So if you think about
analytics,
making sure that you're able to,
have that trustworthy
dataset
at the point of care so that physicians
are able to take action upon those.
We're seeing it through this calendar year 2026
regulatory guidance that was just released this month
that is jam packed with some regulatory changes
that are up and coming for this next
year, very much focused on capitalizing
both risk adjustment and quality initiatives
that are impacting both payers
and providers.
At the end of the day, it's all
in how we establish that trusting relationship
that will ultimately benefit the health outcomes for
the member or the patient. Yeah. Such a
helpful overview. Thank you both for really painting
the the picture for our listeners.
And I know you had just mentioned,
risk adjustment
home assessments,
tech driven strategies. So from your perspectives, how
is that space evolving, and where is technology
making the biggest difference right now?
That's a perfect segue.
We see that,
risk adjustment and quality are becoming the same.
Risk adjustment
from, its
traditional retrospective view will always be around from
a a way to get paid properly for
the risks that are in your patient population,
getting the proper premium for bearing those risks
as a health plan or an ACO.
Likewise, though, shifting
from a retrospective
view to a prospective view will be a
bigger
ROI
on the investment in
the outcomes that you're gonna measure from a
performance standpoint
and from a client's health, both the quality
of the care that they receive through metrics
for things like HEDIS,
but also from the outcomes are, do we
have a healthier and happier patient population?
Another example of
quality and risk adjustment
commingling for the future
is the use of in home assessments.
In home assessments are sending a qualified caregiver
to a person's home.
And, traditionally, it has been
very, very expensive
to, in a rural situation, send
a nurse practitioner or a doctor to someone's
home
for an annual wellness exam or for just
an encounter. And so virtual care took
the place of that for a few years.
What we have seen the best value come
out of IHAs
is the gathering of social determinants of health
data. When you're in a person's home, you
can see that there are food insecurities
or there are travel insecurities or there's medication
rationing that's going on. These are all direct
drivers
of people's access to care that directly affects
the outcomes.
We've also seen
that when surveyed,
close to eighty percent of patients
don't want
a caregiver coming into their home. So you've
got this
dramatic need
to address
patients who aren't getting care due to access
issues,
at the same time not wanting
a caregiver in their home
out of
fear or embarrassment
or whatever the case might be. So
we see IHAs as valuable,
but
the expense of them has to be driven
toward quality
and the values that you get out of
quality results than you do necessarily for care.
Yeah. And if you don't mind, could I
just ask you a really quick follow-up question,
Michael? You mentioned how risk adjustment and quality
are kind of becoming
one in the same.
So how would you encourage organizations to really
be viewing
quality and risk adjustment as part of their
strategic objectives? Do you recommend any shifts there?
Well, the the biggest shift will be to
focus on the patient, and and that's
it shouldn't be a shift, really. Everybody should
always be focused on the patient.
But from a documentation
process, these government programs
are
now requiring documentation
to justify
and,
clearly report
on the production that these programs have. In
the past, we've seen a number of value
based care contracts.
While their their intent was to incent a
provider organization for a certain performance,
we've not seen them
managed
in the way that they need to to
clearly document the encounters and the successes that
you have and also the the the lack
of success.
Quality thus then becomes
an outcome of patient care and measured across
those, we're we're going to see an extension
and a broadening of the ways that we
measure quality
and,
not only to include
patient preferences or the happiness of the patient,
but the sheer outcomes of the diagnoses
and,
service codes that we document in the encounter.
So interesting. And I I know, Courtney, you've
been in the payer space a long time
too. So what would you add? Anything?
I would add that bringing together both risk
adjustment and quality really fosters that
sense of accountability
for both health plan payers and the physicians
because, ultimately, they have the same objective,
having the the member patient right at the
center of care from a health plan perspective.
Right? They want to make sure that they
are able to
retain the member and offering extremely rich benefits
that will allow the the member to live
that healthy independent
life.
Same goes for a physician. Right? That is
their ultimate goal. If you if you take
out all of the crazy
acronyms of health care, ultimately,
the care of the patient is where health
plan payers and physicians come together, which is
the beauty of why we all get out
of bed each day and and do this.
However, it's extremely challenging,
But bringing together
high stakes,
functions across risk adjustment and quality, and Michael
and I see this every day. And I
can say this because I've been sitting in
the health plan shoes. Right? Ensuring that you
were you're talking and having those conversations in
terms of your objectives and your strategies,
not only from a a patient centric mode,
but in terms of what types of vendor
partnerships or what types of technology or datasets
that you're utilizing
to achieve both the objectives for risk and
quality. Again,
with that that total health, care outcome in
mind. Yeah. Oh, fantastic. And, Courtney, I know
you mentioned a bit earlier in the discussion
too that technology is a really big part
of the trans transformation of getting payers and
providers to work collaboratively, get the shared outcomes
and aims that they have.
And AI is gaining momentum in the payer
and provider operational space. So
over the next year or so, what are,
what are you seeing as realistic use cases
where
they will see measurable impact? That's something our
our listeners are always wanting to know, or
even an area where you're seeing strong potential.
Would you mind just elaborating a bit on
your thoughts there? Sure. Absolutely. Happy to. There's
so much going on in the AI space
at this time. I will talk about a
lot of the exciting things, and then I'll
pass it over to Michael who will talk
about the incredibly important pieces around data governance.
However, what we are seeing right now in
terms of the immediate impact is we we've
talked a little bit about bringing those gaps
in care
at the point of care, whether they be
for risk adjustment or quality. But how do
we ultimately ensure that the documentation
is complete, accurate, and timely,
both from a physician education perspective. Right? We
wanna make sure that we're not overburdening the
physicians.
We're not contributing to that fatigue. We wanna
make it seamless and simple for them in
terms of presenting those gaps in care. One
piece of that in terms of leveraging the
technology is natural language processing, so our NLP,
and certainly our machine learning. We have access
to an incredible depth of data,
And how we use that is extremely important,
whether we're utilizing
case and disease registry data for predictive analytics.
Right? It's establishing
the the grounds of trust and transparency. Again,
bridging that conversation between a health plan payer
and a physician in terms of how did
you determine these particular gaps in care. Right?
What datasets did you utilize? And AI is
a great,
asset
for health plans and physicians to leverage in
that in those means.
So
Veradigm,
has been involved in artificial intelligence and machine
learning and natural language processing and other
application of early stage AI,
for quite some time. Through the process
of of these technologies,
we have created
an artificial intelligence center of excellence at our
company that brings in
broad disciplines of people from functional areas of
a health plan and a provider organization
to look at applications,
for leveraging
AI.
What we're immediately
drawn to are the responsibilities
that go with managing this kind of data
and these types of tools. And so we
have established,
and continue to establish a level of governance
around usage of this information, distribution of the
information
in
our provider,
segment, in our life sciences segment, and in
our payer segment.
And we will continue to see that evolve,
and it's a little bit of a a
an oxymoron of of governance because right now,
there's just very little governance in the AI
world. And so,
we are treading
cautiously
but very optimistically
at using our current capabilities and looking at
new capabilities for the functional areas we just,
we just talked about. But
it it's more than that.
We are we are applying
artificial intelligence to the way we do business
to assist,
physicians
and health plans in improving
their time
or improving their engagement.
To particularly illustrate an example is we have
the ability for providers
to speak
into a microphone and us ambiance scribe their
information
into a coding structure that automatically codes a,
a claim at the point of care,
vastly
facilitating
the documentation time that a provider may have.
Similarly, we have,
capabilities that can automate how a patient gets
scheduled for,
available appointments in a in a doctor's office.
If we know a patient is looking for
a doctor of this type and for this
type of treatment service, we can scan the
available providers and availability on their appointments and
automatically schedule those patients for those encounters,
dramatically improving the front office operation of a
physician office.
So we're using AI to address current functional
areas. And in the future, we hope to
be moving to
where
AI will provide us decision points.
And those decision points meaning
recommended,
diagnoses or recommending,
certain services
or recommending certain
follow-up visits based on treatment protocols. So
the world is wide open for AI, but
we have to proceed very cautiously
but optimistically
to address physician and payer problems.
Yeah. And that that cautious optimism, it really
comes through. Everything that you just outlined is
so exciting to think about that future state,
but having something like the center of excellence
that Veradigm has sounds essential for this for
this time when governance is at a minimum.
So well, thank you both so much. I've
so enjoyed this conversation.
Any final thoughts before we close?
Yes.
Every time we,
we get involved with a physician organization
or
a a payer organization, whether it's any type
of risk bearing ACO or,
subgroup of a payer,
the one thing we have recognized
is that,
our businesses
are still operating in silos.
And,
we still have people within our clients that
we are introducing to one another, that they
are
they are struggling to reach within their own
organizations
and collaborate
among themselves
and each other. And so one of our
biggest
efforts is to make sure that our
clients are dialoguing
within their own walls,
and that are,
whether they be a a provider or a
payer, that they are
educated on the decisions they're trying to make
and the options that are available to them.
And they only get that through a proper
dialogue,
between payers and providers.
Yeah. Such an important point. Courtney, any final
thoughts?
As you think about
bringing
and leveraging technology
and then, of course, the human component to
health care, I think now is an incredibly
exciting and invigorating and certainly an inspiring time,
especially as we sit here this week,
to put
these ideas, thoughts, business cases, the technology into
action. We have all of the pieces and
ready to rock and roll. The only thing
that's keeping us from doing that, right, is
that relationship between the payer and the provider.
And, again, because Veradigm is uniquely positioned in
that aspect and having the expansion
of provider network and then coupled with the
payer experience,
bringing those gaps at the point of care
to ultimately drive improved health outcomes is incredibly
meaningful
to our industry. And I just am so
thrilled to be a part of it.
Well, it's been great hearing from you both.
Such good thought leadership in this short amount
of time together. So thank you both so
much for making the time for Becker's. It
was great having you. Thank you. Thank you.
And we'd also like to thank our podcast
sponsor for today, Veradigm.
Listeners, be sure to tune into more podcasts
from Becker's by visiting our podcast page at
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