Hi, everyone. This is Brian Zimmerman with Becker's
HealthCare. For today's podcast,
I'm excited to be joined by Nirne Patel,
EVP and GM Benefits One, chief digital officer
for Simplify Healthcare.
Thank you so much for joining us today.
Thank you, Brian. Thank you for having having
having me here. Alright. Nunez, so let's get
started with a simple introduction. Why don't you
share a few details about your background and
the work you're doing? Yeah. Of course.
So I get excited at the intersection of
healthcare and technology.
I've been in healthcare space for about fifteen
years and then in in tech for pretty
much all of my career. At Simplify, we
are solving two problem areas,
benefits the problem of benefits management
from an end to end value proposition for
payers
and the problem of provider data management. So
these are the two areas we focus on,
and,
we have an incredible
set of capabilities and customers which,
solve these problems across different markets. So we
specialize in how do we solve this for
Medicare, Medicaid,
commercial, and all the markets, involved. Yeah. And
that that that data management challenge,
I'm sure can create some silos Yeah.
From from time to time. So I guess
from your point of view, how are payers
are doing this really well? How are they
breaking down operational silos between the insure between
insurance and and and care delivery?
Yeah. No. I think I think that's a
that's a great question.
You know, at at a at a very
macro level,
the way we see it is there are
two aspects of of care. There is there
is what I call it design of care,
and then there is delivery of care.
And I think,
where most successful payers and even paywiders, right,
are increasingly going towards is how can we
bridge that gap? Because at the end of
the day, the continuum of care for a
member,
would require
these two areas, right, to be highly integrated.
So for example, when you're designing the care,
you will be looking for what are some
of the shared risk models from a delivery
of care you would like to incentivize the
member.
So designing of the care would mean what
are your strategies with respect to your network,
are there vertical integration option if you are
taking shared risk and capitation models,
what kind of member experience you wanna deliver
before you onboard the member,
and what kind of personalization,
right, you want to deliver after you onboard
the members,
in particular,
during their their care delivery process.
So when we look at these silos, there
are common denominators. Right? Benefits is a common
denominator.
You would want to know when you're shopping
for your insurance plan, how much it's gonna
cost.
And you would want to know the same
question
when you're actually in the middle of a
care episode.
So benefit is one kind of data layer,
which we believe is a common denominator, which
kinda threads the needle between designing the care
and delivery of the care. The last thing
you want is to create a fragmented data
source for such an important layer, which is
where which is the problem we are trying
to solve.
We enable a source of truth for benefits
so that all different stakeholders from actuary
to product design development,
to your customer service, to your claims team,
to the to the care delivery providers who
need access to those benefits,
they all are essentially getting a consistent view
of benefits because it's sourced
from the same source of truth. So those
are some of the value propositions we bring
to the table. And, essentially, you kind of
break down the silos by building
an integrated layer across the continuum of care.
Yeah. And that that that tie in or
that bridge, so to speak, is that the
benefits
information
serve serving as, like, sort of that bridge,
like you said, between design of care, delivery
of care.
And, of course, you know, we're we're talking
about health care in 2025.
So I gotta ask you
what role sort of when doing that work
with with benefits,
and shaping that member experience as you put
it, what role is AI and analytics playing
in helping make this a connected experience
from, you know, benefit navigation to
the proactive care that that I believe,
you know, all of the the the idea
here is to get to a place like
that where there's more proactive care? Yeah. Yeah.
Yeah. Well, you know, we are in this
incredible wave of AI,
here at Becker's. Right? It's hard to even
walk 10 steps without not hearing AI. True.
Yep. So it's it's very exciting.
We we have taken
the mandate of applied AI
at on two fronts. The first one is
how can we
make
access to knowledge
easier? And that becomes more along the lines
of how can we personalize what's important
on the benefits level. So we recently launched,
an AI assistant
feature to benefits one platform. We call it
Benny, which is Benefits Native Intelligence. And, essentially,
the the mandate for Benny is
how can we make sure that,
you have access to all different kinds of
benefits information we house within our platform
almost in a natural language manner. So things
like, hey. I'm gonna go and about to
have a broken bone injury.
What it might cost me?
Now to answer that question, today, you may
be on the phone with a customer service
rep. Right? And and and and and you
will be dealing with calls or multiple,
checkpoints where you would try to get that
information.
Benny would make it easier because we would
source it directly from where the care was
designed again. So this is a perfect example
where the delivery of care and design of
care are kinda eating from the same bucket.
Mhmm. And that just allows,
that removes the human error. It removes the
silos. It it takes the friction and the
rate limiters away, and it gets you to
the source of information and the knowledge as
fast as possible, as natural as possible. So
that's one use case of AI where we
can deliver a lot more personalized
experience on the frontline,
by just limiting the distance from the source
of truth. Yeah. The second one will be
on more on the back office side where
you would want to do a lot more
automation.
So, for example, if you would want to
match your member benefits, right, with incoming data
sources, you would want to automate the end
to end workflows
using an agentic layer to to take care
of your back office functions.
As it comes to benefits and provider, those
are the areas which we are also looking
at. So you can you can you can
talk to Benny in future, right, and say,
hey. I would like to renew this plan
for next plan year.
Show me, right, what are some of the
plan recommendations I should be making as I
look into design of care for next year.
Now when you actually have that level of
sophistication, you will be able to create and
compile and design a plan. So your starting
point of taking that process is incredibly sophisticated,
and that would mean that you would save
a lot of time, cost, and you can
spend more time, right, designing the care versus
dealing with, a lot more manual processes which
exist today.
Yeah. When I when I come back to
sort of sort of Benny and thinking about
that that sort of, that sort of capability,
I think it's come up being on-site at
at Becker's Parachute's roundtable come up a lot.
Like, the the demand for such a tool
is high, and the need for it for
members is high.
When you think about
how complex insurance can be to to the
average member,
being able to cut through the noise, not
have to be on hold to have a
direct answer. I mean, are am I reading
that correctly just from the rooms I've been
in during the conference?
Yeah. Absolutely. You know, we we have multiple
solution options that simplify Benny. It essentially solves
the problem of,
exposing benefits information
to all all of the product
design, actuary, right, document management, compliance, a lot
of the stakeholders which we have. We also
have benefit inquiry solution, which empowers the day
in the life of a customer service and
the member.
So again, it's all the same source of
truth information.
The demand is high because,
as we both know, Brian, it's a it's
a team sport. The moment you are about
to embark upon an episode of care,
you are talking you're you're talking to at
least interact with anywhere between 18 to 25
people,
and that's the simplest form of care. Mhmm.
And as you are interacting
and as your as your care delivery needs
gets more complicated, you will just have more
stake
Right? You not only have doctors, but you
have to you have to schedule appointments. You
have to talk to insurance
companies on how much you are going to
pay for it. If you are prescribed, let's
say,
you know, pharmacy, now you have pharmacist. So
now you will go back to your formularies
and understand, hey. What what is this drug
type? Tier one, tier two, tier three. So,
again, this pendulum kinda keeps swinging between who
designed the care, which is more along the
lines of payers and who is delivering the
care, which is more on the providers and
pharmacy.
But as a member, I would be talking
to both of these because I'm trying to
take care of the episode of care, right,
for myself.
So we see an incredible demand here of
kind of bridging this gap because at the
end of the day, one common goal across
both of these entities is how can we
improve the life of a member and how
can we make sure that they are delivering
and meeting the outcomes, right, the healthy outcomes
we all intend for. Yeah. And and speaking
about that, I think what you just,
what you just shared kinda gets at this,
but to zero and even closer, but maybe
a a a finer point on it. What
are the most important moments that shape a
member's perception
of of the benefits they're getting of of
the value from their plan?
Yeah. I think,
it's it's almost like the perception of the
member is
so intertwined with the market or the
care access channel, which they're coming from. And
what I meant for
the moments that matter for a Medicare member
will be different
than a Medicaid member,
which will be different
from a commercial member. If you look at
Medicare
member,
for example,
every year they have an opportunity to shop.
Right.
And that would mean that,
every year
there is just an extremely hyper focus on
access to care,
experience
to care,
because you would want,
like, anywhere from onboarding and retaining
a member
all the way to making sure that, you
know, their care needs are met.
And a Medicare member in an urban Chicago
versus Medicare member in a rural Chicago, rural
Illinois. Right?
Could be very, very different need. Right? So,
so I think moments that matter for a
Medicare member would be
how good is your broker network system, which
can educate the member,
how aware you are with their current
care needs, and how accessible that care is.
And the problem for Medicaid would be completely
different. What are the social determinants? They are
much more amplified, right, for Medicaid.
Versus with commercial, you're talking about, hey, what
employer are we talking about? What kind of
benefits is that employer subscribed to?
So I think that the moments that matter
for the member are
onboarding and educating the member. I think that
is a common theme there across all markets.
Customer service becomes an important one, and then
access to care and provider experience becomes an
important one. So across all three markets, those
are the common denominators.
But there are so many nuances as you
can imagine. Onboarding a Medicare member would be
very, very different than onboarding a commercial member.
So the devil is really in the details.
You know, one may think that, yes, these
are the areas we want to improve and
kinda get more sophisticated on. But the playbook
for each one of these market is extremely
nuanced and different. And I think those are
the areas, right, which we essentially offer a
lot more value for our customers.
In considering everything we've we've we've talked about
so far, Nirneh,
what do you believe should be on the
top of the innovation
agenda this year for payers?
Yeah. I think,
I think it's it's really enabling
more integrated, connected journey for
the members
and and your internal stakeholders alike.
So,
personalization
of benefits,
which allows to meet
more competitive needs in the marketplace,
much more member facing needs in the marketplace,
partnerships with providers and different entities,
especially on value based and other shared risk
arrangement that kinda start shifting the the output
to the outcomes conversation.
So we're excited about that trend line. Mhmm.
But at a at a macro level,
we believe that the more bridging the silos
happen between design and the delivery of the
care, I think that's kind of the shared
space, right, where it's a win win win.
And when I say win win win, and
there are three stakeholders here, there's member, there
is
holders here, there's member,
there's peer, and provider. So how can we
get these three wins?
And it's really founded in how well we
can integrate
the delivery of the care and design of
the care.
AI is making a lot more
lot more of these
use cases much more easier, faster, and more
accessible.
We, we have use cases like how can
we do how can we recommend plan for
a particular member or a particular market. Right?
So
your your journey of onboarding a member becomes
a lot more smarter
knowing what was the delivery of care formula,
right, which worked for that member. So with
all the data available between peers and provider,
some of these use cases on enabling a
connected journey becomes much more easier. And those
are the value propositions we bring to the
table at Simplify.
Yeah. And can we talk about I think
that's that's,
an important point. Maybe we can go even
deeper for for our final question here, which
is really about,
you know, they're either payers are gonna have
to partner, obviously, here or they're gonna have
to to to build solutions of their own
to sort of get to this future state,
fill this need that members have, and, you
know, the the payers that do this are
gonna be the ones that thrive in the
future. So I guess the final question is,
what should they be looking for in partners,
or what kind of capability should be looking
for as they go to build their own,
so that they can get to this future
state of a more connected future for for
members? Yeah. No. I think that's a great
that that's a great question. So it's almost
like, you know,
there are two constraints,
which which which we see. The the first
one is
really invest and improve upon
personalizing your experience for your members.
And on the other end, there is an
incredible pressure of
doing that at scale
without adding a lot more cost.
And if you look at these two constraints,
right, it's inevitable
for you to not leverage platforms.
And what platforms bring to the table, what
platform thinking brings to the table, the technology
which comes into picture here is
it can kinda allow you to kill both
birds with same stone. Right? So on the
on the front line and on your digital
front doors, it can enable a personalized experience
for the member because it's using the data
to have a much more integrated
story, more accessible story for your members.
And, for your back office teams, it brings
incredible automations. So your manual silos goes away,
which is exactly where a lot more admin
savings and cost and a lot more exhaustion,
frankly speaking, because there
are highly regulated environments, which has timelines, which
are high pressure. And there's just a lot
of customers try to kinda endure that.
So having a platform which allows you to
improve,
on personalizing for your members at scale,
at the same time not adding more cost.
Like, we have a story with, our customer
where they improved their NPS score by 12
points without really adding,
you know, any person on their employee staff.
Now it cannot be possible because as you
grow in,
in geographically in more markets,
as you add on more members,
if you're not adding more
admin cost,
it it's a litmus test, right, on how
the degree of automation and sophistication you have
in your operating protocols. Those are the areas
which we we think are going to be
important for,
for journey onwards. Yeah. Appreciate that that sort
of, it it's very easy to conceptualize the
way you put it in terms of this
becomes a litmus test in terms of how
effective the technology is being.
And, Nirne, it was a pleasure speaking with
you today. Thank you so much for coming
on the podcast. Yeah. Sounds good. Likewise, thank
you so much, and,
have a nice day. Yeah. Absolutely.
I also wanna thank Simplify Healthcare for sponsoring
today's podcast.
Invite our listeners to tune in to more
podcasts from Becker's Healthcare by visiting our podcast
page at beckershospitalreview.com.
Hope you all have a wonderful rest of
your day.