Hi, everyone. This is Erica Spicer Mason with
Becker's Healthcare. Thank you so much for tuning
in to the Becker's Healthcare podcast series today.
So today, we're going to talk about how
payers are preparing for 2026.
And joining me for this conversation, we have
Bob Tavernier,
the sales solution executive at Quest Analytics,
and Rick Harbitt, senior manager of provider network
programs and strategy at Blue Cross Blue Shield
of North Carolina.
Bob, Rick, welcome to the podcast. Thanks for
joining me today. Thank you, Erica. Thanks. Yeah.
Great to have you both here today.
Before we get into the discussion, I wanted
to see if you both like to share
just a little bit more about yourselves, your
organizations, whatever you think is helpful for listeners
to know going into the conversation today. Rick,
do you wanna kick us off? Sure. Sure.
So, happy to be here, Erica, once again.
And, yeah. So I've been with Blue Cross
Blue Shield now for, a little over half
a decade.
And prior to that, I was with the
health care delivery organizations,
in the Southeast, couple of them. So about
twelve years, in the industry on both sides
of of the aisle.
Excellent. Great to have you with us, Rick.
And, Bob? Well, Rick, the the blues are
very familiar with, myself.
I was actually at health care service corporation
for
twenty six years. I was born there. So
I guess you could say I'm blue blooded,
but, you know, focused predominantly not only on
internal operations,
with product development, claims customer service, IT, as
well as external operations, national accounts.
Also focusing on government networks as well as
government clinical operations. Nice to be here today.
Oh, great to have you both with us.
And, you know, we're recording here today at
the Parachute's roundtable at Becker's CEO CFO conference.
So throughout these next few days, I know
we're going to hear a lot about these
growing financial and regulatory pressures that plans are
facing as they head into 2026.
So, Rick, I wanted to start with you
in getting your perspective.
How are some of these forces reshaping priorities
around provider network design? Yeah. So, Eric, as
you know, it's
was never projected to be a great year
for payers, in 2025, and I think, it's
even been more challenging than what many of
them were expecting. And, you know, we're, no
stranger to that, unfortunately. And so,
ultimately, it it comes down to what can
we prioritize and what can we deprioritize.
We have to be smarter with the approach
that we take in many cases.
It's not always the the first thing that
comes to mind that we can do. It,
really needs to be buttoned up when it
comes to our business case. So,
CapEx is is,
nearly nonexistent
in many cases,
at least through 2025.
And so we really have to look at
the future both from a three year and
five year perspective rather than the short term.
Yeah. I really appreciate how you're emphasizing prioritization,
staying really disciplined.
Appreciate that, Rick. And, Bob, I know you
you're having conversations with payers on a national
scale in your work with Quest Analytics.
So So what trends are you seeing in
how organizations are balancing compliance,
performance goals, some of the areas that Rick
touched on as well? Rick, I can't agree
enough in terms of prioritization and discipline. You
know, from a national landscape, we're seeing
a huge shift in diversification of lines of
business, you know, plans that are getting out
of certain lines of business,
investing more in other lines of business.
We're seeing doubling down around, the areas of
profitability
and less around
service air expansions and pure growth, as its
own.
From a compliance perspective,
compliance is is absolutely key, you know, whether
it's, you know, state based or federal based.
And it's really being able to meet the
baseline requirements of compliance,
but also be able to have a good
management and monitoring strategy overall that you're continuing
to invest in,
your practices operationally
to remain compliant,
and then balancing that with areas in terms
of performance,
and being able to utilize data as your
key. So data and analytics is really golden,
to really find those nuggets
of how do you truly focus around things
like profitability,
thinking about things like,
PMPM,
MLR,
thinking about areas, from a claims perspective.
How do you truly leverage that and look
deeper into your network and be able to
make investments incrementally?
But back to Rick's point, in terms of
that long term plan, so the three to
five year
taking steps now, it takes time, to be
able to establish discipline,
establish governance, and be able to, eventually roll
that out, to match the plans that,
the not only the national players are expecting,
but also the regional players as well.
Yeah, Bob. And I noticed in your response,
you touched on the network. And so I
wanna go a little bit deeper and talk
about network adequacy.
We're seeing plans move past those traditional time
and distance standards, and they're taking a more
holistic view of what network adequacy really means.
So I'd love to hear from you both
on this. What does that evolution really look
like in practice, and how does it translate
into real access and member satisfaction?
Yeah. Erica, in on the North Carolina side,
I can tell you network adequacy two point
o is really moving from what we have
to do to what we should
do it's not about necessarily checking that proverbial
box for regulator although that does have to
be done it's looking at our membership and
what they need so it's it's moving beyond
the regulatory piece to do we have enough
members even beyond the minimum required amount? Do
we have enough providers to meet the need?
Do we have the right type of providers?
Are they the highest quality that we can
can offer? And
are they coming at a in at a
competitive rate when it comes to the cost?
So
that's really what two point o is for
us, and that as Bob mentioned, that's really
all centered around
data and intelligence, right, and how we apply
that to our network adequacy.
There's a lot of meat on the bone
for that, and that's really what two point
o does. Thanks, Rick. And what would you
add, Bob? Yeah. Rick, really appreciate your response
and, you know, the direction where where you're
headed with two point o. I mean, two
point o has really blossomed,
over the last few years. You're hearing not
only the things, you know, that have to
be applied, like the price transparency act, but,
you know, also,
access to care,
appointment wait times.
Truly, and to Rick's point, right, really making
sure that you have strong bench strength when
it comes to your networks, your providers,
where are your members concentrated at, what comorbidities
do they have, do you have the right
providers in place to support the member populations
in the local communities that they reside in?
And then even, you know, on the broader
landscape going beyond urban, suburban and thinking about
rural and scenic areas, how do you true
truly have an omnichannel or a multichannel approach
when you're thinking about access to care and
you're thinking about servicing those members, not only
from a brick and mortar perspective, but also
from a telehealth perspective? So access two point
o or network adequacy two point o is
really going above and beyond the standard to
truly focus on
getting the member to the not only the
right level of care, but at the right
time, in the right place to truly help,
manage the overall toast total cost of care.
Yeah. Thank you both. And I can see
in taking this holistic stance that plans
are starting to embrace more and more the
the key role that advanced analytics or or
technology would play in helping to understand these
many factors that that play into network adequacy.
And I wanna go back to something that
we also touched on earlier. You know, we
talked about kind of this perfect storm of
cost, competition, regulatory change that payers are facing
right now. And, Rick, you touched on prioritization
and the role that that's playing at Blue
Cross Blue Shield of North Carolina.
So how are you prioritizing initiatives when budgets
are so tight and ROI expectations are higher
than they've been before? Yeah. So, Eric, I
think that the key takeaway there is higher
than they've been before. They've always been you
know, competing priorities have always been a thing.
To your point, though, you know, budgets are
tighter than what we were expecting, what we'd
like to see, and so prioritization is key,
and deprioritization
is key. And so how we're doing that
is, certainly,
we need to focus on the things that
mean the most to the plan overall in
the enterprise.
There's things we'd like to do with the
departmental and divisional levels that, just really aren't
there
at least for 2025.
And so we're that's why we're looking at
the our three and five year plan. So
our shift is
more
focused on what can we do to be
in a better place in 2030
than what can we do to be in
a better place in 2025 and 2026 because
it's simply not gonna gonna matter,
in the short term. So,
you know, I'll I'll wrap all that up
to say
that, really, what we need to do is
just focus on the long term versus the
short term and what we can do to
to support those goals. Yeah. Rick, thank you
for that perspective.
And, Bob, I know you we've already touched
on kind of the role that analytics can
play in this space, the importance of data
in achieving some of these aims and prioritization
to Rick's point. So can you shed a
little bit more light on how payers can
use
data and market insights to really focus their
limited resources on where it will have the
greatest impact? Absolutely, Erica. You know, when we
think about data and analytics and
thinking about some of the levers such as
cost,
such as quality. You know, a lot of
that is focused around,
truly being able to look at the the
macro level, you know, not only across the
service areas that you are serving,
but also, the different product and benefit designs
that you have,
the different, providers,
as well as facilities that you have lined
up to support specific
benefit and network designs.
When you think about cost and quality,
the name of the game is utilization.
Right? And I don't care if you're a
regional or a national,
payer.
You know, you really wanna focus in around
managing that medical expense.
And, you know, it's again, to Rick's point,
you're in it for the long game. Right?
And you wanna be able to build up
your reserves. You wanna be able to service
your members.
But being able to look at opportunities where
you see
high cost opportunities and being able to negotiate
down or be able to provide further
direction, to, members
on, you know, the best choice of care,
being high quality, low cost,
to truly help that man member manage their
condition.
But then also being able to, you know,
stay up to date with things like provider
directories, which we know churn at
a 60 to 70% rate.
What are you doing as a payer organization
to truly help to enable
a high performing network with a network that
is truly accurate. So when a members are
shopping for insurance, they look at those online
provider finders, they look at the directories,
and they know that the PCP or specialist
that they're signing up for is gonna be
there,
when they sign up. So there's a lot
of different things to factor in,
When you think about the perfect storm, you
think about cost, and quality and just using
data overall, to make informed decisions. Yeah. Yeah.
Thank you so much.
And as we look ahead,
you know, when when we consider this concept
of network adequacy two point o and and
where the market is headed, what advice would
you both offer to leaders who are just
starting to evolve toward that two point o
mindset or even rethink their network performance strategy
overall?
Yeah. Erica, that's a great question because, you
know, ultimately, I I think I would say
that what the plan has to do is
understand where their specific goals are,
and understand current state because, you know, one
of the things that we've talked about, you
know, really has been multifaceted.
There's multiple
components to this problem, and no single plan
is gonna have every one of those same
things happening to them as what's happening on
the North Carolina side or or others. And
so understanding where you're at, where you wanna
go,
and then being open to alternative ways to
get there. Right? So building it yourself is
not always the best case. I can tell
you on the North Carolina side, we evaluated
multiple options, and one of which were were
internal solutions.
We ultimately ended up finding a partner to
go with, because just their their time to
scale and time to market was just so
much better,
and the value prop they offered was was
much better. And so I think being open
to partnerships such as that would be in
everyone's best interest. Yeah. It's great takeaway. And,
Bob, what would you say? You know, it's
it is a state of evolution. You know,
Rick, you bring up a really good point
in terms of the North Carolina market and
things that are in integral to your, your
communities and your markets.
But the communities vary right across The United
States and just, you know, there's different shifts
in terms of our overall strategies,
really being able to, you know, to take,
you know, incremental steps towards the goal. If
you have long term goals, three to five
year plans,
if you're really focusing
in on a a diversification
and looking at,
different lines of business, being able to truly
think about how do you take steps incrementally
to get there, how do you measure success,
You know, thinking about workflow optimization, thinking about
ways to use data, ways to use technology
to help you,
not only from a staffing perspective, but truly
from a a functional and an output perspective
to help you achieve the outcomes that you're
expecting to achieve.
There's so many different things going on right
now, you know, buzzwords like AI.
But AI only means something if you're able
to truly apply it within the application,
of your your standard business practices,
your operations.
So truly being able to utilize data and
utilize technology in a way that can be
effective
and make incremental steps towards the goal annually
and ultimately in support of your long term
goals.
Fantastic.
If I have a takeaway from this conversation,
it's that network adequacy two point o is
really the long game. It's something that organizations
have to have a really holistic approach behind
and one that's fueled by technology and analytics
as possible in meaningful ways to your point,
Bob.
This has been a great conversation. Before we
close, is there anything else that you'd like
to add or maybe something we glossed over
too quickly?
Eric, I would just say thank you very
much for Becker's Healthcare and your partnership and
everything that you are, offering for us today.
We appreciate it. Thanks, Paul. I agree. Oh.
I agree. That's great. Thank you. Thank you
both. It's been a great conversation. And, of
course, we'd like to also thank the podcast
sponsor for today, Quest Analytics.
Listeners, please tune in to more Becker's podcasts
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