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Hi, everyone. This is Erica Spicer Mason with

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Becker's Healthcare. Thank you so much for tuning

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in to the Becker's Healthcare podcast series today.

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So today, we're going to talk about how

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payers are preparing for 2026.

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And joining me for this conversation, we have

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Bob Tavernier,

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the sales solution executive at Quest Analytics,

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and Rick Harbitt, senior manager of provider network

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programs and strategy at Blue Cross Blue Shield

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of North Carolina.

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Bob, Rick, welcome to the podcast. Thanks for

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joining me today. Thank you, Erica. Thanks. Yeah.

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Great to have you both here today.

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Before we get into the discussion, I wanted

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to see if you both like to share

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just a little bit more about yourselves, your

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organizations, whatever you think is helpful for listeners

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to know going into the conversation today. Rick,

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do you wanna kick us off? Sure. Sure.

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So, happy to be here, Erica, once again.

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And, yeah. So I've been with Blue Cross

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Blue Shield now for, a little over half

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a decade.

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And prior to that, I was with the

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health care delivery organizations,

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in the Southeast, couple of them. So about

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twelve years, in the industry on both sides

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of of the aisle.

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Excellent. Great to have you with us, Rick.

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And, Bob? Well, Rick, the the blues are

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very familiar with, myself.

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I was actually at health care service corporation

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for

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twenty six years. I was born there. So

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I guess you could say I'm blue blooded,

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but, you know, focused predominantly not only on

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internal operations,

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with product development, claims customer service, IT, as

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well as external operations, national accounts.

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Also focusing on government networks as well as

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government clinical operations. Nice to be here today.

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Oh, great to have you both with us.

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And, you know, we're recording here today at

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the Parachute's roundtable at Becker's CEO CFO conference.

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So throughout these next few days, I know

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we're going to hear a lot about these

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growing financial and regulatory pressures that plans are

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facing as they head into 2026.

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So, Rick, I wanted to start with you

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in getting your perspective.

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How are some of these forces reshaping priorities

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around provider network design? Yeah. So, Eric, as

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you know, it's

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was never projected to be a great year

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for payers, in 2025, and I think, it's

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even been more challenging than what many of

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them were expecting. And, you know, we're, no

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stranger to that, unfortunately. And so,

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ultimately, it it comes down to what can

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we prioritize and what can we deprioritize.

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We have to be smarter with the approach

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that we take in many cases.

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It's not always the the first thing that

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comes to mind that we can do. It,

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really needs to be buttoned up when it

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comes to our business case. So,

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CapEx is is,

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nearly nonexistent

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in many cases,

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at least through 2025.

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And so we really have to look at

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the future both from a three year and

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five year perspective rather than the short term.

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Yeah. I really appreciate how you're emphasizing prioritization,

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staying really disciplined.

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Appreciate that, Rick. And, Bob, I know you

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you're having conversations with payers on a national

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scale in your work with Quest Analytics.

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So So what trends are you seeing in

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how organizations are balancing compliance,

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performance goals, some of the areas that Rick

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touched on as well? Rick, I can't agree

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enough in terms of prioritization and discipline. You

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know, from a national landscape, we're seeing

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a huge shift in diversification of lines of

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business, you know, plans that are getting out

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of certain lines of business,

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investing more in other lines of business.

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We're seeing doubling down around, the areas of

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profitability

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and less around

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service air expansions and pure growth, as its

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own.

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From a compliance perspective,

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compliance is is absolutely key, you know, whether

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it's, you know, state based or federal based.

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And it's really being able to meet the

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baseline requirements of compliance,

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but also be able to have a good

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management and monitoring strategy overall that you're continuing

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to invest in,

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your practices operationally

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to remain compliant,

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and then balancing that with areas in terms

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of performance,

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and being able to utilize data as your

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key. So data and analytics is really golden,

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to really find those nuggets

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of how do you truly focus around things

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like profitability,

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thinking about things like,

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PMPM,

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MLR,

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thinking about areas, from a claims perspective.

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How do you truly leverage that and look

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deeper into your network and be able to

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make investments incrementally?

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But back to Rick's point, in terms of

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that long term plan, so the three to

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five year

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taking steps now, it takes time, to be

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able to establish discipline,

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establish governance, and be able to, eventually roll

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that out, to match the plans that,

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the not only the national players are expecting,

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but also the regional players as well.

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Yeah, Bob. And I noticed in your response,

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you touched on the network. And so I

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wanna go a little bit deeper and talk

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about network adequacy.

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We're seeing plans move past those traditional time

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and distance standards, and they're taking a more

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holistic view of what network adequacy really means.

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So I'd love to hear from you both

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on this. What does that evolution really look

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like in practice, and how does it translate

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into real access and member satisfaction?

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Yeah. Erica, in on the North Carolina side,

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I can tell you network adequacy two point

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o is really moving from what we have

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to do to what we should

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do it's not about necessarily checking that proverbial

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box for regulator although that does have to

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be done it's looking at our membership and

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what they need so it's it's moving beyond

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the regulatory piece to do we have enough

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members even beyond the minimum required amount? Do

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we have enough providers to meet the need?

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Do we have the right type of providers?

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Are they the highest quality that we can

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can offer? And

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are they coming at a in at a

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competitive rate when it comes to the cost?

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So

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that's really what two point o is for

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us, and that as Bob mentioned, that's really

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all centered around

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data and intelligence, right, and how we apply

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that to our network adequacy.

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There's a lot of meat on the bone

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for that, and that's really what two point

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o does. Thanks, Rick. And what would you

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add, Bob? Yeah. Rick, really appreciate your response

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and, you know, the direction where where you're

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headed with two point o. I mean, two

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point o has really blossomed,

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over the last few years. You're hearing not

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only the things, you know, that have to

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be applied, like the price transparency act, but,

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you know, also,

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access to care,

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appointment wait times.

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Truly, and to Rick's point, right, really making

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sure that you have strong bench strength when

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it comes to your networks, your providers,

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where are your members concentrated at, what comorbidities

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do they have, do you have the right

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providers in place to support the member populations

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in the local communities that they reside in?

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And then even, you know, on the broader

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landscape going beyond urban, suburban and thinking about

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rural and scenic areas, how do you true

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truly have an omnichannel or a multichannel approach

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when you're thinking about access to care and

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you're thinking about servicing those members, not only

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from a brick and mortar perspective, but also

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from a telehealth perspective? So access two point

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o or network adequacy two point o is

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really going above and beyond the standard to

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truly focus on

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getting the member to the not only the

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right level of care, but at the right

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time, in the right place to truly help,

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manage the overall toast total cost of care.

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Yeah. Thank you both. And I can see

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in taking this holistic stance that plans

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are starting to embrace more and more the

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the key role that advanced analytics or or

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technology would play in helping to understand these

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many factors that that play into network adequacy.

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And I wanna go back to something that

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we also touched on earlier. You know, we

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talked about kind of this perfect storm of

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cost, competition, regulatory change that payers are facing

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right now. And, Rick, you touched on prioritization

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and the role that that's playing at Blue

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Cross Blue Shield of North Carolina.

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So how are you prioritizing initiatives when budgets

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are so tight and ROI expectations are higher

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than they've been before? Yeah. So, Eric, I

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think that the key takeaway there is higher

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than they've been before. They've always been you

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know, competing priorities have always been a thing.

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To your point, though, you know, budgets are

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tighter than what we were expecting, what we'd

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like to see, and so prioritization is key,

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and deprioritization

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is key. And so how we're doing that

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is, certainly,

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we need to focus on the things that

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mean the most to the plan overall in

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the enterprise.

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There's things we'd like to do with the

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departmental and divisional levels that, just really aren't

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there

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at least for 2025.

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And so we're that's why we're looking at

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the our three and five year plan. So

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our shift is

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more

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focused on what can we do to be

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in a better place in 2030

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than what can we do to be in

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a better place in 2025 and 2026 because

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it's simply not gonna gonna matter,

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in the short term. So,

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you know, I'll I'll wrap all that up

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to say

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that, really, what we need to do is

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just focus on the long term versus the

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short term and what we can do to

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to support those goals. Yeah. Rick, thank you

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for that perspective.

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And, Bob, I know you we've already touched

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on kind of the role that analytics can

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play in this space, the importance of data

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in achieving some of these aims and prioritization

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to Rick's point. So can you shed a

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little bit more light on how payers can

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use

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data and market insights to really focus their

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limited resources on where it will have the

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greatest impact? Absolutely, Erica. You know, when we

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think about data and analytics and

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thinking about some of the levers such as

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cost,

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such as quality. You know, a lot of

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that is focused around,

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truly being able to look at the the

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macro level, you know, not only across the

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service areas that you are serving,

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but also, the different product and benefit designs

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that you have,

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the different, providers,

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as well as facilities that you have lined

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up to support specific

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benefit and network designs.

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When you think about cost and quality,

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the name of the game is utilization.

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Right? And I don't care if you're a

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regional or a national,

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payer.

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You know, you really wanna focus in around

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managing that medical expense.

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And, you know, it's again, to Rick's point,

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you're in it for the long game. Right?

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And you wanna be able to build up

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your reserves. You wanna be able to service

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your members.

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But being able to look at opportunities where

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you see

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high cost opportunities and being able to negotiate

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down or be able to provide further

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direction, to, members

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on, you know, the best choice of care,

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being high quality, low cost,

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to truly help that man member manage their

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condition.

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But then also being able to, you know,

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stay up to date with things like provider

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directories, which we know churn at

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a 60 to 70% rate.

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What are you doing as a payer organization

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to truly help to enable

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a high performing network with a network that

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is truly accurate. So when a members are

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shopping for insurance, they look at those online

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provider finders, they look at the directories,

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and they know that the PCP or specialist

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that they're signing up for is gonna be

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there,

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when they sign up. So there's a lot

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of different things to factor in,

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When you think about the perfect storm, you

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think about cost, and quality and just using

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data overall, to make informed decisions. Yeah. Yeah.

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Thank you so much.

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And as we look ahead,

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you know, when when we consider this concept

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of network adequacy two point o and and

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where the market is headed, what advice would

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you both offer to leaders who are just

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starting to evolve toward that two point o

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mindset or even rethink their network performance strategy

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overall?

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Yeah. Erica, that's a great question because, you

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know, ultimately, I I think I would say

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that what the plan has to do is

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understand where their specific goals are,

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and understand current state because, you know, one

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of the things that we've talked about, you

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know, really has been multifaceted.

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There's multiple

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components to this problem, and no single plan

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is gonna have every one of those same

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things happening to them as what's happening on

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the North Carolina side or or others. And

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so understanding where you're at, where you wanna

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go,

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and then being open to alternative ways to

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get there. Right? So building it yourself is

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not always the best case. I can tell

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you on the North Carolina side, we evaluated

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multiple options, and one of which were were

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internal solutions.

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We ultimately ended up finding a partner to

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go with, because just their their time to

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scale and time to market was just so

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much better,

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and the value prop they offered was was

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much better. And so I think being open

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to partnerships such as that would be in

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everyone's best interest. Yeah. It's great takeaway. And,

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Bob, what would you say? You know, it's

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it is a state of evolution. You know,

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Rick, you bring up a really good point

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in terms of the North Carolina market and

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things that are in integral to your, your

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communities and your markets.

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But the communities vary right across The United

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States and just, you know, there's different shifts

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in terms of our overall strategies,

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really being able to, you know, to take,

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you know, incremental steps towards the goal. If

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you have long term goals, three to five

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year plans,

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if you're really focusing

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in on a a diversification

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and looking at,

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different lines of business, being able to truly

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think about how do you take steps incrementally

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to get there, how do you measure success,

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You know, thinking about workflow optimization, thinking about

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ways to use data, ways to use technology

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to help you,

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not only from a staffing perspective, but truly

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from a a functional and an output perspective

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to help you achieve the outcomes that you're

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expecting to achieve.

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There's so many different things going on right

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now, you know, buzzwords like AI.

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But AI only means something if you're able

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to truly apply it within the application,

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of your your standard business practices,

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your operations.

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So truly being able to utilize data and

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utilize technology in a way that can be

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effective

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and make incremental steps towards the goal annually

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and ultimately in support of your long term

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goals.

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Fantastic.

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If I have a takeaway from this conversation,

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it's that network adequacy two point o is

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really the long game. It's something that organizations

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have to have a really holistic approach behind

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and one that's fueled by technology and analytics

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as possible in meaningful ways to your point,

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Bob.

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This has been a great conversation. Before we

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close, is there anything else that you'd like

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to add or maybe something we glossed over

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too quickly?

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Eric, I would just say thank you very

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much for Becker's Healthcare and your partnership and

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everything that you are, offering for us today.

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We appreciate it. Thanks, Paul. I agree. Oh.

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I agree. That's great. Thank you. Thank you

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both. It's been a great conversation. And, of

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course, we'd like to also thank the podcast

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00:14:33,054 --> 00:14:34,674
sponsor for today, Quest Analytics.

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Listeners, please tune in to more Becker's podcasts

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