This is Brian Zimmerman with Becker's Healthcare. Thank
you so much for tuning in to the
Becker's Healthcare podcast.
Today, we're going to talk about health plan
readiness for 2026,
trends shaping the next phase of change.
Joining me for this discussion is Steve Levin,
CEO of Quest Analytics.
Steve, thank you so much for being on
the podcast. Thanks for having me, Brian.
To get going here, can you can you
share a bit about your yourself, your professional
background,
what you're doing as as as CEO of
Quest Analytics?
Yeah. So who am I?
Exactly. It's
so, look. I usually describe myself as a,
reformed consultant.
I was a HP management consultant. I did
a corporate development and sort of, strategy work,
among my clients for a lot of years
for
health plans
and payer companies,
health systems,
consumer product companies.
And then, at at some point after, you
know, over a decade or so,
I decided I should try and,
pre you know, do what I preach, if
you will. And I hopped over the wall.
One of my clients invited me to start
a company.
So I,
engaged in building a venture. Right? Built a
new company for a decade or so in,
predictive analytics and rev cycle
back when, big data and SAS was all
brand new. This was 2005,
2006 era.
Built a predictive analytics business, serve serving providers,
health systems, and, hospitals.
And from there,
that ultimately was
acquired by sort of a middleware company, a
clearinghouse.
So I got to go from the provider
side to the middle. And then,
in 2020,
by the start of COVID,
I joined Quest,
and I became, CEO here, which is sort
of a capstone opportunity for me.
Quest is really interesting, you know, network design.
We live at sort of the e the
intersection of of, payers,
providers,
regulators, and then, you know, networks or what
members experience and health plans are built on.
So it's a very interesting
spot in the middle.
And, you know, in in the kind of
softer moments, I would say, it's a great
mission.
We're a company that is
exclusively focused on helping every American get access
to health care and helping sort of find
those networks and make them work. So it's
it's really quite exciting. So, that's who I
am.
Wonderful to have you. I think your your
professional journey lends you an interesting perspective in
in sort of sitting in this this this
intersection space. Right? I think that's also a
valuable perspective for for our listeners to get.
So
let let's get into it. Health plans, of
course, are, you know, getting ready for another
year of significant regulatory and market change.
What are the most important pressures you're seeing
as sort of these plans look toward 2026
and how they're shaping strategic priorities? You know?
There's always transformation disruption
happening in health care. Of course, it's not
static, but this does seem like an
exceptionally,
interesting moment in in in the industry. So
can you expand on how health plans are
sort of getting ready for the changes that
are coming?
Look. It you know, it so first off,
it is an interesting time, and health care
has never been static. It's it's always been
changing. I think the pace of change recently
has really picked up.
And,
you know, I think every everyone listening to
this understands that there's sort of margin pressure,
in health care, and that problem has gotten
much more acute.
You know, behind that, there's a bunch of
different things that are shaping that shape that
pressure and that acceleration, which in some ways
are gonna
drive what we think of as 2026
and sort of what payers, providers, regulators are
all thinking about and likely to be kinda
trying to accomplish.
You know, we have
the underlying
cost drugs, devices, equipment, all
those continue to kind of accelerate and, you
know, increase in cost.
We have utilization
that's that's gone up, sort of a little
bit of the hangover out of the public
health emergency.
All of that is leading to sort of
MLR pressures,
challenges of sort of
having the cost and the margin match the
plan design.
We're seeing, as a result of some of
this, all these,
events,
a series of things. So first off, we're
seeing regulators get really sensitive to
real provider access. Is the provider
seeing patients? Is this location real?
Is there sufficient,
you know, availability? So average wait time sort
of things.
That that focus on access is
really, you know, pressing things around data and
data integrity. We'll get to that later.
Providers are are facing real contract and and
and rate challenges, and they are consolidating. So
we're seeing the continued
consolidation of provider groups. So we're seeing health
systems get bigger. We're seeing groups get bigger.
You can see that when you look around
and look at the contract disputes. I'm up
in the New England area,
and,
you know,
Bay State Health and and
South Coast Health, we're seeing every almost everyday
challenges of of in network, out of network
negotiations with our local
payers up here. And then we're seeing, you
know, the the payers themselves trying to figure
out how to
do more,
manage utilization against the premium and control sort
of the the whole premium dollars.
It is becoming
like a you know, one of the things
that I like to think of it is
a game of Tetris.
This is why we all play the the
the game of Tetris, and so the blocks
are falling.
Groups are getting bigger. The financial challenges
are getting bigger, and the blocks are falling
faster. We we have to sort of make
these networks
kind of all fit,
and it's speeding up.
You know, I think the the pace of
change in Washington has gone up a lot
too recently. We're seeing more
more innovation out of CMS, more innovation at
the state level in the regulatory thing. So
all this stuff is accelerating faster faster and
more
pressing. More pressing. The stakes are high.
You laid out so much of of what's
happening in the environment to make that sort
of that pace of change that that is
easy. If you ever played Tetris, it's really
easy to to picture that when things start
moving a little bit faster, it gets real
tricky. So,
wanna get here now to I wanna reference
sort of a survey we did earlier this
year that
suggest high performing plants often operate with more
targeted,
streamlined networks.
With that in mind,
what what data insights should executives rely on
to assess the performance of their networks? I
know access is super important.
But especially if they're considering a narrow network
strategy, what what should be they be be
looking at measuring? It
it's,
so your your research was very, very,
enlightening,
and it actually, by the way, just it
it married or kind of matched some research
done by the the KFF
who similarly did some work looking at Medicare
Advantage Plans and star ratings.
Their research showed that sort of it's e
you know, low performing networks of three stars
and less tend to be narrow narrow as
well, but they found that high performing networks,
the five stars, were also narrow. I mean,
they're actually in fact the narrowest,
which was reinforcing to what you guys are
talking about, which is, you know, bigger is
not necessarily better when it comes to networks,
and the member experience and the provider.
I think what
it's interesting is for for many years, we've
all thought that the way to kind of
control cost is to kind of
shape utilization
of of how members
utilize health care. So we're gonna help influence
them and direct them to better doctors, or
we're gonna try
and kinda, you know, bad words like gatekeep.
And and
when increasingly, what what everyone is seeing is
that a better designed foundational
network actually leads to a better experience. It
leads to,
less abrasion
for providers. It leads to better natural
care routines, care pathways.
It leads to better outcomes, more satisfaction, lower
cost, all that good stuff. And
even regulators are understanding that bigger is not
necessarily better. What they really want is true
access. They want to understand that that, are
all these primary care doctors,
in fact seeing patients?
Are all these locations, in fact, real?
And,
you know, so what we're we're seeing
that it's,
a conversation about network composition, who's in, who's
out, how to think of that.
You know, even in
step back for a sec. We even use
the word like narrow network. A narrow network
may have a lot of primary care access
points. A narrow network may be actually quite
broad for ambulatory surgery centers.
It may just be narrower as it gets
to whether it's the acute or some of
the some of the more
value sensitive things like oncology or other specialties.
So, like,
narrow, we ban you a word like narrow
around, and it every network
in every sort of care
footprint has very, very,
specialized and sort of nuanced dimensions to it.
And that's what
it really comes down to sort of the
the challenge for for executives.
It you really do need some very granular,
high quality local data.
You need to understand,
the provider,
their care capabilities, like what kind of services
they really do. We should understand their their
their their value in that care service. So
is it, you know, low cost and not
always high value. Low cost can be low
cost.
And so what's the value at the care
site? And, ultimately, I think that we're finding
that it's more and more important for people
to think about
the network relative to other networks in the
market.
This is a consumer product at some level.
Right? We are trying to create a have
a have a consumer
experience great health care, and so you need
to understand
the provider, the service line, and then sort
of the other options in the market.
And the last part, Brian, which I think
we all intuitively understand is,
networks are, you know, highly dynamic.
3%
of the
provider kind of at location information is changing
in any given month.
Providers are retiring, groups are restructuring,
offices move. I mean, like, for a lot
of reasons, the network that was here last
month isn't here today.
Right. Right. It's it's it's an interesting space.
And and it it's a lot to get
your arms around too,
in terms of really getting that that that
accuracy and understanding what's happening in in markets
and your networks. So what steps can can
health plan leaders take to to really
strengthen performance and get more efficient, but they've
also gotta maintain compliance. Right? Yeah.
Can you talk a little bit unpack that
for us, especially when it comes to ensuring
that private provider data accuracy, network adequacy, those
those types of things that you're mentioning? How
can you pursue better performance while maintaining compliance?
Right. You know,
interestingly so a lot of people at the
moment, a lot of organizations,
if they don't step back and think about
the network, the network is sort of
one of the few
or the core assets
that connects all parts of the of a
a payer,
business. Right? It's
part you have the bills that to be
compliant, then you have to design it so
that it sort of meets the membership and
the market needs.
You have to, you know, fit the network
and match it to the product and the
offering.
The network will dictate in many ways what
members they're gonna see and and where who
they're gonna be working with. So it it's
a very, very it's an enterprise wide asset.
And I think that gets to this sort
of the imperative for what a a payer
needs to do as they look to kind
of
really be, you know, performing here. The the
yes. At one level, they have to create
sort of a single place where their network
data lives. They need to create
a, kind of a clear,
trusted enterprise
source of content.
They need to be somewhat rigorous, relentless, and
continuous on making sure that their database is
higher fidelity. And if those are the things
that's perfect,
it just sort of has to be continually
managed and maintained.
The second thing you need to do is
you need to make that content available across
their company so that their it guesses their
teams that are focused on compliance,
need access to that content to make sure
they understand and are analyzing relative to the
the regulatory requirements.
But they also need that same information available
for their mark in market teams who are
thinking about their their messaging and their marketing
in their in their kind of sales
programs. And so you need we would think
of it you need a network decisioning tool
that crosses the organization,
serves a content to each of your
kind of your teams that are sort of
at the front lines of delivering
in delivering health care to their to the
market.
It needs to be kind of workflow enabling.
It needs to eliminate handoffs or simplify handoffs,
and it needs to get the right information
to the experts at the right point.
You know, the network conversation needs to move
from being what I think it is reactive
to proactive.
It needs to help everybody sort of understand
not only not where they've been, but where
they wanna get to.
And,
a lot of what we see in, across
the industry is conversations
not about the business or the network,
but about sort of whose data was more
right or or wrong.
We need to shift this from a data
debate
to one about of action and decisions.
I I appreciate the comments. And and and
I think, you know, to do this work,
to do what what you're talking about doing,
getting your arms around that data, making that
content available across their company,
messaging, informing, marketing, all all that, Steve. Right?
You're gonna need you're gonna need
a a a particular emphasis on on on
technology, and there's perhaps a a two letter
acronym. I'm dancing around here. But what's the
what's the role of technology
in this process and driving innovation? And, I
guess, what should folks help plan leaders listening
to this really be paying special attention to
in 2026?
Yeah. Look.
So I think, you know, we we are
seeing and I've and I've seen that every
every organization has a CRM tool. Right? They've
they've they've got someone doing their client relationship
management and doing marketing and messaging. And mostly
most people have
some
single enterprise,
accounts receivable and accounts payable application. And organizations
have a single if you're if you're in,
materials, you've got an ERP in in resource
planning and supply chain. Well, I think networks,
is a similar spot. We need an enterprise
network platform, decisioning platform.
So you need a tool that connects it.
But but all these tools, as as you're
alluding to,
are are reliant on great data
and sort of bringing that data to a
single spot.
I think it they then need sort of
what I think are accepted
analytics.
In the unique thing about networks is because
of the geolocation
aspect of them, they're they're understanding a network
and how it meets a member need is
very processing intensive. It's a time and distance
calculation.
There's an experience
driving issue,
and you need
what are effectively sort of the in the
accepted endorsed
measures of that,
so that people can rely on the conversations
of measurement.
And then lastly, you need to kinda put
all this stuff in the context of a
workflow, and you have to connect people. And
I think this last part is where we're
gonna see
that two letter acronym that you are kinda
dancing around, which is AI and Agentic and
what we're seeing in there. I think with
good data,
with good analytics, you can start to accelerate
the kind of the insight and decision making
with some of this Agentic technology.
You can put experts at the edges of
organizations
and get them access to content that in
a way that they can engage with it
faster and get fat better decisioning.
So it's a really exciting time.
You know, we're seeing
organizations really get excited about this idea of
a network platform.
We're seeing people understand the power of data
and and the need to to kind of
really govern and and and kind of integrate
the data pieces.
And, slowly but surely,
getting excited about AI and how it can
be real workflow enabling.
Yeah. Because the the the AI technology component
of it, it's it's kind of there. Right?
It's it's got the capacities. It's but it's
it's kind of about getting that data right,
getting that data underneath it so you can
you can really unlock the
the the power of that technology. Correct, Steve?
Yeah. And it's funny. When I think about
the AI space, a lot of
we're not looking at AI to tell you
which doctor is the best answer.
You know? Yes. It you know, it it
it's not it it's it's not hard to
say, look. In this in this market,
here are three
potential configurations
for your network to be to meet your
business objectives.
And so the technology can help you do
that,
you know, get you to three or four
different scenarios faster.
But there's gonna be an expert who's gonna
look at those scenarios and and evaluate them
for sort of the the things
static model or and kind of an agent's
not gonna get to.
So I think there's, yes, there's something about
more
insight faster for people through some of the
Genentech stuff. But the second part I think
is really important, which is workflow.
I think, the AI stuff is gonna be
really, really transformative in helping take
content from one end of the organization
and move it rapidly to the other side
and say, hey. You may not know this
yet, but here's what happened with this market.
You've got an emerging gap or
this organization
has changed,
its affiliations, and now you've got sort of
competitive issue. Here are three choices. What do
you wanna do about that? The ability to
get that content across the organization fast,
really powerful.
Yeah. Excellent. Yeah. Truly, truly able to conceptualize
just how powerful that would be for an
organization. For, ultimately, for for for for members.
There's just so many different benefits that could
come from that sort of vision of the
future.
Is there anything, Steve, we didn't touch on
our conversation today that you wanna make sure
to to leave listeners with? Maybe it's something
you wanna reemphasize or a fresh point. I
kinda leave it to you. But how do
you how do you wanna close out today?
So, look,
you know, Brian, we started with this comment
about how it's a complicated time and it's
a real challenge and the margin pressure.
I think, you know, I'm really excited. I
see people at all these organizations
facing real difficulty, but also facing it with
some optimism.
I'm really motivated
by the meaningful
kind of creativity,
the innovation,
the changes that I'm hearing from our clients
and, you know, around the ecosystem, providers,
payers,
regulators,
and there's a real optimism. It may not
feel that way, but I think people are
looking at the future saying it could be
great. And I'm really excited. I know I've
got hundreds of people here at Quest that
are excited about sort of the the power
of what's ahead. So
put it all together. It you know, we
can help hundreds of millions of Americans get
better health care.
Well, Steve, it really was a pleasure and
truly appreciate you ending on that that optimistic
note. I think,
important for all of us to get healthy
doses of of optimism these days. Thank you
so much for coming on the podcast, Steve.
We also wanna thank our podcast sponsor, Quest
Analytics.
You can tune in to more podcasts from
Becker's Healthcare by visiting our podcast page at
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