Hello, everyone. This is Jacob Emerson with the
Becker's Payer Issues podcast.
Thrilled today to be joined by Ellen Sexton,
who serves as executive vice president and chief
growth officer at Blue Shield of California.
Ellen, thank you so much for taking the
time to be with me on the podcast
today.
Hi, Jacob. It's great to be here. I'm
looking forward to it. Likewise, Ellen. And before
we dive into everything we wanna talk with
you about today, can you first tell us
a little bit more about yourself, your background
in health care, and what it is that
you do today at Blue Shield?
Yes. Absolutely. So,
Ellen Sexton again, and I'm the executive vice
president and chief growth officer for Blue Shield
of California,
which means I oversee both the commercial and
the government markets
for the organization. And we serve 6,000,000 members
both in and outside California.
For our employer group, actually, a third of
our 4,000,000 members are outside of California. California.
And then in the government program business, we
serve Covered California, which is the state exchange
business here. We have Medicare Advantage and MedSup
plans. And then we also have our Promise
Blue Shield plan,
which serves Medicaid beneficiaries
in Los Angeles and San Diego Counties. So
it's very diversified,
high impact,
and we like to lead with innovation
in California,
both I think as a health plan as
well as a state, and that's really what
attracted me to to joining Blue Shield of
California.
And my prior experience points to just a
passion around serving in health care,
over two decades of experience. It's hard to
believe when I when I count back the
years.
I was at UnitedHealthcare
for many, many years across all different capacities.
I ran a Medicaid plan in Wisconsin
for them. When part d was rolled out.
I was one of the original pioneers in
rolling that out.
I had also the ability to lead their
group retiree business. So
I've seen a lot of different capacities and
coverage areas across the health care landscape.
I was also at Humana for a while.
And then more recently,
before I joined Blue Shield of California,
I was at a startup called Curative, which
was based out of Austin, Texas.
And we were really trying to to revolutionize
the employer group coverage business. So,
I have a real passion for health care
and,
just enjoyed thinking through, you know, how do
we improve it
and how do we improve access as well
as coverage and affordability.
Absolutely. So you've been in the industry for
a long time, Ellen.
Fair to say that you are an expert
in your craft. And so
I I wanted to get us started today
by talking about,
some of the legislative shifts we've seen this
year. It has certainly been something that has
been top of mind to all the the
senior leaders we talked to at health plans
and at hospital systems across the country.
Specifically,
the one big beautiful bill,
HR one,
you know, passed this summer,
and and, you know, I know the bulk
of a lot of this this legislation and
the changes that will go into effect don't
come into fruition,
for for a little bit more time,
2027.
But
I'd love to hear your immediate
and and,
long term thoughts in terms of the impact
here,
on on how you're thinking about this specifically
for the Medicaid population that you serve.
Sure. It's certainly,
very impactful, the different changes and the policies
that are coming down,
from an implementation
side. So first of all, on the Medicaid
side, there's removal of ex parte or the
expedited
renewal process as well as an additional
semiannual
renewal requirement for Medicaid beneficiaries, and that just
creates extra eligibility
hurdles for them to have to get access
to care.
And, you know, from that, we see many
of those members that that may not go
through all those, challenging forms, if you will,
and actually lose coverage.
There's also the implementation
of work requirements, and so how we work
to to streamline that and make the eligibility
requirements around that
are type of top of mind. And then
there's also impacts to members
with on sack unsatisfactory
immigration
status,
from right now and enrollment freeze for new
members as well as decreased benefits for for
members as far as maybe having to have
co pays or additional premiums,
which may extend also beyond into the the
adult,
expansion.
And then there's possible nonrenewal
of what California
has as far as CalAIM.
We'll be trying to figure out how to
cover all of those with these federal cuts.
And the Cal AIM waivers really looked at
areas like enhanced care management
and other flexible community support services like housing
and nutrition and behavioral health
that really extended
in the community and and improved health outcomes.
So
all of these are are really big impacts
to Medicaid. And then I would lift up
as far as covered California
the fact that the extension of the enhanced
tax credits is still,
being considered, although probably not too likely. It's
got a real impact across the Medicaid because
some of those members, of course, flip in
and out of either the exchange coverage or
Medicaid. And so, you know, we've had to
file two rates with the state whether or
not the tax subsidies
are approved or not, and it just creates
a lot of confusion in the system
for members as well as as thinking about
their eligibility.
And so, you know, we're really lifting up
programs that can help people meet these eligibility
requirements. And so the 28 page Medicaid eligibility
form,
We've thought through, you know, how do we
apply
artificial intelligence to try and prepopulate
parts of it to help identify these members
sooner.
We've also lifted up a GED program to
help people actually go back and get their,
high school diploma.
And and so, you know, the promise Medicaid
plan that we have within Blue Shield, they're
just so creative,
Jacob, and they come up with all these
different areas to really extend, you know, what
I would call beyond insurance and help people
continue their coverage.
Understood. I mean, there's there's so much going
on here in terms of what you just
talked about, Alan, between the work requirements,
the changes with with CalAIM,
and then, of course,
you know, in in extension, all the the
the changes around the enhanced ACA subsidies,
and what may or may not happen as
we go into next year. I know it's
been, like you mentioned, pretty difficult for insurers
all over the country, trying to prepare different
rates, depending on on what happens over these
next few weeks.
I I wonder then how does a company
as large as Blue Shield of California
respond to these policy changes? How do you
prepare and prep for,
uncertain situations that might not even come to
fruition?
And, ultimately, what are you doing,
from where you sit, Ellen, to ensure that
your members, whether it's,
currently insured by Medicaid or or ACA,
or even commercial, that they still receive that
that quality coverage that you all provide?
Yes. We I mean, we are preparing for
implementation
and interpretation of it on all all fronts.
And I think one of the first things
is to be
really close partners with your state agencies and
with
other providers in the community
and some of the organizations that help members.
That goes beyond just the doctor's office, if
you will. And so a first focus for
us is gonna be ensuring the access and
care for our members
while ensuring overall population health,
emergency
care, and and continuity of care. And so
one of the things we have are community
resource centers, and they serve everyone in the
communities, not not just our health plan members.
And they provide really high impact services
reinforcing
the benefits of health care coverage and enrollment.
And we offer these in partnership with with
LA care in LA County, and we have
14 different community resource centers.
And they offer support to people on health
care, eligibility,
and other social determinants of health. And they're
just real difference makers in the lives of
many and and just go one step beyond
in this situation. So
I think you also have to think about
continuity of care, and that is really top
of mind for me. So how do you
ensure that members that might be in the
middle of oncology treatment for cancer
or think about an expectant
mother who is in her last trimester. You
know, making sure that we identify
those members
and ensure that they're not losing eligibility during
this time period is just really
important.
And you can imagine if you're somebody in
that situation,
you know, losing your your health care coverage
during those times would be just really stressful.
So that's one of the things, that we're
definitely trying to do is ensure continuity of
care through all of these policy changes.
Understood. And and and and, to your point,
I I appreciate the acknowledgment that it is
a stressful time for a lot of people.
It's it's an emotional issue as much as
it is a a political and a financial
one. So I I think a really great
point there, Helen.
I do wanna switch gears and ask a
little bit about some of the trends that
you're seeing right now in the commercial employer
market, especially as we go into next year.
We we've heard,
numbers
from from employer groups all over the country,
predicting that 2026
might be one of the largest
increases
in in rates,
in in the last few years, maybe even
up to a decade,
on average. And and we've heard things, you
know, increased utilization
overall, more chronic conditions,
but then, you know, there's the GLP one
factor,
that that's contributing to all of this. And
we've also we've heard a lot about the
growth of stop loss insurance,
in in contextually
as part of this conversation as well. So
would would love your take in terms of
what you're seeing from where you sit.
Yes. I mean, employers want stability
and predictability in their solutions. Right? And so
all of those
areas that you just mentioned, you know, really
start to increase what we're seeing, you know,
a pressured employer group coverage
marketplace.
We are seeing that rising utilization that you're
talking about that's, you know, resulting in these
double digit,
increases, and it's happening in both medical and
pharmacy.
You mentioned GLP one. So, you know, one
of the biggest areas is, you know, how
you decide to cover that with with the
employer group at hand. And I think you
also see some of these amazing
new cell and gene therapies and their tremendous
innovation and results, but they can also come
at a cost of 2 to 3,000,000 for
a treatment. And so how we think about
making those affordable affordable
and stratify the financial risk of coverage is
is really imperative.
I think many employer groups, you know, as
they look, they're trying to find solutions
to still offer their employees
great access but at an affordable price.
And many times to do this, I think
you'll see employers
and us as health payers
looking to engage their employees in their own
health and help them help us select the
best, highest performing providers. And so how we
modernize our health plans to give incentives and
provide the right digital tools
so that their employees can actually make good
decisions, and their health care selections is key
as we go forward.
The other areas that I see as far
as programs for employer groups that are really
picking up in in need is, first of
all, behavioral health. And I think you see
workforce stress as well as burnout and people
just really looking at their own behavioral health
as far as a big need, but also
the the employees' children.
There's more and more access issues as far
as behavioral health and really trying to help
employers with this big need in the market.
And then, one that's near and dear to
my heart is just solutions around women's health
and really thinking about some of the specific
treatment conditions that come through and just haven't
been as much of a focus sometimes.
And then overall,
you know, employers are also looking for convenience
for their employees. And so whether that's through
virtual or telehealth,
or also a solution that we just rolled
out with Zocdoc, which is online appointment booking.
And we had over one million hours on
care able to be booked online. And I
think consumers
are just looking for the same way that
they can go forward and, you know, order
something,
a package from Amazon or order their meals.
They wanna be able to do things online.
And and so I think how health care
is delivered in that similar matter is just
gonna be coming to the forefront. But
all of these things are gonna get at,
you know, how do we create some predictability
and how do we actually get ahead of
these rising core
rising costs for employer groups is just gonna
be really important for the future,
sustainability of employer group offerings.
Absolutely. And that and that really does reflect
what we are hearing from leaders all over
the country of really trying to support
their employer clients,
with stability
and then, you know, trying to meet that
demand,
for behavioral care, for more women's focused health
care.
That is has been top of mind from
what we're hearing as well.
I wonder if we if we shift towards
a little bit more, toward your role and
some of the work you're doing in the
day to day, Helen.
What would you say are some of the
biggest priorities for you right now, for for
your role specifically,
for the health plan as a whole in
the year ahead? I mean, really, what are
you trying to achieve as chief growth officer
for Blue Shield of California?
Yep. One of my biggest priorities is how
do we not only come up with great
ideas to innovate, but also implement those ideas?
I always say to my team, great ideas
are great, but implemented ideas are are even
better, and it's what the market's looking for.
And I think as we come up across
this year, how we come up with joint
efforts with providers to actually
actually good at the cost of of health
care that's rising,
but then also create stability for our members
and employer groups and plan sponsors
so that we can lead through all of
these policy changes
and and really bring the right outcomes to
the market.
And to do that, I think you have
to really instill some resiliency
in your teams right now because there's many
challenges
that they're taking
taking on and these policy changes,
a lot of times, are actually in conflict,
right, with our mission. And our mission has
been to actually increase care and coverage. And
so to think about, you know, millions of
people across the country that may be losing
coverage is
is really hard, I think, for sometimes the
for the teams to fathom.
And as a nonprofit health plan, we're focused
on providing more
comprehensive coverage that's reflective of community needs. So
so the policy changes can fly in the
face of that.
We'll be working really closely, as I said,
with providers
to interpret and implement and then ensure that
continuity of care, that's definitely
at the forefront.
And these changes are gonna hit not only
urban areas, but also rural. And so how
we support providers is gonna be really important.
And and for us, you know, we don't
look
to change how we show up in the
market.
We serve people in every county in California,
and we were the first to do so
on the exchange, and and we'll continue to
be doing that. And I think as we
all reflect across the system,
as more and more people become uninsured because
of these policy implications,
there's gonna be a ripple effect. And people
end up in the ER with more pervasive
conditions, and
that could really end up stretching the capacity
in hospitals,
and the cost then just ends up being
spread back to employer groups. And so how
we prevent that is is really at the
forefront
of our mission
and, you know, one that the team and
I are working really hard on.
Yeah. And I I think that's such an
interesting point,
of what you just said there, Alan, that,
that health plan leaders all over the country
typically are in this work because they wanna
make a difference. And it is tough for
for many to see some of these some
of these uninsured rates
go back up,
in the face of the work that so
many do in the day to day. So
I, you know, I I think that's such
a interesting point that you made there.
And in that vein, I I would ask,
is there anything that you would wanna share
with the other
insurance leaders listening in right now from all
over the country? Any any final thoughts or
final bits of advice that you would wanna
share with them as we close out the
year?
I think it's gonna take all of our
collective efforts working together. And I think how
we put forward solid plans and and consistent
consistency in those,
you know, we're doing a lot of scenario
planning,
of course, and and that's to bring the
right kind of stability
to the market and and also how we
deliver high quality care with our partners. And
so you can't stay in a vacuum. You
really have to get out there
and work with your local state policymakers
because,
you know, as these policy changes come down,
they're not always all fully vetted. And so
how we carefully plan, I think, across all
our different
partners and providers
and and even with other health plans is
gonna be really important. And so, you know,
I like to think about
particular how we deliver in the health care
space as more of a partnership
that's focused on that and less transactional.
And being in health care always has its
challenges. As you referenced, we're we're generally the
leaders in it, very mission focused. And I
think if we keep the mission at hand
first and the forefront,
we're gonna be successful together.
And, you know, there's millions of Americans depending
on us to do that, and
I sure wanna be be the ones that
help leave a legacy
that really help bring,
the coverage and affordability
that that's worthy of our friends and families.
That's our mission here at Blue Shield of
California, and I know many of my fellow
leaders across,
health plans across America feel that same way.
Wonderful. Well, Ellen, I wanna thank you for
taking the time to sit down with us
on the podcast today and for sharing your
insights with our audience. We really appreciate it.
Thanks, Jacob. I really enjoyed the conversation.
Likewise. And to our listeners, if you'd like
to listen to more podcasts from Becker's Health
Care, you can visit beckershospitalreview.com.