This is where health insurance leadership comes together.
Becker's fourth annual spring payer issues roundtable brings
together over 400 payer and health plan executives
and more than 100 speakers to Chicago April.
This year's event includes keynote conversations with the
industry's top leaders and former president George W.
Bush. For the full agenda and event details,
visit beckershospitalreview.com
and click on the events tab in the
upper right. We're looking forward to hosting you
here in Chicago.
Hello, everyone, and welcome to the Becker's Healthcare
Podcast. I'm Scott King. Thrilled today to be
joined by a very special guest, Howard Weiss,
vice president, government affairs with EmblemHealth.
Howard, how are you doing today?
Just fine. Thanks for having me. Thanks so
much for joining us. I I really appreciate
it. You know, I know we're gonna get
into a lot of kind of the big
trends and topics,
facing health care today. But before we get
started, could you please just tell me a
little bit about your background, Howard, and and
how you started your career journey?
Sure. So,
I work at EmblemHealth.
We are a nonprofit health insurer
headquartered in New York City and mostly serving
Downstate New York.
I've
been working in government relations here for about
nine years.
Before that, I worked at the National Trade
Association
representing health insurers,
AHIP, for fifteen years in Washington DC,
mostly focusing on Medicare and Medicaid issues. And
before that, worked at another trade association
in DC,
representing Chang pharmacies.
Thanks so much for sharing that background info
there, Howard.
The first topic I wanted to get to,
first question I have for you is how
are your relationships with providers
changing as both sides face cost pressure and
workforce shortages?
Yeah.
It's a very, interesting question.
I think speaking at the system level,
you know, that the American health care system
is being challenged by consumers and government in
unprecedented
ways.
Despite all the good collaboration between plans and
providers
to develop arrangements rewarding value over volume, there
remains
strong levels of dissatisfaction
about the quality and cost of care.
At EmblemHealth, we have a unique relationship with
a physician practice called
AdvantageCare
Physicians of New York or ACPMY
that provides primary specialty care to about half
a million people in New York City and
Long Island.
We have seen from our arrangements with ACPMY
and others
how developing value based arrangements
holding both the plan and provider accountable
leads to better outcomes and more affordable care.
However, in many cases, especially with some of
the large hospital systems,
we have had difficulty developing
similar types of arrangements.
We at EmblemHealth firmly believe that the best
solutions to
the the growing dissatisfaction with the health care
system
will come from collaborations between plans and providers.
How however, we will need to meet each
other halfway
to create real changes for the people we
serve.
Now from a health plan perspective, that means
fixing our systems that take clinicians
away from treating patients and reduce the availability
of services people really need.
That includes taking a serious look at our
utilization management processes,
eliminating them to services where there is significant
evidence of misuse,
and making it as easy as possible for
providers to work with us.
From a provider perspective,
there needs to be a recognition that high,
that the high prices they sometimes charge
affect everyone.
Health insurance usually protects consumers
from,
the high list prices
for expensive services like hospital stays and some
prescription drugs.
And that's really important because that's the way
people access care.
However, these high price increases,
these high prices
increase the cost of health insurance,
which means fewer people can afford the coverage
that they need.
We really hope that the pressures that we
all we are all under
from consumers and from policymakers
will lead to more constructive collaborations
on solutions that best serve our customers.
Howard, I I wanna follow-up some on something
you said there. It's really interesting. You know,
obviously, we we've heard about, you know, the
this administration, how it's affecting health care, the
regulations. But you you mentioned consumers, and I
thought that was interesting. How are you
seeing consumer and maybe consumer demands kind of
challenge,
the system and and the work health plans
are doing?
Yeah. I mean, I think,
what we're hearing from policymakers
in large part reflects the real concerns of
consumers.
And we've heard loud and clear,
and I think in more intense ways than
we have in the twenty five years that
I've been doing this,
that
there's dissatisfaction
with the high cost of health care and,
yes, from some of the utilization
managements,
techniques that plans use, which people
see as
denying them access to the care they need.
So
not only from a micro sort of market
level
perspective, from a broader perspective,
these are the real pressures that, you know,
ICR industry is under,
and how we navigate those pressures
can really dictate the industry's future.
Absolutely.
And moving along to the next topic, where
do you see the biggest gap today between
payer strategy
and operational execution?
Yeah.
Well, I wanna preface my response because you
might think I won't be getting to the
answer, but I promise you I will.
The I am really fortunate to work for
a company that understands how active participation
in communities
is not only good practice, it's good business
strategy.
For example, EmblemHealth really made,
recently made significant
investments
in addressing food insecurity in the areas we
serve.
My colleague, Heather Tamberrino, our chief financial officer,
recorded
a Becker's podcast on this initiative not too
long ago that I would really encourage others
to listen to to better understand the business
case for doing good.
And in addition, EmblemHealth operates 15 neighborhood care
centers
throughout New York City where we offer free
services to all members in the community, so
not just our members.
And these services include wellness classes,
help with social service navigation,
and nutritious food, giveaways.
However, as we have pursued this approach, we
have often found that there's a gap between
strategy and successful execution
at the community level
where these well intentioned strategies
meet real world barriers.
When the programs we operate don't reflect how
members and communities access care,
it can create a a sense of disconnect
or distrust
in many of the entities that are responsible
for their care.
We saw this recently play out in our
community diabetes wellness program,
a free community based initiative focused on prevention,
education,
and ongoing
support,
which we piloted in The Bronx, a part
of our city that is home of diverse
communities with high levels of chronic disease.
One key takeaway,
from this project was that sustained participation
required an engagement strategy that was designed around
trust, culture, and convenience.
That meant understanding that offering classes in multiple
languages, flexibility
in class design,
whether it be in person, virtual, or hybrid
options,
and timing to fit our, our neighbor schedules
early morning, evening, and weekend classes
and bringing care to,
directly to the community we serve
in non traditional spaces
like places of worship or community centers
or local block parties.
We learned these lessons and,
after one year, the program demonstrated that a
neighborhood based model could measurably improve access, engagement,
and clinical outcomes.
We held more than a 100 diabetes
related events,
across The Bronx with,
almost 1,500
community
participants who
were able to get get screened
or get advice on,
lifestyle changes,
that they could make to be,
healthier.
So
to me, the success of this program reinforces
that
closing the gaps between strategy and successful execution
depends on meeting communities on their terms,
in their languages,
and in their neighborhoods
to build the kind of trust that improves
health care outcomes.
Yeah. I I think that that sounds like
tremendous work done in the community there, Howard.
You know, great job to everyone.
When you're able to plan and execute that
way and and you and you see the
impact it has in the community, do do
you think about what it takes to scale
something like that, or or or do you
kinda work on another initiative?
Yeah. I I mean,
we specifically chose The Bronx
to do a pilot program. I think that
those
of my colleagues,
are now thinking about ways to
more broadly offer these,
types of programs throughout the rest of the
city.
So,
for us, right, I mean, I I think
we,
not to toot our own horn, but we
approached in a very smart way,
understanding that we are trying something new,
and we want to learn from what we
were doing,
before we,
more broadly offered this type of,
this type of program.
Well, yeah, I I think that's incredible. I
think programs like that obviously make a huge
difference.
And now, Howard, if I can get you
to put on your, health plan fortune telling
hat and look into your, health plan crystal
ball, what's one investment or initiative you believe
will most reshape how health plans operate over
the next two to three years?
Well, Scott, I'm gonna surprise you with this
answer, but I'm I'm gonna mention
AI or artificial intelligence.
I'm sure you haven't heard that answer,
from
anyone
else. Right.
But we do think it has a a
a great potential,
in several different ways.
Again, I'm going to,
recommend a recent Becker's podcast with EmblemHealth's,
executive chair, Karen Ignani, and our chief medical
officer,
doctor Dan Net, in which they explain how,
our company is establishing
AI based initiatives that identify our enrollees who
are most affected by climate events like heat
waves or snowstorms
and help them connect with the resources they
need.
We also have used AI to encourage our
enrollees to get their flu vaccines
and are concerning other ways to help them
get this the services they need.
From my perspective and hitting on some of
the issues that, we discussed earlier,
my hope is that responsible use of AI
will improve health plan relationships with providers,
whether that means creating more uniform clinically based
utilization management tech standards
across the industry
or improvements to administrative processes,
AI has the potential to eliminate many consumer
concerns about the health care system.
And if you could change one regulatory or
industry practice
tomorrow to improve affordability and and access,
what would it be and why?
Yeah. Scott, as you can imagine, I'm sort
of a pie in the sky type of
person.
But I consulted with colleagues, and they recommended
that we talk about things that were actually
doable.
And as we
look at the, existing environment,
there are several achievable reforms that will reduce
cost for health plans and providers
and allow clinicians to focus on patients rather
than paperwork.
The one that always comes to our mind
is
the issue about
provider directories,
right, and the accuracy of provider directories, which
we all agree that health plan enrollees need
accurate information about the providers in our networks.
However, that means that provider offices spend hours
and hours responding to the same questions
from different health plans looking to update their
directories.
We know now that the Federal Centers for
Medicare and Medicaid Services
is working on solutions that will allow providers
to send
or may update it information
once to a database that health plans would
consult without having to,
contact their offices.
These solutions could also be a source of
credentialing information,
limiting the need for providers to submit different
forms to multiple health plans.
So that's just one if I can be
granted one and a half. You know, we
would also mention,
scope of practice reforms,
which we think also has a way of
alleviating,
pressures on
advanced clinicians so that they can focus on
what they do best and increase
satisfaction amongst other,
providers.
We're very hopeful that these changes will improve
plan provider relationships
and support more collaboration on solutions to improve
affordable access to health care services
for everyone.
And the last question I have for you,
Howard,
what issue is putting the most pressure on
health plan margins right now, and how are
you responding responding differently or are going to
respond differently in in 2026?
Yeah. I mean, I think we know that
each insurer is developing
strategies for what promises to be another challenging
year.
You know, I think that includes
dealing with high hospital and drug costs,
plus the changes to Medicaid and other public
health programs
that were put into the into place by
HR one.
As I you know, the issue that I
tend to focus on and dwell on, I
think my colleagues would probably say, is the
increased scrutiny of federal state governments
that are all focused on reducing health care
costs.
You know, as I mentioned before, I don't
think that this is an issue that we
can address alone,
and I'm very satisfied that the level of
dissatisfaction
pardon me, that we are seeing industry efforts,
to reestablish
trust
such as the national effort to voluntarily reform
prior authorization practices
led by AHIP and the Blue Cross Blue
Shield as association.
We think that that's a really significant step.
However,
in order to address
the real,
issues affecting our health care system, we need
significant cooperation from health care facilities and drug
companies
to make health insurance more affordable and increase
accountability for outcomes.
Otherwise, all of us are at risk for
creating an even larger role for government in
the health care system.
Well, I think a lot of us can
certainly agree on that, Howard, and thanks so
much for joining us on podcast and and
for a great conversation. I look forward to
working with you again in the future. Thank
you very much.