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This is where health insurance leadership comes together.

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Becker's fourth annual spring payer issues roundtable brings

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together over 400 payer and health plan executives

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and more than 100 speakers to Chicago April.

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This year's event includes keynote conversations with the

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industry's top leaders and former president George W.

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Bush. For the full agenda and event details,

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visit beckershospitalreview.com

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and click on the events tab in the

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upper right. We're looking forward to hosting you

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here in Chicago.

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Hello, everyone, and welcome to the Becker's Healthcare

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Podcast. I'm Scott King. Thrilled today to be

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joined by a very special guest, Howard Weiss,

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vice president, government affairs with EmblemHealth.

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Howard, how are you doing today?

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Just fine. Thanks for having me. Thanks so

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much for joining us. I I really appreciate

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it. You know, I know we're gonna get

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into a lot of kind of the big

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trends and topics,

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facing health care today. But before we get

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started, could you please just tell me a

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little bit about your background, Howard, and and

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how you started your career journey?

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Sure. So,

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I work at EmblemHealth.

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We are a nonprofit health insurer

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headquartered in New York City and mostly serving

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Downstate New York.

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I've

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been working in government relations here for about

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nine years.

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Before that, I worked at the National Trade

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Association

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representing health insurers,

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AHIP, for fifteen years in Washington DC,

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mostly focusing on Medicare and Medicaid issues. And

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before that, worked at another trade association

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in DC,

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representing Chang pharmacies.

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Thanks so much for sharing that background info

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there, Howard.

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The first topic I wanted to get to,

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first question I have for you is how

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are your relationships with providers

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changing as both sides face cost pressure and

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workforce shortages?

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Yeah.

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It's a very, interesting question.

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I think speaking at the system level,

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you know, that the American health care system

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is being challenged by consumers and government in

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unprecedented

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ways.

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Despite all the good collaboration between plans and

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providers

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to develop arrangements rewarding value over volume, there

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remains

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strong levels of dissatisfaction

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about the quality and cost of care.

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At EmblemHealth, we have a unique relationship with

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a physician practice called

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AdvantageCare

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Physicians of New York or ACPMY

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that provides primary specialty care to about half

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a million people in New York City and

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Long Island.

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We have seen from our arrangements with ACPMY

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and others

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how developing value based arrangements

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holding both the plan and provider accountable

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leads to better outcomes and more affordable care.

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However, in many cases, especially with some of

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the large hospital systems,

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we have had difficulty developing

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similar types of arrangements.

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We at EmblemHealth firmly believe that the best

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solutions to

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the the growing dissatisfaction with the health care

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system

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will come from collaborations between plans and providers.

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How however, we will need to meet each

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other halfway

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to create real changes for the people we

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serve.

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Now from a health plan perspective, that means

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fixing our systems that take clinicians

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away from treating patients and reduce the availability

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of services people really need.

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That includes taking a serious look at our

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utilization management processes,

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eliminating them to services where there is significant

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evidence of misuse,

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and making it as easy as possible for

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providers to work with us.

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From a provider perspective,

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there needs to be a recognition that high,

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that the high prices they sometimes charge

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affect everyone.

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Health insurance usually protects consumers

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from,

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the high list prices

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for expensive services like hospital stays and some

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prescription drugs.

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And that's really important because that's the way

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people access care.

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However, these high price increases,

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these high prices

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increase the cost of health insurance,

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which means fewer people can afford the coverage

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that they need.

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We really hope that the pressures that we

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all we are all under

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from consumers and from policymakers

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will lead to more constructive collaborations

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on solutions that best serve our customers.

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Howard, I I wanna follow-up some on something

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you said there. It's really interesting. You know,

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obviously, we we've heard about, you know, the

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this administration, how it's affecting health care, the

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regulations. But you you mentioned consumers, and I

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thought that was interesting. How are you

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seeing consumer and maybe consumer demands kind of

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challenge,

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the system and and the work health plans

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are doing?

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Yeah. I mean, I think,

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what we're hearing from policymakers

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in large part reflects the real concerns of

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consumers.

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And we've heard loud and clear,

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and I think in more intense ways than

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we have in the twenty five years that

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I've been doing this,

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that

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there's dissatisfaction

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with the high cost of health care and,

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yes, from some of the utilization

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managements,

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techniques that plans use, which people

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see as

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denying them access to the care they need.

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So

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not only from a micro sort of market

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level

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perspective, from a broader perspective,

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these are the real pressures that, you know,

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ICR industry is under,

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and how we navigate those pressures

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can really dictate the industry's future.

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Absolutely.

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And moving along to the next topic, where

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do you see the biggest gap today between

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payer strategy

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and operational execution?

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Yeah.

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Well, I wanna preface my response because you

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might think I won't be getting to the

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answer, but I promise you I will.

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The I am really fortunate to work for

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a company that understands how active participation

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in communities

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is not only good practice, it's good business

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strategy.

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For example, EmblemHealth really made,

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recently made significant

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investments

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in addressing food insecurity in the areas we

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serve.

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My colleague, Heather Tamberrino, our chief financial officer,

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recorded

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a Becker's podcast on this initiative not too

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long ago that I would really encourage others

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to listen to to better understand the business

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case for doing good.

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And in addition, EmblemHealth operates 15 neighborhood care

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centers

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throughout New York City where we offer free

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services to all members in the community, so

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not just our members.

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And these services include wellness classes,

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help with social service navigation,

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and nutritious food, giveaways.

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However, as we have pursued this approach, we

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have often found that there's a gap between

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strategy and successful execution

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at the community level

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where these well intentioned strategies

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meet real world barriers.

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When the programs we operate don't reflect how

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members and communities access care,

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it can create a a sense of disconnect

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or distrust

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in many of the entities that are responsible

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for their care.

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We saw this recently play out in our

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community diabetes wellness program,

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a free community based initiative focused on prevention,

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education,

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and ongoing

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support,

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which we piloted in The Bronx, a part

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of our city that is home of diverse

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communities with high levels of chronic disease.

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One key takeaway,

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from this project was that sustained participation

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required an engagement strategy that was designed around

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trust, culture, and convenience.

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That meant understanding that offering classes in multiple

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languages, flexibility

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in class design,

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whether it be in person, virtual, or hybrid

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options,

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and timing to fit our, our neighbor schedules

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early morning, evening, and weekend classes

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and bringing care to,

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directly to the community we serve

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in non traditional spaces

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like places of worship or community centers

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or local block parties.

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We learned these lessons and,

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after one year, the program demonstrated that a

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neighborhood based model could measurably improve access, engagement,

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and clinical outcomes.

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We held more than a 100 diabetes

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related events,

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across The Bronx with,

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almost 1,500

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community

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participants who

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were able to get get screened

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or get advice on,

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lifestyle changes,

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that they could make to be,

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healthier.

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So

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to me, the success of this program reinforces

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that

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closing the gaps between strategy and successful execution

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depends on meeting communities on their terms,

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in their languages,

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and in their neighborhoods

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to build the kind of trust that improves

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health care outcomes.

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Yeah. I I think that that sounds like

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tremendous work done in the community there, Howard.

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You know, great job to everyone.

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When you're able to plan and execute that

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way and and you and you see the

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impact it has in the community, do do

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you think about what it takes to scale

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something like that, or or or do you

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kinda work on another initiative?

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Yeah. I I mean,

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we specifically chose The Bronx

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to do a pilot program. I think that

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those

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of my colleagues,

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are now thinking about ways to

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more broadly offer these,

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types of programs throughout the rest of the

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city.

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So,

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for us, right, I mean, I I think

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we,

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not to toot our own horn, but we

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approached in a very smart way,

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understanding that we are trying something new,

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and we want to learn from what we

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were doing,

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before we,

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more broadly offered this type of,

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this type of program.

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Well, yeah, I I think that's incredible. I

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think programs like that obviously make a huge

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difference.

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And now, Howard, if I can get you

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to put on your, health plan fortune telling

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hat and look into your, health plan crystal

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ball, what's one investment or initiative you believe

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will most reshape how health plans operate over

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the next two to three years?

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Well, Scott, I'm gonna surprise you with this

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answer, but I'm I'm gonna mention

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AI or artificial intelligence.

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I'm sure you haven't heard that answer,

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from

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anyone

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else. Right.

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But we do think it has a a

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a great potential,

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in several different ways.

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Again, I'm going to,

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recommend a recent Becker's podcast with EmblemHealth's,

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executive chair, Karen Ignani, and our chief medical

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officer,

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doctor Dan Net, in which they explain how,

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our company is establishing

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AI based initiatives that identify our enrollees who

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are most affected by climate events like heat

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waves or snowstorms

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and help them connect with the resources they

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need.

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We also have used AI to encourage our

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enrollees to get their flu vaccines

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and are concerning other ways to help them

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get this the services they need.

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From my perspective and hitting on some of

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the issues that, we discussed earlier,

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my hope is that responsible use of AI

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will improve health plan relationships with providers,

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whether that means creating more uniform clinically based

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utilization management tech standards

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across the industry

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or improvements to administrative processes,

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AI has the potential to eliminate many consumer

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concerns about the health care system.

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And if you could change one regulatory or

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industry practice

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tomorrow to improve affordability and and access,

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what would it be and why?

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Yeah. Scott, as you can imagine, I'm sort

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of a pie in the sky type of

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person.

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But I consulted with colleagues, and they recommended

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that we talk about things that were actually

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doable.

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And as we

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look at the, existing environment,

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there are several achievable reforms that will reduce

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cost for health plans and providers

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and allow clinicians to focus on patients rather

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than paperwork.

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The one that always comes to our mind

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is

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the issue about

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provider directories,

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right, and the accuracy of provider directories, which

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we all agree that health plan enrollees need

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accurate information about the providers in our networks.

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However, that means that provider offices spend hours

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and hours responding to the same questions

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from different health plans looking to update their

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directories.

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We know now that the Federal Centers for

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Medicare and Medicaid Services

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is working on solutions that will allow providers

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to send

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or may update it information

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once to a database that health plans would

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consult without having to,

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contact their offices.

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These solutions could also be a source of

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credentialing information,

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limiting the need for providers to submit different

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forms to multiple health plans.

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So that's just one if I can be

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granted one and a half. You know, we

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would also mention,

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scope of practice reforms,

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which we think also has a way of

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alleviating,

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pressures on

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advanced clinicians so that they can focus on

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what they do best and increase

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satisfaction amongst other,

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providers.

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We're very hopeful that these changes will improve

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plan provider relationships

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and support more collaboration on solutions to improve

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affordable access to health care services

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for everyone.

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And the last question I have for you,

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Howard,

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what issue is putting the most pressure on

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health plan margins right now, and how are

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you responding responding differently or are going to

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respond differently in in 2026?

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Yeah. I mean, I think we know that

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each insurer is developing

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strategies for what promises to be another challenging

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year.

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You know, I think that includes

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dealing with high hospital and drug costs,

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plus the changes to Medicaid and other public

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health programs

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that were put into the into place by

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HR one.

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As I you know, the issue that I

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tend to focus on and dwell on, I

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think my colleagues would probably say, is the

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increased scrutiny of federal state governments

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that are all focused on reducing health care

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costs.

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You know, as I mentioned before, I don't

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think that this is an issue that we

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can address alone,

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and I'm very satisfied that the level of

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dissatisfaction

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pardon me, that we are seeing industry efforts,

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to reestablish

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trust

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such as the national effort to voluntarily reform

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prior authorization practices

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led by AHIP and the Blue Cross Blue

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Shield as association.

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We think that that's a really significant step.

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However,

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in order to address

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the real,

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issues affecting our health care system, we need

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significant cooperation from health care facilities and drug

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companies

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to make health insurance more affordable and increase

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accountability for outcomes.

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Otherwise, all of us are at risk for

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creating an even larger role for government in

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the health care system.

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Well, I think a lot of us can

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certainly agree on that, Howard, and thanks so

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much for joining us on podcast and and

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for a great conversation. I look forward to

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working with you again in the future. Thank

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00:15:35,095 --> 00:15:35,995
you very much.