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 Becker's Healthcare podcast.
I'm Scott King. Thrilled today to be joined
by a very special guest, Heather Tamberrino,
chief financial officer with EmblemHealth.
Heather, how are you doing? Thanks so much
for joining us.
I'm great. Thanks so much for letting me
join you today. I'm so excited.
Of course. We have, you know, new year,
some same issues,
in health care and and with health plans
and and some some new ones as well.
But before we jump into all that, I
was wondering if you could just please tell
us a little bit about your background
and your career journey.
Sure thing.
I've been here now with EmblemHealth as the
chief financial officer for the last five years,
and and that entails what you would expect
it to entail, controllership,
actuarial,
FP and A, treasury,
the the norm.
And my background's a bit of a a
mixed bag. You know, I started with Deloitte,
in the traditional accounting space,
moved into
working in enterprise risk management and performance management,
and have bounced around
in both IT spaces,
operational performance spaces,
and both
profit and nonprofit.
Probably my last, twenty years has been in
the nonprofit space,
with a variety of blues,
and now here at EmblemHealth.
Well, excellent. Thank you so much for sharing
all that info. Heather, really appreciate it. You
you're coming from a lot of different, experience
and perspectives there. The first topic I wanna
get to, how are your relationships with providers
changing
as both sides face cost pressure and workforce
shortages?
Yeah. It's as you said, it's a it's
always been a question, but as with the
more recent
challenges,
it it can be a little challenging now.
But our goal is to continue
to move, focus on the relationship,
and move to value based
and really focus on integration
in a cost efficient manner.
But, you know, it's strained with those pressures.
All that said, I think what we're continuing
to do is look at opportunities
to really think about unique contracting
opportunities,
you know, hybrid
contracts, you know, blending fee for service versus
pure value based,
and really focus on what is the common
goal for both the payer and the provider.
And that's putting our members and patients right
at the middle, right at the center.
And we're working on engaging on a number
of fronts,
really focusing on educating our provider partners on,
you know, what can drive premium incentive dollars
and sharing
actionable info
in a really consultative way
and show them how that improves the outcome,
not only for the patient, but for their
reimbursement and financials.
We're also
doing things like providing predictive analytics
to our providers,
so we can help catch rising risk and
again allow both the payer and the provider
side to nudge members towards lifestyle
or
engagement
channels
and changes.
And the other thing we're trying to do
with our providers is when we think about
contracting,
it's how do we take a multiyear view
on measures and improvements. So we're not asking
a provider to step immediately into a new
reimbursement
methodology or something when they're struggling with other
cost and
revenue challenges.
And we think as long as we take
these multi year
views on measures and improvements
that can help with chronic care management, that
can help with,
both outcome improvement
on the payer and provider side.
And last, I would say
we're in a slightly unique position at Emblem
because we have our own provider group. And
given that many of our members are tied
to our own provider group, that's Advantage Care
Physicians,
this gives us a great opportunity to really
incubate and sort of test and pilot
new solutions,
new capabilities,
technologies
that really support the long term management
of our member needs. And then we can
work to extend those capabilities
to our provider or broader provider base because
we've had the opportunity to test them. And
that can help minimize cost and investment to
the providers when we're all trying to manage
through these,
this pressured period.
Where do you see the biggest gap today
between payer strategy and operational execution?
I think if you
focus on fundamental strategies
on the payer side,
it's really gonna be around
member engagement and outcomes.
And when you think about the gap,
it sort of takes two to tango, you
know, in that
in
that support of the member and getting that
outcome and engagement.
Payer strategies focused on partnership with the providers
are gonna continue to to be critical to
deliver the care and quality that our members
need.
And so Emblem's focus, our focus, is to
continue to prioritize how do we engage these
providers
through sharing data and technologies,
easing administrative processes,
creating capabilities that really support shared decisions regarding
care and patient engagement.
But but when you think about that, that's
our that's our
focus
to close that operational gap. You gotta do
that in an efficient
sort of cost effective manner. We just talked
about all the pressures both the payers and
providers are facing.
You know, one place you're gonna see people
focusing is on AI capabilities.
But we really need to be artful and
thoughtful in our strategies of AI utilization.
So we're focusing
on areas that specifically ease the administrative burden
regarding the integration of process
with the payer and the provider.
So this creates an opportunity for clinicians and
administrators
to spend time and resources really focused on
patient care and engagement
versus back office.
And when we think about,
you know, where we need to invest,
that's where we have to invest, capabilities that
meet our common goals
and and really focus on operational execution. It's
meeting those common goals, and then both sides
can come to the dance floor in a
real way for our members.
Heather, could you could you dive a little
deeper maybe into into what Emblem is kinda
looking to focus on in regards to AI
in 2026?
I would say, you know, it is one
of the key investments that most of the
payers that or providers that you'd be talking
about would be would be addressing.
If I look at it from our provider
side, it's around revenue cycle. They're looking at
AI opportunities
there.
I think if you look at it on
the health plan side,
you know and, again, this is one of
our most sort of critical initiatives.
We have to go beyond
I think many payers are gonna focus on
what's the most advantage advantageous
to the health plan itself.
And I think our initiatives will need to
go beyond
those internal operations of the health plan and
focus on how do we extract data,
focus on driving it to the payer
in a way that's easy for them to
digest into their systems.
Absolutely.
Heather, let me ask you, what's one investment
or initiative you believe will most
reshape how health plans operate over the next
two to three years?
I mean, we started to talk about it.
Right? We started to talk about
AI, and I think that is going to
be one of the ways.
But, again,
that that AI focus
and investment focus really around the integration with
providers,
deepening both sides, technical capabilities, and common goals.
It doesn't have to just be AI. Right?
It can be looking to say, how do
we leverage data integration? How do we leverage
other components
that allows us to
drive actionable activities
to the providers in such a way that
they can utilize it in a fashion
that that's where we're spending a lot of
our time, interoperability,
engagement of data.
And as we continue to see these escalating
costs
and these diminishing revenue levers,
partnership in these initiatives for data exchanges that
really manage outcomes
and risk and reduce system wide administrative costs
will be the key to ongoing longevity.
There's an increasing urgency here.
Again, leveraging
our provider practice ACP,
it's a good way to test
the interaction
systemically
between the two, the the payer and the
provider,
and make sure that as we're deploying these
investments, we can make sure that it works
in real time, and then we can lever
that to some of our other,
provider partners.
If you could change one regulatory
or industry practice tomorrow
to improve affordability and access,
what would it be and why?
Well, if you're only giving me one,
I would say
and and we're sort of I I think
I keep coming back to a similar theme.
It really would be how do we focus
on a framework?
Can be an industry framework, but a framework
that really allows us to integrate decision support
right in the electronic health record.
You know, how do we provide actionable data
and feedback
at the point of encounter
so that it helps delivered improved quality and
improved outcomes?
This framework can leverage
provider data and payer data
to allow providers to close care gaps immediately.
This can eliminate
this back and forth
post visit with the provider.
Limiting that follow-up,
you know, between the health plans and their
partners,
you know, helps
with the the overall cost structure that we've
been talking about. It helps align incentives.
It makes transparency
better.
If you you said one. If you were
gonna let me pick an additional area of
opportunity,
you hear about it all the time, but
how do we think differently
about prior authorization?
The goal between a payer and a provider,
it it's the same.
We wanna make sure that we're delivering the
right care at the right time and location.
Location's important
to to us.
You know? And in emblem, that's what we're
focused on today. We continue to sort of
iterate and ideate on how do we
provide more immediate electronic feedback,
ease the entire process electronically,
only seek to address
areas of most critical need.
And then this really helps avoid the delay
in care
that is a constant point of friction, but
more than friction trust for all parties, whether
you're the member or the provider or the
payer. So
I picked two.
One really around
actionable common framework in the electronic health record
that we can support each other. And then
the the second one really around how do
we think continue to think differently about
where and how to do prior authorization, but
do it in a way that's really
efficient
and immediate.
I'm glad you broke the rules and pick
two because prior authorization is is a very
big deal. I appreciate your your thoughts on
it there, Heather. The last question I have
for you,
what issue is putting the most pressure on
health plan margins right now, and how are
you responding differently or or are going to
respond differently in 2026?
It's interesting you asked that because you could
pick five or six things that are putting
pressure on health plan margins right now.
One thing that I would say we're explicitly
focused on, and I bet if you ask
many payers, it's it's a or providers,
it's a common item.
It's really around pharmacy costs
because I think anything you look at or
read, whether you're a national,
for profit, not for profit,
pick a product segment,
pharmacy costs today are continuing to rise and
continuing to be a pressure point.
What are we doing differently?
Really important thing, and we started this back
in 2024.
We reevaluated
our PBM,
and we selected a partner that we thought
really had a similar mission and goals
that we had with and a real focus
on transparency
and growth.
So EmblemHealth recently announced that we did pick
a new pharmacy benefit collaboration,
with Prime Therapeutics, and we think there's an
opportunity to really provide a more transparent
and affordable
pharmacy experience for our members.
And I think it's more
really focusing on giving members,
you know, within a construct,
more choice and convenience and how they access
their medications,
including, like, real time competitive referrals for specialty
prescription drugs,
and,
you know, fast home delivery through Amazon pharmacy.
You know, this is a time when both
health care and pharmacy costs are rising. That's
putting pressure on our margins,
but we're trying to introduce,
you know, innovative solutions
that give our members
real time information,
you know, clear picture of the cost for
them
and convenience for them that puts their needs
right in front. And we think by putting
our members sort of more in the driver's
seat of their pharmacy experience,
we can potentially remove some of the friction
points
that tend to lead towards nonadherence,
missed doses, you know, and poor health outcomes.
That drives cost into the entire system for
everybody.
The transparency components that we're working through as
well
with Prime also puts us in a position
where we can more actively manage the cost.
We know where they're driving their margin. We
know how to get the most affordable outcomes.
So it's a bit of a win win
for all of us, and that was critical
in our choice.
The last little bit on that, when you
think about pharmacy
beyond what we've discussed,
it's really about the gene therapies. Right? As
more and more gene therapies emerge,
we don't have all the answers, nor does
the rest of the industry. But there is
a real need to address
thoughtful care management
and look at risk transfer arrangements that work
for all the parties when you're talking about
these drugs that are
really critical to improving
member health,
but also common 2 and $3,000,000
price tags per dosage.
So those would be the couple of key
things that I would highlight we're really focusing
on
in 2026
as one of the pressure points
on our health plan margins.
Heather, thanks so much for joining us on
the podcast. It was a great conversation. We're
really looking forward to you speaking at the
spring payer issues roundtable.
Thank you so much for inviting me. Happy
to participate, and and I think it's gonna
be great fun when we get together at
the roundtable.
Definitely will be.