1 00:00:02,240 --> 00:00:05,059 This is where health insurance leadership comes together. 2 00:00:05,279 --> 00:00:08,960 Becker's fourth annual spring payer issues roundtable brings 3 00:00:08,960 --> 00:00:12,259 together over 400 payer and health plan executives 4 00:00:12,400 --> 00:00:16,524 and more than 100 speakers to Chicago April. 5 00:00:16,904 --> 00:00:19,785 This year's event includes keynote conversations with the 6 00:00:19,785 --> 00:00:23,064 industry's top leaders and former president George W. 7 00:00:23,064 --> 00:00:25,704 Bush. For the full agenda and event details, 8 00:00:25,704 --> 00:00:27,785 visit beckershospitalreview.com 9 00:00:27,785 --> 00:00:29,224 and click on the events tab in the 10 00:00:29,224 --> 00:00:31,519 upper right. We're looking forward to hosting you 11 00:00:31,519 --> 00:00:32,659 here in Chicago. 12 00:00:34,000 --> 00:00:36,500 Hello, everyone, and welcome to Becker's Healthcare podcast. 13 00:00:36,719 --> 00:00:38,719 I'm Scott King. Thrilled today to be joined 14 00:00:38,719 --> 00:00:40,899 by a very special guest, Heather Tamberrino, 15 00:00:41,280 --> 00:00:43,695 chief financial officer with EmblemHealth. 16 00:00:44,074 --> 00:00:45,274 Heather, how are you doing? Thanks so much 17 00:00:45,274 --> 00:00:46,254 for joining us. 18 00:00:46,634 --> 00:00:49,274 I'm great. Thanks so much for letting me 19 00:00:49,274 --> 00:00:50,814 join you today. I'm so excited. 20 00:00:51,354 --> 00:00:53,195 Of course. We have, you know, new year, 21 00:00:53,195 --> 00:00:54,254 some same issues, 22 00:00:54,795 --> 00:00:56,795 in health care and and with health plans 23 00:00:56,795 --> 00:00:59,210 and and some some new ones as well. 24 00:00:59,210 --> 00:01:00,489 But before we jump into all that, I 25 00:01:00,489 --> 00:01:01,850 was wondering if you could just please tell 26 00:01:01,850 --> 00:01:03,469 us a little bit about your background 27 00:01:03,929 --> 00:01:05,069 and your career journey. 28 00:01:05,849 --> 00:01:06,569 Sure thing. 29 00:01:07,369 --> 00:01:09,609 I've been here now with EmblemHealth as the 30 00:01:09,609 --> 00:01:12,509 chief financial officer for the last five years, 31 00:01:12,745 --> 00:01:14,905 and and that entails what you would expect 32 00:01:14,905 --> 00:01:16,364 it to entail, controllership, 33 00:01:16,905 --> 00:01:17,405 actuarial, 34 00:01:18,344 --> 00:01:19,564 FP and A, treasury, 35 00:01:20,744 --> 00:01:21,805 the the norm. 36 00:01:22,185 --> 00:01:23,944 And my background's a bit of a a 37 00:01:23,944 --> 00:01:26,685 mixed bag. You know, I started with Deloitte, 38 00:01:27,370 --> 00:01:29,310 in the traditional accounting space, 39 00:01:30,409 --> 00:01:31,390 moved into 40 00:01:31,689 --> 00:01:35,230 working in enterprise risk management and performance management, 41 00:01:36,170 --> 00:01:37,549 and have bounced around 42 00:01:38,010 --> 00:01:40,349 in both IT spaces, 43 00:01:40,650 --> 00:01:42,349 operational performance spaces, 44 00:01:43,424 --> 00:01:44,405 and both 45 00:01:44,784 --> 00:01:45,844 profit and nonprofit. 46 00:01:46,944 --> 00:01:49,265 Probably my last, twenty years has been in 47 00:01:49,265 --> 00:01:50,644 the nonprofit space, 48 00:01:51,104 --> 00:01:52,644 with a variety of blues, 49 00:01:53,104 --> 00:01:54,484 and now here at EmblemHealth. 50 00:01:55,459 --> 00:01:56,979 Well, excellent. Thank you so much for sharing 51 00:01:56,979 --> 00:01:59,299 all that info. Heather, really appreciate it. You 52 00:01:59,379 --> 00:02:01,299 you're coming from a lot of different, experience 53 00:02:01,299 --> 00:02:03,619 and perspectives there. The first topic I wanna 54 00:02:03,619 --> 00:02:06,359 get to, how are your relationships with providers 55 00:02:06,500 --> 00:02:07,000 changing 56 00:02:07,459 --> 00:02:09,959 as both sides face cost pressure and workforce 57 00:02:10,019 --> 00:02:10,519 shortages? 58 00:02:11,594 --> 00:02:14,314 Yeah. It's as you said, it's a it's 59 00:02:14,314 --> 00:02:17,435 always been a question, but as with the 60 00:02:17,435 --> 00:02:18,174 more recent 61 00:02:18,634 --> 00:02:19,134 challenges, 62 00:02:19,514 --> 00:02:21,435 it it can be a little challenging now. 63 00:02:21,435 --> 00:02:24,014 But our goal is to continue 64 00:02:24,555 --> 00:02:26,414 to move, focus on the relationship, 65 00:02:27,330 --> 00:02:29,030 and move to value based 66 00:02:29,409 --> 00:02:31,270 and really focus on integration 67 00:02:31,650 --> 00:02:33,510 in a cost efficient manner. 68 00:02:34,050 --> 00:02:36,629 But, you know, it's strained with those pressures. 69 00:02:37,170 --> 00:02:39,510 All that said, I think what we're continuing 70 00:02:39,569 --> 00:02:40,950 to do is look at opportunities 71 00:02:41,775 --> 00:02:43,955 to really think about unique contracting 72 00:02:44,655 --> 00:02:45,155 opportunities, 73 00:02:45,615 --> 00:02:46,514 you know, hybrid 74 00:02:46,814 --> 00:02:49,694 contracts, you know, blending fee for service versus 75 00:02:49,694 --> 00:02:50,915 pure value based, 76 00:02:51,455 --> 00:02:53,935 and really focus on what is the common 77 00:02:53,935 --> 00:02:55,775 goal for both the payer and the provider. 78 00:02:55,775 --> 00:02:58,229 And that's putting our members and patients right 79 00:02:58,229 --> 00:03:00,009 at the middle, right at the center. 80 00:03:00,789 --> 00:03:02,949 And we're working on engaging on a number 81 00:03:02,949 --> 00:03:03,689 of fronts, 82 00:03:04,229 --> 00:03:07,930 really focusing on educating our provider partners on, 83 00:03:07,989 --> 00:03:10,889 you know, what can drive premium incentive dollars 84 00:03:10,949 --> 00:03:11,770 and sharing 85 00:03:12,584 --> 00:03:13,724 actionable info 86 00:03:14,745 --> 00:03:16,764 in a really consultative way 87 00:03:17,544 --> 00:03:19,625 and show them how that improves the outcome, 88 00:03:19,625 --> 00:03:21,644 not only for the patient, but for their 89 00:03:21,784 --> 00:03:23,245 reimbursement and financials. 90 00:03:24,185 --> 00:03:25,004 We're also 91 00:03:25,480 --> 00:03:28,140 doing things like providing predictive analytics 92 00:03:28,680 --> 00:03:29,580 to our providers, 93 00:03:30,360 --> 00:03:33,240 so we can help catch rising risk and 94 00:03:33,240 --> 00:03:35,719 again allow both the payer and the provider 95 00:03:35,719 --> 00:03:38,300 side to nudge members towards lifestyle 96 00:03:38,680 --> 00:03:39,180 or 97 00:03:39,560 --> 00:03:40,060 engagement 98 00:03:40,520 --> 00:03:40,965 channels 99 00:03:41,844 --> 00:03:42,584 and changes. 100 00:03:43,525 --> 00:03:45,125 And the other thing we're trying to do 101 00:03:45,125 --> 00:03:47,384 with our providers is when we think about 102 00:03:47,444 --> 00:03:47,944 contracting, 103 00:03:48,644 --> 00:03:51,064 it's how do we take a multiyear view 104 00:03:51,604 --> 00:03:54,245 on measures and improvements. So we're not asking 105 00:03:54,245 --> 00:03:57,389 a provider to step immediately into a new 106 00:03:58,169 --> 00:03:58,669 reimbursement 107 00:03:58,969 --> 00:04:01,770 methodology or something when they're struggling with other 108 00:04:01,770 --> 00:04:02,669 cost and 109 00:04:03,050 --> 00:04:04,110 revenue challenges. 110 00:04:04,650 --> 00:04:06,090 And we think as long as we take 111 00:04:06,090 --> 00:04:07,229 these multi year 112 00:04:07,689 --> 00:04:09,389 views on measures and improvements 113 00:04:10,074 --> 00:04:12,394 that can help with chronic care management, that 114 00:04:12,394 --> 00:04:13,215 can help with, 115 00:04:13,995 --> 00:04:15,534 both outcome improvement 116 00:04:15,834 --> 00:04:17,535 on the payer and provider side. 117 00:04:17,914 --> 00:04:19,694 And last, I would say 118 00:04:20,555 --> 00:04:23,035 we're in a slightly unique position at Emblem 119 00:04:23,035 --> 00:04:25,439 because we have our own provider group. And 120 00:04:25,439 --> 00:04:27,600 given that many of our members are tied 121 00:04:27,600 --> 00:04:30,319 to our own provider group, that's Advantage Care 122 00:04:30,319 --> 00:04:30,819 Physicians, 123 00:04:31,600 --> 00:04:34,100 this gives us a great opportunity to really 124 00:04:34,319 --> 00:04:36,660 incubate and sort of test and pilot 125 00:04:37,279 --> 00:04:38,020 new solutions, 126 00:04:38,480 --> 00:04:39,220 new capabilities, 127 00:04:39,920 --> 00:04:40,420 technologies 128 00:04:41,435 --> 00:04:43,854 that really support the long term management 129 00:04:45,115 --> 00:04:46,875 of our member needs. And then we can 130 00:04:46,875 --> 00:04:48,654 work to extend those capabilities 131 00:04:49,035 --> 00:04:52,394 to our provider or broader provider base because 132 00:04:52,394 --> 00:04:54,920 we've had the opportunity to test them. And 133 00:04:54,920 --> 00:04:57,560 that can help minimize cost and investment to 134 00:04:57,560 --> 00:05:00,279 the providers when we're all trying to manage 135 00:05:00,279 --> 00:05:01,100 through these, 136 00:05:01,480 --> 00:05:02,699 this pressured period. 137 00:05:03,800 --> 00:05:05,740 Where do you see the biggest gap today 138 00:05:05,879 --> 00:05:08,939 between payer strategy and operational execution? 139 00:05:10,055 --> 00:05:11,035 I think if you 140 00:05:12,055 --> 00:05:14,235 focus on fundamental strategies 141 00:05:14,855 --> 00:05:16,074 on the payer side, 142 00:05:16,455 --> 00:05:18,154 it's really gonna be around 143 00:05:18,455 --> 00:05:20,154 member engagement and outcomes. 144 00:05:20,615 --> 00:05:22,314 And when you think about the gap, 145 00:05:22,660 --> 00:05:24,420 it sort of takes two to tango, you 146 00:05:24,420 --> 00:05:25,480 know, in that 147 00:05:25,860 --> 00:05:26,360 in 148 00:05:26,819 --> 00:05:28,819 that support of the member and getting that 149 00:05:28,819 --> 00:05:29,879 outcome and engagement. 150 00:05:30,660 --> 00:05:33,540 Payer strategies focused on partnership with the providers 151 00:05:33,540 --> 00:05:36,295 are gonna continue to to be critical to 152 00:05:36,295 --> 00:05:38,615 deliver the care and quality that our members 153 00:05:38,615 --> 00:05:39,115 need. 154 00:05:39,814 --> 00:05:43,014 And so Emblem's focus, our focus, is to 155 00:05:43,014 --> 00:05:45,654 continue to prioritize how do we engage these 156 00:05:45,654 --> 00:05:46,154 providers 157 00:05:46,870 --> 00:05:48,649 through sharing data and technologies, 158 00:05:49,189 --> 00:05:50,889 easing administrative processes, 159 00:05:52,069 --> 00:05:56,229 creating capabilities that really support shared decisions regarding 160 00:05:56,229 --> 00:05:57,449 care and patient engagement. 161 00:05:57,829 --> 00:05:59,430 But but when you think about that, that's 162 00:05:59,430 --> 00:06:00,649 our that's our 163 00:06:01,110 --> 00:06:01,610 focus 164 00:06:02,014 --> 00:06:04,894 to close that operational gap. You gotta do 165 00:06:04,894 --> 00:06:05,954 that in an efficient 166 00:06:06,254 --> 00:06:08,574 sort of cost effective manner. We just talked 167 00:06:08,574 --> 00:06:10,814 about all the pressures both the payers and 168 00:06:10,814 --> 00:06:11,954 providers are facing. 169 00:06:12,334 --> 00:06:14,254 You know, one place you're gonna see people 170 00:06:14,254 --> 00:06:16,115 focusing is on AI capabilities. 171 00:06:16,979 --> 00:06:19,139 But we really need to be artful and 172 00:06:19,139 --> 00:06:22,120 thoughtful in our strategies of AI utilization. 173 00:06:23,060 --> 00:06:24,120 So we're focusing 174 00:06:24,819 --> 00:06:28,500 on areas that specifically ease the administrative burden 175 00:06:28,500 --> 00:06:30,519 regarding the integration of process 176 00:06:31,134 --> 00:06:32,915 with the payer and the provider. 177 00:06:33,375 --> 00:06:36,495 So this creates an opportunity for clinicians and 178 00:06:36,495 --> 00:06:36,995 administrators 179 00:06:38,014 --> 00:06:40,654 to spend time and resources really focused on 180 00:06:40,654 --> 00:06:42,274 patient care and engagement 181 00:06:42,895 --> 00:06:44,115 versus back office. 182 00:06:44,495 --> 00:06:46,115 And when we think about, 183 00:06:46,480 --> 00:06:48,180 you know, where we need to invest, 184 00:06:49,120 --> 00:06:51,680 that's where we have to invest, capabilities that 185 00:06:51,680 --> 00:06:52,980 meet our common goals 186 00:06:53,839 --> 00:06:56,480 and and really focus on operational execution. It's 187 00:06:56,480 --> 00:06:58,960 meeting those common goals, and then both sides 188 00:06:58,960 --> 00:07:00,399 can come to the dance floor in a 189 00:07:00,399 --> 00:07:01,779 real way for our members. 190 00:07:02,814 --> 00:07:04,095 Heather, could you could you dive a little 191 00:07:04,095 --> 00:07:06,814 deeper maybe into into what Emblem is kinda 192 00:07:06,814 --> 00:07:08,974 looking to focus on in regards to AI 193 00:07:08,974 --> 00:07:10,354 in 2026? 194 00:07:11,854 --> 00:07:14,175 I would say, you know, it is one 195 00:07:14,175 --> 00:07:16,834 of the key investments that most of the 196 00:07:17,209 --> 00:07:19,610 payers that or providers that you'd be talking 197 00:07:19,610 --> 00:07:21,629 about would be would be addressing. 198 00:07:22,569 --> 00:07:24,250 If I look at it from our provider 199 00:07:24,250 --> 00:07:27,129 side, it's around revenue cycle. They're looking at 200 00:07:27,129 --> 00:07:27,870 AI opportunities 201 00:07:28,170 --> 00:07:28,670 there. 202 00:07:29,384 --> 00:07:30,824 I think if you look at it on 203 00:07:30,824 --> 00:07:32,044 the health plan side, 204 00:07:32,345 --> 00:07:33,944 you know and, again, this is one of 205 00:07:33,944 --> 00:07:36,044 our most sort of critical initiatives. 206 00:07:37,384 --> 00:07:38,764 We have to go beyond 207 00:07:39,305 --> 00:07:42,204 I think many payers are gonna focus on 208 00:07:43,560 --> 00:07:45,419 what's the most advantage advantageous 209 00:07:46,279 --> 00:07:47,740 to the health plan itself. 210 00:07:48,279 --> 00:07:50,439 And I think our initiatives will need to 211 00:07:50,439 --> 00:07:51,259 go beyond 212 00:07:51,959 --> 00:07:54,759 those internal operations of the health plan and 213 00:07:54,759 --> 00:07:57,419 focus on how do we extract data, 214 00:07:58,014 --> 00:07:59,955 focus on driving it to the payer 215 00:08:00,335 --> 00:08:02,175 in a way that's easy for them to 216 00:08:02,175 --> 00:08:03,714 digest into their systems. 217 00:08:04,975 --> 00:08:05,475 Absolutely. 218 00:08:06,574 --> 00:08:09,074 Heather, let me ask you, what's one investment 219 00:08:09,455 --> 00:08:11,634 or initiative you believe will most 220 00:08:11,980 --> 00:08:14,620 reshape how health plans operate over the next 221 00:08:14,620 --> 00:08:15,680 two to three years? 222 00:08:17,180 --> 00:08:18,860 I mean, we started to talk about it. 223 00:08:18,860 --> 00:08:20,639 Right? We started to talk about 224 00:08:22,939 --> 00:08:24,699 AI, and I think that is going to 225 00:08:24,699 --> 00:08:25,920 be one of the ways. 226 00:08:26,300 --> 00:08:27,120 But, again, 227 00:08:27,764 --> 00:08:29,704 that that AI focus 228 00:08:30,805 --> 00:08:35,044 and investment focus really around the integration with 229 00:08:35,044 --> 00:08:35,544 providers, 230 00:08:36,164 --> 00:08:39,445 deepening both sides, technical capabilities, and common goals. 231 00:08:39,445 --> 00:08:41,625 It doesn't have to just be AI. Right? 232 00:08:41,845 --> 00:08:43,659 It can be looking to say, how do 233 00:08:43,659 --> 00:08:46,320 we leverage data integration? How do we leverage 234 00:08:46,460 --> 00:08:47,200 other components 235 00:08:47,740 --> 00:08:49,200 that allows us to 236 00:08:50,460 --> 00:08:52,320 drive actionable activities 237 00:08:52,700 --> 00:08:55,120 to the providers in such a way that 238 00:08:55,500 --> 00:08:57,679 they can utilize it in a fashion 239 00:08:58,144 --> 00:08:59,904 that that's where we're spending a lot of 240 00:08:59,904 --> 00:09:01,125 our time, interoperability, 241 00:09:02,144 --> 00:09:03,445 engagement of data. 242 00:09:03,985 --> 00:09:06,485 And as we continue to see these escalating 243 00:09:06,784 --> 00:09:07,284 costs 244 00:09:07,745 --> 00:09:09,924 and these diminishing revenue levers, 245 00:09:11,170 --> 00:09:13,970 partnership in these initiatives for data exchanges that 246 00:09:13,970 --> 00:09:15,269 really manage outcomes 247 00:09:15,809 --> 00:09:18,850 and risk and reduce system wide administrative costs 248 00:09:18,850 --> 00:09:20,710 will be the key to ongoing longevity. 249 00:09:21,330 --> 00:09:23,509 There's an increasing urgency here. 250 00:09:23,924 --> 00:09:25,065 Again, leveraging 251 00:09:25,445 --> 00:09:27,544 our provider practice ACP, 252 00:09:28,004 --> 00:09:29,544 it's a good way to test 253 00:09:29,924 --> 00:09:30,825 the interaction 254 00:09:31,845 --> 00:09:32,345 systemically 255 00:09:33,205 --> 00:09:35,605 between the two, the the payer and the 256 00:09:35,605 --> 00:09:36,105 provider, 257 00:09:36,500 --> 00:09:38,419 and make sure that as we're deploying these 258 00:09:38,419 --> 00:09:40,419 investments, we can make sure that it works 259 00:09:40,419 --> 00:09:42,179 in real time, and then we can lever 260 00:09:42,179 --> 00:09:43,639 that to some of our other, 261 00:09:44,659 --> 00:09:45,559 provider partners. 262 00:09:46,899 --> 00:09:48,600 If you could change one regulatory 263 00:09:49,059 --> 00:09:50,679 or industry practice tomorrow 264 00:09:51,245 --> 00:09:53,105 to improve affordability and access, 265 00:09:53,644 --> 00:09:54,945 what would it be and why? 266 00:09:56,044 --> 00:09:57,824 Well, if you're only giving me one, 267 00:09:58,445 --> 00:09:59,345 I would say 268 00:10:00,524 --> 00:10:02,044 and and we're sort of I I think 269 00:10:02,044 --> 00:10:04,304 I keep coming back to a similar theme. 270 00:10:04,889 --> 00:10:06,970 It really would be how do we focus 271 00:10:06,970 --> 00:10:07,790 on a framework? 272 00:10:08,809 --> 00:10:11,470 Can be an industry framework, but a framework 273 00:10:11,529 --> 00:10:14,830 that really allows us to integrate decision support 274 00:10:15,610 --> 00:10:17,710 right in the electronic health record. 275 00:10:18,105 --> 00:10:20,745 You know, how do we provide actionable data 276 00:10:20,745 --> 00:10:21,485 and feedback 277 00:10:22,184 --> 00:10:23,404 at the point of encounter 278 00:10:24,504 --> 00:10:27,544 so that it helps delivered improved quality and 279 00:10:27,544 --> 00:10:28,524 improved outcomes? 280 00:10:29,144 --> 00:10:30,764 This framework can leverage 281 00:10:31,289 --> 00:10:33,230 provider data and payer data 282 00:10:33,610 --> 00:10:36,110 to allow providers to close care gaps immediately. 283 00:10:36,809 --> 00:10:37,789 This can eliminate 284 00:10:38,169 --> 00:10:39,549 this back and forth 285 00:10:40,409 --> 00:10:42,110 post visit with the provider. 286 00:10:42,649 --> 00:10:43,950 Limiting that follow-up, 287 00:10:44,524 --> 00:10:46,445 you know, between the health plans and their 288 00:10:46,445 --> 00:10:46,945 partners, 289 00:10:47,325 --> 00:10:48,304 you know, helps 290 00:10:49,085 --> 00:10:51,565 with the the overall cost structure that we've 291 00:10:51,565 --> 00:10:53,985 been talking about. It helps align incentives. 292 00:10:54,285 --> 00:10:55,345 It makes transparency 293 00:10:55,804 --> 00:10:56,304 better. 294 00:10:57,590 --> 00:11:00,230 If you you said one. If you were 295 00:11:00,230 --> 00:11:02,549 gonna let me pick an additional area of 296 00:11:02,549 --> 00:11:03,049 opportunity, 297 00:11:04,149 --> 00:11:05,830 you hear about it all the time, but 298 00:11:05,830 --> 00:11:07,129 how do we think differently 299 00:11:07,910 --> 00:11:09,129 about prior authorization? 300 00:11:10,245 --> 00:11:12,325 The goal between a payer and a provider, 301 00:11:12,325 --> 00:11:13,465 it it's the same. 302 00:11:14,004 --> 00:11:16,725 We wanna make sure that we're delivering the 303 00:11:16,725 --> 00:11:19,225 right care at the right time and location. 304 00:11:19,285 --> 00:11:20,424 Location's important 305 00:11:20,884 --> 00:11:21,785 to to us. 306 00:11:22,320 --> 00:11:24,000 You know? And in emblem, that's what we're 307 00:11:24,000 --> 00:11:27,539 focused on today. We continue to sort of 308 00:11:27,679 --> 00:11:30,259 iterate and ideate on how do we 309 00:11:30,639 --> 00:11:32,820 provide more immediate electronic feedback, 310 00:11:33,519 --> 00:11:35,460 ease the entire process electronically, 311 00:11:36,240 --> 00:11:37,779 only seek to address 312 00:11:38,214 --> 00:11:39,995 areas of most critical need. 313 00:11:40,534 --> 00:11:43,174 And then this really helps avoid the delay 314 00:11:43,174 --> 00:11:43,914 in care 315 00:11:44,375 --> 00:11:46,695 that is a constant point of friction, but 316 00:11:46,695 --> 00:11:49,414 more than friction trust for all parties, whether 317 00:11:49,414 --> 00:11:51,335 you're the member or the provider or the 318 00:11:51,335 --> 00:11:52,235 payer. So 319 00:11:52,759 --> 00:11:53,740 I picked two. 320 00:11:54,120 --> 00:11:55,259 One really around 321 00:11:55,879 --> 00:11:59,080 actionable common framework in the electronic health record 322 00:11:59,080 --> 00:12:01,559 that we can support each other. And then 323 00:12:01,559 --> 00:12:03,559 the the second one really around how do 324 00:12:03,559 --> 00:12:06,460 we think continue to think differently about 325 00:12:06,764 --> 00:12:09,325 where and how to do prior authorization, but 326 00:12:09,325 --> 00:12:10,865 do it in a way that's really 327 00:12:11,245 --> 00:12:11,745 efficient 328 00:12:12,205 --> 00:12:13,184 and immediate. 329 00:12:14,205 --> 00:12:15,805 I'm glad you broke the rules and pick 330 00:12:15,805 --> 00:12:17,725 two because prior authorization is is a very 331 00:12:17,725 --> 00:12:19,805 big deal. I appreciate your your thoughts on 332 00:12:19,805 --> 00:12:21,965 it there, Heather. The last question I have 333 00:12:21,965 --> 00:12:22,500 for you, 334 00:12:23,059 --> 00:12:25,460 what issue is putting the most pressure on 335 00:12:25,460 --> 00:12:27,940 health plan margins right now, and how are 336 00:12:27,940 --> 00:12:29,700 you responding differently or or are going to 337 00:12:29,700 --> 00:12:31,720 respond differently in 2026? 338 00:12:33,059 --> 00:12:34,740 It's interesting you asked that because you could 339 00:12:34,740 --> 00:12:36,644 pick five or six things that are putting 340 00:12:36,644 --> 00:12:38,985 pressure on health plan margins right now. 341 00:12:39,524 --> 00:12:41,785 One thing that I would say we're explicitly 342 00:12:42,085 --> 00:12:44,245 focused on, and I bet if you ask 343 00:12:44,245 --> 00:12:46,825 many payers, it's it's a or providers, 344 00:12:47,539 --> 00:12:48,839 it's a common item. 345 00:12:49,299 --> 00:12:51,399 It's really around pharmacy costs 346 00:12:51,779 --> 00:12:54,179 because I think anything you look at or 347 00:12:54,179 --> 00:12:56,120 read, whether you're a national, 348 00:12:56,500 --> 00:12:58,199 for profit, not for profit, 349 00:12:58,659 --> 00:12:59,959 pick a product segment, 350 00:13:01,059 --> 00:13:04,495 pharmacy costs today are continuing to rise and 351 00:13:04,495 --> 00:13:06,195 continuing to be a pressure point. 352 00:13:07,054 --> 00:13:08,514 What are we doing differently? 353 00:13:09,215 --> 00:13:12,095 Really important thing, and we started this back 354 00:13:12,095 --> 00:13:13,294 in 2024. 355 00:13:13,294 --> 00:13:13,955 We reevaluated 356 00:13:14,414 --> 00:13:15,154 our PBM, 357 00:13:16,210 --> 00:13:18,529 and we selected a partner that we thought 358 00:13:18,529 --> 00:13:21,429 really had a similar mission and goals 359 00:13:21,809 --> 00:13:24,769 that we had with and a real focus 360 00:13:24,769 --> 00:13:25,590 on transparency 361 00:13:26,210 --> 00:13:26,950 and growth. 362 00:13:27,649 --> 00:13:31,625 So EmblemHealth recently announced that we did pick 363 00:13:31,625 --> 00:13:33,884 a new pharmacy benefit collaboration, 364 00:13:34,985 --> 00:13:38,105 with Prime Therapeutics, and we think there's an 365 00:13:38,105 --> 00:13:40,684 opportunity to really provide a more transparent 366 00:13:41,589 --> 00:13:42,409 and affordable 367 00:13:42,870 --> 00:13:45,049 pharmacy experience for our members. 368 00:13:45,589 --> 00:13:47,049 And I think it's more 369 00:13:47,509 --> 00:13:49,850 really focusing on giving members, 370 00:13:50,230 --> 00:13:51,690 you know, within a construct, 371 00:13:52,789 --> 00:13:55,929 more choice and convenience and how they access 372 00:13:55,990 --> 00:13:56,730 their medications, 373 00:13:57,684 --> 00:14:01,625 including, like, real time competitive referrals for specialty 374 00:14:01,764 --> 00:14:02,745 prescription drugs, 375 00:14:03,204 --> 00:14:03,704 and, 376 00:14:04,164 --> 00:14:08,024 you know, fast home delivery through Amazon pharmacy. 377 00:14:08,804 --> 00:14:11,304 You know, this is a time when both 378 00:14:11,860 --> 00:14:14,259 health care and pharmacy costs are rising. That's 379 00:14:14,259 --> 00:14:15,960 putting pressure on our margins, 380 00:14:16,419 --> 00:14:18,200 but we're trying to introduce, 381 00:14:18,899 --> 00:14:20,600 you know, innovative solutions 382 00:14:21,220 --> 00:14:22,360 that give our members 383 00:14:22,899 --> 00:14:24,120 real time information, 384 00:14:25,225 --> 00:14:27,384 you know, clear picture of the cost for 385 00:14:27,384 --> 00:14:27,884 them 386 00:14:28,264 --> 00:14:31,065 and convenience for them that puts their needs 387 00:14:31,065 --> 00:14:33,485 right in front. And we think by putting 388 00:14:33,544 --> 00:14:36,024 our members sort of more in the driver's 389 00:14:36,024 --> 00:14:37,644 seat of their pharmacy experience, 390 00:14:38,470 --> 00:14:41,269 we can potentially remove some of the friction 391 00:14:41,269 --> 00:14:41,769 points 392 00:14:42,389 --> 00:14:44,169 that tend to lead towards nonadherence, 393 00:14:45,110 --> 00:14:48,169 missed doses, you know, and poor health outcomes. 394 00:14:48,230 --> 00:14:50,870 That drives cost into the entire system for 395 00:14:50,870 --> 00:14:51,370 everybody. 396 00:14:52,485 --> 00:14:55,125 The transparency components that we're working through as 397 00:14:55,125 --> 00:14:55,625 well 398 00:14:56,085 --> 00:14:59,044 with Prime also puts us in a position 399 00:14:59,044 --> 00:15:01,365 where we can more actively manage the cost. 400 00:15:01,365 --> 00:15:03,365 We know where they're driving their margin. We 401 00:15:03,365 --> 00:15:05,544 know how to get the most affordable outcomes. 402 00:15:06,049 --> 00:15:08,069 So it's a bit of a win win 403 00:15:08,289 --> 00:15:09,889 for all of us, and that was critical 404 00:15:09,889 --> 00:15:10,709 in our choice. 405 00:15:11,329 --> 00:15:13,089 The last little bit on that, when you 406 00:15:13,089 --> 00:15:14,230 think about pharmacy 407 00:15:14,689 --> 00:15:16,149 beyond what we've discussed, 408 00:15:16,929 --> 00:15:19,569 it's really about the gene therapies. Right? As 409 00:15:19,569 --> 00:15:21,509 more and more gene therapies emerge, 410 00:15:22,674 --> 00:15:24,674 we don't have all the answers, nor does 411 00:15:24,674 --> 00:15:26,754 the rest of the industry. But there is 412 00:15:26,754 --> 00:15:28,615 a real need to address 413 00:15:29,554 --> 00:15:30,855 thoughtful care management 414 00:15:31,634 --> 00:15:34,355 and look at risk transfer arrangements that work 415 00:15:34,355 --> 00:15:36,860 for all the parties when you're talking about 416 00:15:36,860 --> 00:15:38,240 these drugs that are 417 00:15:38,620 --> 00:15:40,320 really critical to improving 418 00:15:40,940 --> 00:15:41,840 member health, 419 00:15:42,299 --> 00:15:45,100 but also common 2 and $3,000,000 420 00:15:45,100 --> 00:15:46,720 price tags per dosage. 421 00:15:47,419 --> 00:15:49,595 So those would be the couple of key 422 00:15:49,595 --> 00:15:52,495 things that I would highlight we're really focusing 423 00:15:52,555 --> 00:15:53,055 on 424 00:15:53,434 --> 00:15:54,715 in 2026 425 00:15:54,715 --> 00:15:56,335 as one of the pressure points 426 00:15:56,715 --> 00:15:58,175 on our health plan margins. 427 00:15:59,274 --> 00:16:00,875 Heather, thanks so much for joining us on 428 00:16:00,875 --> 00:16:03,195 the podcast. It was a great conversation. We're 429 00:16:03,195 --> 00:16:04,720 really looking forward to you speaking at the 430 00:16:04,720 --> 00:16:06,019 spring payer issues roundtable. 431 00:16:06,559 --> 00:16:09,279 Thank you so much for inviting me. Happy 432 00:16:09,279 --> 00:16:11,679 to participate, and and I think it's gonna 433 00:16:11,679 --> 00:16:13,200 be great fun when we get together at 434 00:16:13,200 --> 00:16:13,860 the roundtable. 435 00:16:14,320 --> 00:16:15,539 Definitely will be.