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, Rob Andrews,
chief executive officer of Health Transformational Alliance. Rob,
how are you doing today? Thanks so much
for joining us. God, I'm doing great, and
it it's nice to have a chance to
be with you. I appreciate your time. And,
you know, we have a lot of big,
topics to get into here with with health
plans and and, you know, the health in
general
across the board. But before we we dive
into those, Rob, you just tell us a
little bit about your your background and your
career journey.
Well, I had the honor of serving in
the US House of Representatives,
for about twenty five years,
during which by the time the Affordable Care
Act was enacted, and I was privileged to
be a part of that,
representing a district in New Jersey. When when
I left the Congress, I started practicing law
and was given the chance to represent a
group of companies that
were interested in binding together to form what
became the HTA,
which is a group that combines the data
and the purchasing power and the experience and
judgment
of a lot of major American companies.
We're now up to over 80 companies.
And our our job really is to
look for the highest value care,
not the cheapest care, but the highest value
care that produce the best results. So I've
had a chance
to experience health care as a as a
dad,
you know, as a parent, as now as
a grandparent,
as a public servant
legislator,
and now as someone, helping to lead the
HTA. So I feel very blessed.
That's certainly a lot of different perspectives with
health care, and we appreciate you blending them
to us for this podcast, Rob. And kind
of the first topic I want to get
to is
how are your relationships with providers changing
as both sides face cost pressure and workforce
shortages?
I think they're changing for the better because
both sides see the
opportunities
that come with the challenges that, providers have.
Well, everyone
who listens to this podcast
knows
that,
health care providers under extreme financial pressures,
reimbursements
are
lagging, in some cases being cut.
Demands are growing, particularly with an increasingly elderly
population.
It's hard to find and retain talented men
and women to work in health care fields.
It's a really tough time to be running
a provider system or contributing to running one.
At the same time, employers are beset by
a series of challenges.
The costs keep going up 9% last year
across the market.
The quality isn't necessarily going up.
The demands and challenges of the employees in
the workforce are as high as they've ever
been. So I think what you're finding is
provider systems and employers are looking for ways
to
take advantage of,
was it Rahm Emanuel said, never let a
good crisis go to waste. Right.
The the there there's some critical problems have
to be solved, and I think more and
more
employers and providers are looking for a way
to solve them together.
Not to the exclusion necessarily of carriers or
PBMs, but
probably with those groups playing a less important
role
and providers and employers playing a more prominent
and primary role.
So, Rob, you kinda think that because both
providers and payers are are both under, you
know, different kinds of pressures and challenges. There's
almost a united front
in that relationship with, like, we're both dealing
with a lot right now. Let's just try
to work together the best we can. Is
that kinda what you've been seeing?
I do. I I think it's evolving in
that direction, and
the math tells you why.
By and large, provider systems are either operating
at a very thin margin
or an in nonexistent
margin. They're operating in the red.
Employers
are paying,
in some cases, double digits more than they
paid in other years, but certainly in the
high single digits.
So where is the money going?
Right? If you've got a an environment where
employers are paying 9% more, but providers have
seen their margins
cut by two thirds or disappearing.
You know, the money is is going, in
some cases, to,
middlemen who provide some important functions. I'm not
in any way
demeaning
the work that some of those groups do.
But is it the right share? Is it
the right share? And I think the answer
is usually no.
So looking for a way to reallocate that
money so the person,
you know, seeing triaging the patient in the
emergency room or doing physical therapy with the
patient or performing surgery or delivering the baby
or
you're doing the actual healing work,
that more of the money goes to the
provider and less of it goes to the
people in the middle. I think that's a
common cause for employers and providers.
I think you're right, Rob. And, you know,
you you discussed real real allocating that that
money, but where do you see the biggest
gap today when you look at,
you know, payer strategy and operational execution?
I think the biggest gap is the,
lack of meaningful competition
among carriers.
I think carriers should
be competing on the basis of outcome.
Who helps to make people healthier?
Not on the basis of rates or discounts.
Now discounts are important.
No one wants to overpay for something, but
I don't think anybody wants the cheapest mammogram
for their daughter or their wife,
or, you know, the cheapest cancer screening for
their husband or their brother. I I I
think if we could create a world where
carriers competed on the basis of delivering great
outcomes
and providers were a part of that in
a fair way, then I think employers and
consumers would benefit.
What's one investment or initiative you believe will
most reshape how health plans operate over the
next two to three years?
I think it will be the emergence of
technologies that can match the right drug with
the right patient,
which doesn't really happen very often now. Formularies
are written,
frankly, with economic
considerations
in mind.
But we know from looking at at genetic
studies and we know from looking at comorbidities,
some drugs
are incredibly beneficial
for a patient.
Many of them are.
Some are expensive but ineffective,
and a few can even have a harmful
impact, particularly if if mixed with other drugs
that that are the patient's taking. So I
think you're gonna see the market move toward
more personalized formularies
where physicians
and others writing prescriptions
are privy to information that would help understand
whether this is the right drug for the
person. And
that, I think, will lead to much better
outcomes.
Fewer cardiac incidents,
you know, fewer
gastro
incidence
and so forth. I think that's something that's
on the horizon
and could be very positive.
I think it's really interesting, Rob. You know,
we talk about a lot of ways to
use using emerging technology
in the patient journey and and to personalize
things more. But having that specific that right
medication for a patient, now you said it's
on the horizon. Do we think that that
it's something that could happen sooner or rather
than later with all the emerging tech we're
seeing?
I think it'll happen sooner rather than later
for two reasons.
The first is
in in an economy where health care costs
are burgeoning,
drug costs are growing the most. It's the
biggest pain point, whether it's GLP ones or
or,
you know, the immune
autoimmune drugs.
So there's a lot of attention being focused
in the area. And then second is the
advance of AI,
the ability of AI to understand the relationship
among drugs,
drugs with certain comorbidities,
the genetic characteristics of the patient.
I think
pharmacogenomics,
which was fairly exotic and expensive a decade
ago,
will become a lot more common and less
expensive.
It'll be used by more providers,
and it'll lead to better outcomes. That that's
something I think is on the pretty near
term horizon.
If you could change one regulatory
or industry practice tomorrow
to improve affordability and excess, what would it
be and why?
Gag clauses and agreements between providers and network
builders
and, drug,
PBMs in the case of drugs.
Markets I think markets fundamentally work,
and markets work when there is meaningful transparency
for people who are buyers in that market.
We have erratic transparency
right now.
A lot of payers, whether they're employers or
health plans or individuals,
don't really know what they're paying.
There's this vast difference between the,
you know, the the charge that's on your
bill, the charge rate, and what's really being
paid.
You can't have an effective market unless people
know what the real cost is that they're
being asked to bear and what the benefit
of it is. So
I I think
a legislative approach that would,
you know, open the kimono,
let let pricing be known,
I think would disrupt the industry in a
positive way, and I think it's coming.
The last thing I want to ask you,
Rob, what's
what is the issue you think is putting
the most pressure on health plan margins right
now,
and how are you going to respond differently,
or or have you even started to respond
differently in 2026?
When you say health plans, do you mean
employer sponsored health plans?
Yes. Yeah. I think what's putting the most
pressure now is, GLP ones in the short
run.
Many more people are taking these drugs. They're
still very expensive.
They have good benefits. I mean, they they
do
work for a lot of consumers in a
lot of situations. So I think that
what you're gonna see is employers looking toward
creative ways to take advantage of some of
the direct pricing
that's being offered by the drug manufacturers.
You can't read,
Becker's
any day and not read a story about
a drug company
that's offering a price for GLP one through
its consumer portal that's, like, less than half
of what employers are paying in their health
plans. Well, that's just not gonna sustain itself.
If a
if a drug is being sold for a
$190
a month to someone who puts their credit
card down,
but it's $500
a month net of rebates for employer plan,
employers are gonna do something to change that.
They're either gonna work around it and
try to reimburse the consumer, or they're gonna
insist that the PBMs and
the manufacturers
normalize that price. So
I think that's what's putting a lot of
pressure on, and that's the direction in which
you'll see it go. Rob, thanks so much
for joining us on the podcast. It was
a great conversation. Look forward to having you
speak, in the spring at our Payor Issues
Roundtable. Scott, I'm sure Chicago will be a
great experience, and thank you for making it
so.