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. Welcome to Becker's Healthcare Podcast. I'm
Scott King. Thrilled today to be joined by
very special guest, Emily Durfee, partner, corporate venture
capital
with HealthWorks. Emily Hardy, thanks so much for
joining the podcast.
Thank you so much for having me. I'm
doing really well. How are you doing today?
I'm doing great. We were just talking before.
You know, it's getting, like, a little bit
warmer in Chicago, which is, like, 25 degrees.
So, you know, getting those sunglasses ready. But,
no, we thanks so much for joining. We
have a lot to to get to, a
lot of kind of big topics in in
health care and and with health plans as
always. But, before we do that, Emily, I
was wondering if you could just share a
little about your background and your, career in
health care.
Absolutely. So I have one of those quote,
unquote, nontraditional
backgrounds, which is either a good thing or
a bad thing depending on your perspective. Obviously,
I think it's a good thing. But I
spent most of my career in startups and
venture capital. So actually started my career in
Nairobi, Kenya, worked for a startup in Sub
Saharan Africa for about five years,
did impact investing into health care and education
over there, and then moved more into The
US focused world. So, worked for, at that
point, a Neo, insurance company called Clover Health
from 2015 to 2017 out in San Francisco,
and joined this company about five years ago.
So since then, have been working, HealthWorks as
the innovation investment arm of CareFirst BlueCross BlueShield,
and have been focused on how can we
drive innovation in health care as well as,
you know, meet the needs of the strategics
in health care, like the big payers and
providers,
in order to marry the the traditional,
reach and value of, health care players, and
the innovation of some of the folks coming
out of whether it's San Francisco, New York,
or whatever small town you're part of.
Well, I think sometimes, you know, it gives
you a really unique perspective to be outside
of that, you know, traditional
landscape of of health care and, you know,
a career trajectory. So I think you bring
a really unique perspective, and thanks so much
for sharing all that. Absolutely. I'm excited to
share what I can and, obviously, just really
grateful for the opportunities that I've gotten through
the course of my career.
Excellent. And, you know, the first thing I
wanted to ask you about, Emily, is how
are your relationships with providers changing as both
sides face, you know, all kinds of regulatory
pressures, but specifically cost pressure
and workforce shortages?
Yeah. Absolutely. I mean, I I would say
that I don't think that this is new.
Right? We've been seeing the writing on the
wall for these pressures, these cost pressures, these
employment pressures for a really long time. And
so I would say that our strategies haven't
changed significantly. They're just accelerating. Right? And so
we're really focused on how can we continue
to work collaboratively
with providers. How can we identify
win wins for both of us. Right? So
whether that's certain types of contract types, value
based care arrangements, shared savings contracts, if that's
different types of referral systems.
And then also, right, we're looking at how
do we partner with new types of providers,
whether that's different types of nationalized telemedicine providers
or local providers,
that cover some of the gaps that our
members are experiencing. And so how can we
continue to both work creatively with our current
provider partners and add additional provider partners in
to ensure that we are, you know, working
across the board to serve our members?
But the reality is I don't think there's
a silver bullet in this one, and we
need to continue to be collaborative and thoughtful
in how we approach each other to solve
these problems together.
You know, some people I've talked to on
the health plan side feel like there is
more of a kind of collaboration.
You know, I don't wanna say it's easier
and working easier right now, but it's there
it seems more collaborative, I guess, because both
payers and providers are both up against, you
know, all kinds of specifically regulatory pressures. Is
that is that what you find? Like, people
are both sides just kinda wanna get things
done, so maybe there is a little more
collaboration right now than than normally?
Yeah. I would say I at least from
my perspective, we haven't had bad collaboration in
the past. I think, you know, we're really
lucky as a regional blues plan. We're really
much more focused on, you know, building deep
relationships in our geographic region. And so, you
know, I think compared to some of the
maybe larger and more national players, we already
have a lot of that collaboration and that
goodwill between us. But, yes, of course. Right?
Like, the reality is that we we both
know that we can't function without each other.
And given all of the the movements that
are happening in the payer and the provider
space. Right? If you're thinking about roll ups,
if you're thinking about, certain types of especially
government programs, payer, per like, state shutting down.
There's just so much that's going on that's
making us turn towards each other as opposed
to away from each other even more right
now.
Absolutely.
And where do you see the biggest gap
today between payer strategy and operational execution?
You know, obviously, I'm a little biased because
I sit on the kind of innovation and
investment perspective. But from my perspective, it's really
the speed of adoption around new technologies for
payers. Right?
This isn't really new.
I feel like one of my favorite facts
or or jokes to make around this is,
you know, email has existed for decades at
this point. Right? And yet still health care
depends significantly on faxes
as a form of communication, which seems slightly
suboptimal.
But especially right now as we're seeing the
rise in artificial intelligence,
and other types of technological advancements, and as
we're seeing these rising costs and especially these
burdens, both for payers and providers, you know,
it's, I think, even more critical that we're
able to quickly adopt some of these new
technologies.
And to be clear, I understand why that's
not happening. Right? It's not all AI has
been fully vetted for the really sensitive business
of health care. There's a lot of risk
for us in adopting new technologies for some
of our core programs because no one likes
it if you have a technological
issue and then suddenly a claim isn't paid.
Right? And so I think that there are
a lot of, reasons that that adoption hasn't
happened quickly. But I do think that that
is the biggest gap right now and the
thing that I'm most excited to try to
work to solve, which is how can we
do this in ways that are lower risk
for providers, for patients, for,
individuals on the payer side, etcetera, but is
actually accelerating
us towards a better and more streamlined future,
because I think we have to in order
to stay sustainable as a business.
Is there a new tech or
or perhaps an AI rollout that was easy
for you or
or HealthWorks to adopt to recently?
You know, I think the easiest options when
it comes to these rollouts are,
niche products. Right? So they're the things that
are very specifically
working with one type of provider, right, or
one type of patient or are part of
one small element of a member's journey through
our system, etcetera.
I think that those are important and they're
really, really good experiments. And the good news
about those is they do, in fact, affect
the outcomes of our members and our providers
and us,
but aren't super, super high risk. If something
doesn't go well, right, if there's a glitch
in the system, if someone can't get to
a web page for a little while, obviously,
that's not something we want, but it's not
going to be, you know, detrimental to the
entire system.
Unfortunately, those are the things that aren't going
to have as much lift. Right? If you
start to talk about, you know, overall claims
processing,
prior authorization,
etcetera. Right? That's where the biggest opportunity set
is, and that's also where the biggest risk
is. And so I think we're still figuring
out exactly how we can continue to to
test
and manage, those types of rollouts effectively.
If you could change one regulatory or industry
practice tomorrow to improve affordability and access,
what would it be and why?
Yeah. You know, I was thinking about this,
and I, like, I have two answers for
you.
The first is maybe table stakes, but I
do think it's important. Like, realistically, on the
regulatory side, I feel like the most important
thing that we would have
is clarity.
Right? And it's not a specific regulatory initiative
that I'm arguing for. It's mostly that, you
know, over the last few years, I think
there's been a lot of swings around, what
to expect on the Medicare side, on the
Medicaid side, on, certain types of states funding,
etcetera.
And I think that's made it really difficult
for payers certainly, I imagine providers too to
make effective decisions and to be able to
stand by those strategic decisions and see through
kind of the long arcs of implementation
and change
that often come with really established systems.
And I think just the the amount of
difference and some some amount of even chaos.
Right? If you even look at kind of,
the number of, debates and shutdowns that the
federal government has had around,
certain types of funding makes it really difficult
for those changes to be implemented in strategic
ways. And so I think at the very
least some amount of,
you know, kind of clarity and stability in
regulation, I think is actually going to be
the biggest and most important driver in the
health care space. At the same time, I
would be remiss if I didn't mention the
fact that, like, the speed of review and
approval around new health care solutions
does make it harder to bring new innovations
to the table. And so I do think
that there's also certain types of regulations that
I would love to see around, you know,
how we can very quickly understand and measure,
whether or not these new innovations work. And
if they are working, bring them to market
more quickly. So I do think that there's
opportunity there as well.
What what do you think is is maybe
one big step that that needs to be
taken to work towards that clarity and stabilization
you were talking about?
Oh, you know, honestly, I think that's outside
of my pay grade, right, in the sense
of I think that there's a lot of
dynamics right now in the health, sorry, in
the American political landscape
Sure. That are incredibly polarized,
that I think are at the root of
a lot of this. Right? But at the
very least, you know, having ways of thinking
through longer term budgeting processes, ideally trying to
have folks who are working,
across the aisle more effectively to come up
with a situation in which we're not kind
of so polarized in what we expect generally
and in health care policy. And, therefore, depending
on who is in power, we're swinging pretty
rapidly between those two pieces.
Yeah. Absolutely. I mean, there's there's there's so
many different things going on. It's hard to
anticipate, so you kinda just have to be
able to pivot and and, you know, have
an awareness there of what you can do
differently.
I think that's a great point. Yeah. And
there's conflict right now even between federal governments
and state governments. Right? And so I think
that's just oh, and and to be clear.
Right? Like, I I think that that is
it's just difficult for us to plan around
and manage.
I think that there are lots of opportunities
for us to build and be successful,
but it is hard when you have such
large organizations to pivot as quickly as our
regulation is changing. Of course. I think everyone
a lot of people can identify with that
a 100%.
And, Emily, what issue do you think is
putting the most pressure on health plan margins
right now,
and
how are you responding differently to that in
2026?
Yeah. Absolutely. I mean, from our perspective, the
rising cost of care is by far the
biggest pressure for us. Right?
There are so many different things that are
actually driving that. There's chronic conditions. There's specialty
pharmaceuticals. There's rising diagnoses of things around behavioral
health, etcetera. Right? There's there's so many different
pieces that are driving that rising cost of
care. But I think that that is and
has been one of the biggest pressures for
us.
To be honest, I'm not sure that we're
changing something super
large in 2026 as much as we're continuing
to accelerate that work. Right? We've always been
in a space where we are trying to
quantify,
you know, where our costs rising and where
our costs rising significantly more than outcomes are
benefiting for our members,
and then figure out solutions that we can
find that will actually improve the ROI on
that care. Right? So improve the outcomes that
our members are experiencing while ideally decreasing the
cost,
of those outcomes.
I think that that work has been true
for the last five years since I've been
part of this organization.
At the same time, I also think that,
like, this is something that we are continuing
to hire more folks and accelerate of, like,
how can we continue to drive better and
better, data analysis on what we need to
target. And then how do we get even
more creative about the different steps that we
can take to solve those problems. And both
thinking about solutions internally of, you know, where
can we
reach out with a care manager or have
a different, data flow or have a different
alert for someone. Right?
And also the external side of, you know,
are there solutions that are moving the needle
here?
And can we bring those into part of
that, you know, workflow for us? And so
I think fundamentally just continuing to try to
figure out how we can manage those rising
cost of care is a top priority for
us in 2026
or the top priority in 2026.
Well, Emily, thank you for joining us on
a podcast and for a great conversation. We're
look we're really looking forward to having you
speak at our spring payer issues roundtable. So
thanks so much. Awesome. Thank you so much,
Scott, for having me.