Speaker 0: 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.

Speaker 1: 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.

Speaker 2: Thank you so much for having me. I'm doing really well. How are you doing today?

Speaker 1: 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.

Speaker 2: 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.

Speaker 1: 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.

Speaker 2: 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.

Speaker 1: 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?

Speaker 2: 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.

Speaker 1: 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?

Speaker 2: 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.

Speaker 1: Absolutely. And where do you see the biggest gap today between payer strategy and operational execution?

Speaker 2: 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.

Speaker 1: 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,

Speaker 2: 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.

Speaker 1: If you could change one regulatory or industry practice tomorrow to improve affordability and access, what would it be and why?

Speaker 2: 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.

Speaker 1: 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?

Speaker 2: 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.

Speaker 1: 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.

Speaker 2: 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

Speaker 1: 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?

Speaker 2: 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.

Speaker 1: 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.

Speaker 2: Awesome. Thank you so much, Scott, for having me.