Hello, everyone, and welcome to Becker's Healthcare Podcast.
I'm Scott King. Thrilled today to be joined
by a very special guest, Gretchen Wagner, associate
vice president, risk management with Humana. Gretchen, how
are you doing? Thanks so much for joining
us. Sure. Thanks for having me, Scott.
Yeah. You know, we have a lot of
big topics to get to here, you know,
on the podcast in in health care and
with health plans, and we're we're definitely looking
forward to having you speak with us at
our spring payer issues roundtable.
But before we, before we get to that,
I was wondering if you could just tell
us a little bit about your background and
your career.
Sure. So I actually started out in education,
a little bit nontraditional to get into health
care, but then made my shift into internal
audit. And that is how I ended up
making my way into health care coming in
from an internal audit perspective,
and found that was a great way to
really learn a company as a new associate
and a young employee at that point in
time because it gave me exposure to a
lot of different parts of
a company. Right? I got to learn different
parts and pieces and how they work and
meet leadership.
And from there,
I really moved up and found my niche
from a clinical perspective,
at Humana and have been with the the
organization now for over fourteen years
and lead our SNP governance.
So work closely with our SNP models of
care, serve as a first line risk and
compliance partner,
support a lot of our quality governance components.
Doing a lot right now with our integrated
D SNPs as we're seeing our Medicaid and
Medicare programs come more closely together
across that D SNP landscape,
and also work very closely with our clinical
operations team. So,
excited to be here and,
excited to talk about really kind of the
the things we're seeing from a health care
perspective,
right now in the state of our our
health players.
Well, appreciate you sharing that background info there,
Gretchen. And, you know, the first kind of
big topic I wanted to get to
is how are your relationships with providers changing
as both sides face cost pressure and workforce
shortages?
Sure. So I would say
we are seeing very significant changes in the
last few years.
Right? We're starting to see
unprecedented
cost pressures
that are only continuing
from especially an MA perspective and a Medicaid
perspective as well as workforce shortages.
You know, when we think about historically what
relationships look like between payers and providers, we
always had very transactional
based
relationships that were very fee for service type
payments where providers were reimbursed for individual services
or procedures,
and payers really focused on that claims processing
and cost containment.
And we found that model created silos and
at times really misaligned
incentives. So one of the things we're really
doing at Humana today is seeing a shift
towards a much more collaborative approach
where we think about partnership and accountability
with a value based model.
So in those arrangements, we're really incentivizing
our providers to not just think about the
volume of care, but really how are we
delivering on quality
and achieving outcomes.
And it really is thinking about how can
we align our goals together
so that we can see our patients get
healthier,
avoid unnecessary
hospitalizations,
and, ultimately, we really wanna make sure our
members are receiving care
at the right time.
We've also found, I think, through that as
we think about that value based care model,
that it allows more innovation and care delivery,
and it really allows us to think about
recognizing
and rewarding
our payers,
when they have better coordination,
fewer gaps in care, and a much more
personalized approach. So really thinking about a much
more holistic and streamlined experience. So
as we think about
how things have changed with this cost pressure,
the workforce shortages that we're having,
we've really got to rethink how we incentivize
our payers and how we incentivize
those relationships.
So it's definitely been a shift as we
make that shift and that change towards those
value based
care arrangements.
But we are finding
it truly is
allowing us to be more effective and efficient
and also make sure we've got better
partnerships
across our our payers,
but also allowing to make sure that,
we can put the member first
when it comes to their health and their
outcomes as well when we take that approach.
Yeah. Absolutely. And I love the idea of
of focusing on quality there. It's something to
kind of put in the middle of that
payer provider relationship to kind of get both
sides to come to the table. I I
think that's great. And I also wanna ask,
where do you see the biggest
gap today between
payer strategy and operational execution?
Yeah.
So
I honestly think the biggest bur
burden that we see
is how do we take that long term
vision
that we have as leaders
and translate that into day to day operations.
Right? Oftentimes, we have
big big rocks that we all are working
towards from a health care perspective as we
think about innovation and quality,
even think about things like utilization of AI
from a strategy perspective.
And it's how can we take that and
realize that
in the daily work of our frontline teams.
That's something that is not a unique gap
to Humana by any means.
It's something that the entire industry is facing,
particularly with this current pace of change.
One of my favorite sayings that I continue
to hear, both internal to Humana
but external in the environment we're living in,
is that the pace of change today
is as slow as it will ever be.
And that's kind of hard to take in
because we are facing a rapid pace of
change
from a technology
perspective,
from a structure and infrastructure
perspective,
from a way in which we live perspective,
from a,
you know, a day to day function perspective.
There is so much that is happening
rapidly,
and we are only gonna continue to see
that progress.
And that can be hard for a lot
of our frontline associates,
to adapt to
as well as our members
and our patients to adapt to,
as we go through this this change acceleration.
So with me saying that, right, of how
do we take this
strategic vision
where we want to innovate, where we wanna
drive quality,
and make a better experience for our members
is
now how do we how do we go
about doing that and doing that in the
right way
in this time of of growth and technology?
So I think one is, like, how do
we start thinking about digital innovation?
Because our our senior population
is no longer
a population that is just working on
on telephone calls and and letters in front
of them.
They are someone who have started to adapt
things like
cell phones, mobile apps, online platforms. They want
virtual care options. They want telehealth options. And
so we've gotta find
coordinated ways
to bring multiple teams together
across not only our operational teams, but our
clinical teams and our provider functions
to make sure that we're doing this and
doing it appropriately.
So I think that's one of the things
that we really gotta find is how can
we find ways as organizations
to create cross functional implementation
that includes
feedback loops from providers,
from members,
and things like I think we've got some
really good platforms at Humana
that are,
in many ways, regulatory
requirements for us and things like our D
SNP and our Medicaid
enrollee advisory committees where we can seek out
member feedback
and try out some of our our new
technology with them. But it's also making sure
we're getting the feedback from associates and from
our frontline teams
to make sure that they are front and
center
when it comes to
the execution
and how they can execute on that strategy
at a day to day level. So it's
really bringing everyone to the to the table,
closing that gap, and making sure that we're
building systems and processes
that consider continuous improvement
and collaboration and communication.
Yeah. And I like what you said about
change. And, you know, it's kind of a
it's kind of a bit jarring, isn't it,
too? Like It is. Like emerging tech, and
is it if this is not gonna slow
down, so you No. You have to jump
on board right now.
Yeah. It it really is. Like,
it's one of those that I feel like
we are in such a time of transformation,
both as a society, but for us in
health care. This is our time to
challenge what we have been doing
and really think about the utilization of technology
in new ways. Right. Because there are other
industries
who are doing things differently
to think about that member experience in a
unique way
that we haven't yet executed on in the
in the health care industry.
And so I think this is this is
really our opportunity
as we are seeing
technology advance
advancement and just the changes that are happening
from a regulatory perspective
as well as a societal perspective, right, and
the adoption of
more people being open to the utilization of
technology and those digital platforms
coming together.
No. I I agree. I think you're you're
right 100%.
I also wanna ask what's one investment or
initiative you believe will most reshape how health
plans operate over the next two to three
years? Yeah. Honestly, it goes back as what
we've been talking about, and that's that's digital
it's digital analytics.
And getting even more specific, I think it's
the analytics
and the interoperability, but it's across the health
care ecosystem.
Right? Right now,
there is a lot of data,
and there is a lot
of information
that we have
across health plans,
across health systems,
but it's fragmented.
And when it's fragmented,
we aren't seeing a holistic view of a
patient's health journey or a member's health journey.
And so one of the things that I
think we need to invest in and one
of the things we're focusing on at Humana
is investing heavily in data infrastructure
and advancing analytics
so that we can really bring all of
that information together from multiple sources.
So So think about things like
clinical records,
pharmacy data, member interactions. So when did we
call a member? Who called a member? When
did they pick up the phone? And even
things we might know about them,
such as social determinants of health,
right, based upon
maybe they have food insecurity,
maybe they have a transportation need. So it's
really how can we build comprehensive
views
of our membership
to know
how to be more pro proactive
in outreaching members and especially outreaching members
at the right time.
Right? We've gotta make sure that we can
take data
and utilize it for good
and not just take data
to have data
and report on data.
We've gotta make sure we're using data
in the right way and pulling it together
through analytics,
through interoperability,
sharing that data
to make sure we're really tailoring it to
drive efficiency
in the payer system, but across the broader
health care system and really focusing on that
member experience through it.
If you could change
one regulatory or industry practice tomorrow to improve
affordability and access, what would it be and
why? Sure.
Well, I feel like I'm I keep talking
about the same thing a little bit, but
I I think it also shows how important
out it is, and that's interoperability.
Right? And that is something we have got
to change and speed up even
more so than we have today.
We have got to
I think about this from my own perspective
frequently
both as
a a patient and as a caregiver,
for my mother who has complex conditions and
sees a number of specialists and doctors across
networks and networks and provider groups, and how
frequently
we don't see the full picture of a
member because we don't have that information,
and how frequently we we have inefficiency
in the work that we do.
How often do we create duplicate tests? How
often do we miss something?
How often do we have the chance to
take action we can't because we don't have
the right information,
but it's sitting in another payer's health system,
or it's sitting in another
health system system at a hospital or at
a doctor's office.
Think about how how many hours just we
as
patients would say if we didn't have to
fill out the same form every time we
went to the doctor's office because that information
was up to date and timely.
We could save ourselves, could save hours
over the course of years in doing that.
And so we really have a chance to
rethink about data
and bringing that together
to create
a better member experience,
but truly
having the chance
to create
a more complete picture for our providers, for
them to make better decisions
and create a better treatment plan.
And for health plans, it's gonna mean that
we can improve the accuracy of what we
do
and make sure we're supporting,
our populations in a more effective manner. And
so going back to where we started,
talking about some of the cost pressures we're
feeling.
The more that we can streamline data and
have the right data, that's only going to
help us as health plans
in a time where we're facing more from
a a margins perspective
and and the cost pressure from a regulatory
aspect that we're seeing right now. So this
is definitely a place where
while
a lot is moving quickly
from a regulatory aspect for us to get
there from an interop aspect,
there's an opportunity for us to move even
quicker here.
And that kinda ties into the last thing
I wanted to ask you, Gretchen, along the
lines of margins. And you you might have
touched on this already, but what issue do
you think is putting the most pressure on
health plan margins right now, and how how
are you responding differently in 2026?
Yeah. It's it's interesting. I feel like it's
such a timely question as we've been seeing
all of the,
the end of year
financial
reports come out from the large health plans
and just how
things from the industry perspective that are coming
out right right now about what is happening
in the health care industry. So it's an
interesting time for us.
And there definitely is pressure that we have
not seen,
especially in the MA space or the Medicaid
space.
And I don't think it's gonna slow down.
And I think there are really
three large contributors
to that. So one is just rising health
care cost.
Primarily,
we're seeing that through the price of specialty
medications and advanced treatments.
But in general, we're just seeing the cost
of health care go up. Everything from a
cost perspective is rising.
Two, I think we're seeing greater utilization.
Our boomer population is aging.
We're seeing chronic conditions become more prevalent.
But I also think we've created
where people are becoming more proactive
and seeking
care, which is positive, but that drives up
that utilization.
And then really the last piece is just
the administrative costs, so the cost to do
business is going up everywhere.
That doesn't matter what industry you're in. That's
not unique to health care, but it's something
we're seeing across industries.
And I think the last piece, as we
know, is the regulatory
requirements. Right? We've seen cuts in Medicaid.
We have
the proposed
you know, payment that came out on the
MA space with the reimbursement rate standing pretty
flat with a slight increase,
that's been a lot of the stocks dropping
massively last week.
So
this is not something
that's gonna go away for sure. And so
I think,
you know, when we think about this, we
have to definitely think from a health plan
perspective.
We've got to be
thinking
about efficiency,
innovation, and value.
And this really is our chance to think
differently
about how we show up,
who we are as a company,
and how we're gonna serve our members. It
really is our chance to distinguish ourselves from
each other
and really think about that member experience
if we ground ourselves in the efficiency, innovation,
and value,
from an organization
perspective. And that's something we're really focused on
here at Humana.
So
I I would say when I think about
this
operational efficiency,
we've all gotta think about leveraging automation
right now, process optimization.
How can we reduce administrative
cost?
Right? We've gotta think about things like
automated claims processing,
analytics. This is a place where I think
we have a chance to think about AI
and how we can utilize
that in the right way to support
some efficiency in our especially in our administrative
processes.
And then I think innovation is something that's
really exciting.
I talked about this is a chance to
do things differently.
How can we think about
things like virtual care,
remote monitoring,
new care management practices?
How can we think
about improving outcomes differently than we have in
the past. So I think the more that
we can think about cost containment over time
by improving health outcomes,
that's gonna help us from an innovation perspective,
but also from a member perspective.
And then the last piece I would ask
is just that value based partnership piece. You
know, the more we can incentivize our providers
with quality,
partnership,
efficiency,
that's gonna help all of us as we
we work through these cost pressures.
But it definitely is gonna be something that
we see and continue to have as payers
going into 2026.
I don't see that something that is going
to change, And so we've all really gotta
think about how we can focus
on member engagement.
Like I said, going back to how do
we think about
efficiency, innovation, and really driving that value
both for
our members,
our payers, and our providers that we work
with.
Well, Gretchen, thanks so much for a great
conversation and for joining the podcast, and I'm
looking forward to you speaking with us in
April.
Absolutely. Thank you so much, Scott.