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Becker’s Healthcare Podcast
Driving Value and Innovation in Health Plan Operations with Gretchen Wagner
00:20:05
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- [00:00]
A
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.
- [00:13]
B
Sure, thanks for having me, Scott.
- [00:15]
A
Yeah, you know, we have a lot of big topics to get to here, you know, on the podcast in healthcare and with health plans. And 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 in your career.
- [00:32]
B
Sure. So I actually started out in education, a little bit non traditional 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 organization now for over 14 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 things we're seeing from a healthcare perspective right now in the state of our health players.
- [01:52]
A
Well, appreciate you sharing that background info there, Gretchen. And 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?
- [02:04]
B
Sure. So I would say we are seeing very significant changes in the last few years. 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. 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 focus 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, 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 want to 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 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.
- [04:48]
A
Absolutely. And I love the idea of focusing on quality. There is 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 think that's great. And I also want to ask, where do you see the biggest gap today between payer strategy and operational execution?
- [05:04]
B
Yeah. So I honestly think the biggest 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. A healthcare 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 changes. 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. That's 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 day to day function perspective. There is so much that is happening rapidly and we are only going to 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 want to 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 senior population is no longer a population that is just working on telephone calls 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 got to 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've really got to 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 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 table, closing that gap and making sure that we're building systems and processes that consider continuous improvement and collaboration and communication.
- [09:02]
A
Yeah, and I like what you said about change and you know, it's kind of, it's kind of a bit jarring, isn't it? Too like emerging tech, and it's not going slow down. So you kind of have to jump on board right now.
- [09:12]
B
Yeah, 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 healthcare, this is our time to challenge what we have been doing and really think about the utilization of technology in new ways, 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 healthcare industry. And so I think this is really our opportunity as we are seeing technology advancement and just the changes that are happening from a regulatory perspective as well as a societal perspective, and the adoption of more people being open to the utilization of technology and those digital platforms coming together.
- [10:10]
A
No, I agree. I think you're right 100%. I also want to ask, what's one investment or initiative you believe will most reshape how health plans operate over the next two to three years?
- [10:21]
B
Yeah, honestly, it goes back as what we've been talking about, and it's digital analytics and getting even more specific. I think it's the analytics and the interoperability, but it's across the healthcare ecosystem 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 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 proactive in outreaching members and especially outreaching members at the right time. Right. We've got to 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 got to 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.
- [12:26]
A
If you could change one regulatory industry practice tomorrow to improve affordability and access, what would it be and why?
- [12:34]
B
Sure. Well, I feel like I keep talking about the same thing a little bit, but I think it also shows how important 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 patient and as a caregiver for my mother who has complex conditions and sees a number of specialists and doctors across 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 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 many hours just we as patients would save 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 going to 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 margins perspective 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.
- [15:16]
A
And that kind of ties into the last thing I wanted to ask you, Gretchen, along the lines of margins, and 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 are you responding differently in 2026?
- [15:29]
B
Yeah, it's interesting. I feel like it's such a timely question as we've been seeing all of 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 now about what is happening in the healthcare 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 going to slow down. And I think there are really three large contributors to that. So one is just rising healthcare 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 healthcare 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 cost. So the cost to do business is going up everywhere. That doesn't matter what industry you're in. That's not unique to healthcare, 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 payment that came out on the MA space with the reimbursement rate standing pretty flat with a slight increase that sent a lot of the stocks dropping massively last week. So this is not something that's going to 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 going to 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 would say when I think about this operational efficiency, we've all got to think about leveraging automation right now, process optimization. How can we reduce administrative cost? Right. We've got to think about things like automating, 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 and especially in our administrative processes. And then I think innovation is something that's really exciting. I talked about this as 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 going to help us from an innovation perspective, but also from a member perspective. And then the last piece I would add is that value based partnership piece. You know, the more we can incentivize our providers with quality partnership efficiency. That's going to help all of us as we work through these cost pressures. But it definitely is going to 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 got to think about how we can focus on member engagement. And 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.
- [19:54]
A
Well, Gretchen, thanks so much for a great conversation and for joining the podcast and looking forward to you speaking with us in April.
- [20:01]
B
Absolutely. Thank you so much, Scott.