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Becker’s Healthcare Podcast
Ellen Sexton, Executive Vice President and Chief Growth Officer at Blue Shield of California
00:19:40
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- [00:00]
A
Hello, everyone. This is Jacob Emerson with the Becker's Payer Issues podcast. Thrilled today to be joined by Ellen Sexton, who serves as Executive Vice President and Chief Growth Officer at Blue Shield of California. Ellen, thank you so much for taking the time to be with me on the podcast today.
- [00:17]
B
Hi Jacob. It's great to be here. I'm looking forward to it.
- [00:20]
A
Likewise, Ellen. And before we dive into everything we want to talk with you about today, can you first tell us a little bit more about yourself, your background in healthcare and what it is that you do today at Blue Shield?
- [00:31]
B
Yes, absolutely. Ellen Sexton again. And I'm Executive Vice President and Chief Growth Officer for Blue Shield of California, which means I oversee both the commercial and the government markets for the organization. And we serve 6 million members both in and outside California for our employer group. Actually, a third of our 4 million members are outside of California. And then in the government program business, we serve covered California, which is the state exchange exchange business. Here we have Medicare Advantage and Med Supp plans. And then we also have our Promise Blue Shield plan, which serves Medicaid beneficiaries in Los Angeles and San Diego County. So it's very diversified, high impact, and we like to lead with innovation in California, both I think, as a health plan as well as a state. And that's really what attracted me to joining Blue Shield of California. And my prior experience points to just a passion around serving in health care over two decades of experience. It's hard to believe when I count back the years I was at UnitedHealthcare for many, many years across all different capacities. I ran a Medicaid plan in Wisconsin for them. When Part D was rolled out, I was one of the original pioneers in rolling that out. I had also the ability to lead their group retiree business. So I've seen a lot of different capacities and coverage areas across the HealthC landscape. I was also at Humana for a while and then more recently, before I joined Blue Shield of California, I was at a startup called Curative, which was based out of Austin, Texas. And we were really trying to revolutionize the employer group coverage business. So I have a real passion for healthcare and just enjoy thinking through how do we improve it and how do we improve access as well as coverage and affordability.
- [02:37]
A
Absolutely. So you've been in the industry for a long time, Ellen. Fair to say that you are an expert in your craft. And so I wanted to get us started today by talking about some of the legislative shifts we've seen this year. It has certainly been something that has been top of mind to all the senior leaders we talk to at health plans and at hospital systems across the country. Specifically the one big beautiful bill, HR1 passed this summer. And you know, I know the bulk of a lot of this, this legislation and the changes that will go into effect don't come into fruition for, for a little bit more time, 2027. But I'd love to hear your immediate and long term thoughts in terms of the impact here on how you're thinking about this specifically for the Medicaid population that you serve.
- [03:32]
B
Sure. It's certainly very impactful the different changes and the policies that from an implementation side. So first of all, on the Medicaid side, there's removal of ex parte or the expedited renewal process as well as an additional semiannual renewal requirement for Medicaid beneficiaries. And that just creates extra eligibility hurdles for them to have to get access to care. And from that we see many of those members that may not go through all those challenging forms, if you will, and actually lose coverage. There's also the implementation, implementation of work requirements. And so how we work to streamline that and make the eligibility requirements around that are top of mind. And then there's also impacts to members with unsatisfactory immigration status from right now an enrollment freeze for new members as well as decreased benefits for members as far as maybe having to have co pays or additional premiums which may extend also beyond into the adult expansion. And then there's possible non renewal of what California has as far as Calaim will be trying to figure out how to cover all of those with these federal cuts. And the Calaim waivers really looked at areas like enhanced care management and other flexible community support services like housing and nutrition and behavioral health that really extended into the community and improved health outcomes. So all of these are really big impacts to Medicaid. And then I would lift up as far as covered California the fact that the extension of the enhanced tax credits is still being considered, although probably not too likely. It's got a real impact across to Medicaid because some of those members of course flip in and out of either the exchange coverage or Medicaid. And so, you know, we've had to file two rates with the state whether or not the tax subsidies are approved or not. And it just creates a lot of confusion in the system for members as well as thinking about their eligibility. And so, you know, we're really lifting up programs that can help people meet these eligibility requirements. And so the 28 page Medicaid eligibility form. We've thought through, you know, how do we apply artificial intelligence to try and pre populate parts of it to help identify these members sooner. Also lifted up a GED program to help people actually go back and get their high school diploma. And so, you know, the promise Medicaid plan that we have within Blue Shield. They're just so creative, Jacob, and they come up with all these different areas to really extend, you know, what I would call beyond insurance and help people continue their coverage.
- [06:39]
A
Understood. I mean there's so much going on here in terms of what you just talked about, Ellen, between the work requirements, the changes with, with Calaim and then of course, you know, in extension, all the, the, the changes around the enhanced ACA subsidies and what may or may not happen as we go into next year. I know it's been like you mentioned, pretty difficult for insurers all over the country trying to prepare different rates depending on, on what happens over these next few weeks. I wonder then how does a company as large as Blue Shield of California respond to these policy changes? How do you prepar for uncertain situations that might not even come to fruition? And ultimately what are you doing from where you sit, Ellen, to ensure that your members, whether it's currently insured by Medicaid or ACA or even commercial, that they still receive that quality coverage that you all provide?
- [07:38]
B
Yes, I mean we are preparing for implementation and interpretation of it on all fronts. And I think one of the first things is to be really close partners with your state agencies and with other providers and the community and some of the organizations that help members that goes beyond just the doctor's office, if you will. And so a first focus for us is going to be ensuring the access and care for our members while ensuring overall population, health, emergency care and continuity of care. And so one of the things we have are community resource centers and they serve everyone in the communities, our health plan members. And they provide really high impact services reinforcing the benefits of healthcare coverage and enrollment. And we offer these in partnership with LA Care in LA county and we have 14 different community resource centers and they offer support to people in health care eligibility and other social determinants of health. And they're just real difference makers in the lives of many and just go one step beyond in this situation. So I think you also have to think about continuity of care and that is really top of mind for me. So how do you ensure that members that might be in the middle of oncology treatment for cancer or think about an expectant mother who is in her last trimester. Making sure that we identify those members and ensure that they're not losing eligibility during this time period is just really important. And you can imagine if you were somebody in that situation, you know, losing your, your healthcare coverage during those times would be just really stressful. So that's one of the things that we're definitely trying to do, is ensure continuity of care through all of these policy changes.
- [09:31]
A
Understood. And to your point, I appreciate the acknowledgement that it is a stressful time for a lot of people. It's an emotional issue as much as it is a political and a financial one. So I think a really great point there. Helen. I do want to switch gears and ask a little bit about some of the trends that you're seeing right now in the commercial employer market, especially as we go into next year. We've heard numbers from employer groups all over the country predicting that 2026 might be one of the largest increases in rates in the last few years, maybe even up to a decade on average. And we've heard things increased utilization overall, more chronic conditions. But then there's the GLP one factor that's contributing to all of this. And we've heard a lot about the growth of stop loss insurance contextually as part of this conversation as well. So would love your take in terms of, of what you're seeing from where you sit.
- [10:35]
B
Yes. I mean employers want stability and predictability in their solutions. Right. And so all of those areas that you just mentioned, you know, really start to increase what we're seeing, you know, a pressured employer group coverage marketplace. We are seeing that rising utilization that you're talking about that's, you know, resulting in these double digit increases. And it's happening in both medical and pharmacy. You mentioned GLP1. So you know, one of the biggest areas is, you know, how you decide to cover that with the employer group at hand. And I think you also see some of these amazing new cell and gene therapies and their tremendous innovation and results. But they can also come at a cost of 2 to 3 million for a treatment. And so how we think about making those of affordable, affordable and stratify the financial risk of coverage is really imperative. I think many employer groups, you know, as they look, they're trying to find solutions to still offer their employees great access, but at an affordable price. And many times to do this. I think you'll see employers and us as health payers looking to engage their employees in their own health and help them Help us select the best, highest performing providers and so how we modernize our health plans to give incentives and provide the right digital tools so that their employees can actually make good decisions and their healthcare selections is key as we go forward. The other areas that I see as far as programs for employer groups that are really picking up in need is first of all behavioral health. And I think you see workforce stress as well as burnout and people just really looking at their own behavioral health as far as a big need, but also the employees, children, there's more and more access issues as far as behavioral health and really trying to help employers with this big need in the market. Then one that's near and dear to my heart is just solutions around women's health and really thinking about some of the specific treatment conditions that come through and, and just haven't been as much of a focus sometimes. And then overall, employers are also looking for convenience for their employees. And so whether that's through virtual or telehealth or also a solution that we just rolled out was ZocDoc, which is online appointment booking. And we had over 1 million hours in care able to be booked online. And I think consumers are just looking for the same way that they can go for forward and you know, order something, a package from Amazon or order their meals. They want to be able to do things online. And so I think how healthcare is delivered in that similar matter is just going to be coming to the forefront. But all of these things are going to get at, you know, how do we create some predictability and how do we actually get ahead of these rising core, rising costs for employer groups is just going to be really important for the future sustainability of employer group offering.
- [13:51]
A
Absolutely. And that really does reflect what we're hearing from leaders all over the country of really trying to support their employer clients with stability and then, you know, trying to meet that demand for behavioral care for more women's focused healthcare that is has been top of mind from what we're hearing as well. I wonder if we, if we shift towards a little bit more toward your role and some of the work you're doing in the day to day. Ellen, what would you say are some of the biggest priorities for you right now for your role specifically for the health plan as a whole in the year ahead. I mean, really, what are you trying to achieve as Chief Growth Officer for Blue Shield of California?
- [14:34]
B
Yeah, one of my biggest priorities is how do we not only come up with great ideas to innovate, but also implement those ideas. I always say to my team, great ideas are great, but implemented ideas are even better. And it's what the market's looking for. And I think as we come up across this year, how we come up with joint efforts with providers to actually, actually get at the cost of health care that's rising, but then also create stability for our members and employer groups and plan sponsors so that we can lead through all of these policy changes and really bring the right outcomes to the market. And to do that, I think you have to really instill some resiliency in your teams right now, because there's many challenges that they're taking, taking on. And these policy changes, a lot of times are actually in conflict right. With our mission. And our mission has been to actually increase care and coverage. And so to think about, you know, millions of people across the country that may be losing coverage is. Is really hard, I think, for sometimes for the teams to fathom. And as a nonprofit health plan, we're focused on providing more comprehensive coverage that's reflective of community needs. So the policy changes can fly in the face of that. We'll be working really closely, as I said, with providers to interpret and implement and then ensure that continuity of care that's definitely at the forefront. And these changes are going to hit not only urban areas, but also rural. And so how we support providers is going to be really important. And for us, we don't look to change how we show up in the market. We serve people in every county in California, and we were the first to do so on the exchange, and we'll continue to be doing that. And I think as we all reflect across the system, as more and more people become uninsured because of these policy implications, there's going to be a ripple effect and people end up in the ER with more pervasive conditions. And that could really end up stretching the capacity in hospitals. And the cost then just ends up being spread back to employer groups. And so how we prevent that is really at the forefront of our mission. And know one that the team and I are working really hard on.
- [16:59]
A
Yeah, and I think that's such an interesting point of what you just said there, Alan, that, that health plan leaders all over the country typically are in this work because they want to make a difference. And it is tough for, for many to see some of these, some of these uninsured rates go back up in the face of the work that so many do in the day to day. So I, you know, I think that's such an interesting, interesting point that you made there. And in that vein, I, I would ask, is there anything that you would want to share with the other insurance leaders listening in right now from all over the country? Any, any final thoughts or final bits of advice that you would want to share with them as we close out the year?
- [17:40]
B
I think it's going to take all of our collective efforts working together and I think how we put forward solid plans and, and consistency in those, you know, we're doing a lot of scenario planning, of course, and, and that's to bring the right kind of stability to the market and, and also how we deliver high quality care with our partners. And so you can't stay in a vacuum. You really have to get out there and work with your local state policymakers because, you know, as these policy changes come down, they're not always is all fully vetted. And so how we carefully plan, I think across all our different partners and providers and even with other health plans is going to be really important. And so I like to think about particular how we deliver in the healthcare space as more of a partnership that's focused on that and less transactional. And being in healthcare always has its challenges. As Hugh referenced, we're generally the leaders in it, very mission, focus, focus. And I think if we keep the mission at hand first and forefront, we're going to be successful together. And you know, there's millions of Americans depending on us to do that. And I sure want to be, be the ones that help leave a legacy that really help bring the coverage and affordability that that's worthy of our friends and families. That's our mission here at Blue Shield of California, California. And I know many of my fellow leaders across health plans across America feel that same way.
- [19:16]
A
Wonderful. Well, Ellen, I want to thank you for taking the time to sit down with us on the podcast today and for sharing your insights with our audience. We really appreciate it.
- [19:26]
B
Thanks, Jacob. I really enjoyed the conversation.
- [19:29]
A
Likewise. And to our listeners, if you'd like to listen to more podcasts from Becker's Healthcare, you can visit Beckershospitalreview.com.