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Becker’s Healthcare Podcast
Navigating Cost Pressures and Data Driven Partnerships at EmblemHealth
00:16:18
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- [00:02]
A
This is where health insurance leadership comes together. Becker's 4th Annual Spring Payer Issues Roundtable brings together over 400 payer and health plan executives and more than 100 speakers to Chicago, April 13th and 14th. 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.
- [00:34]
B
Hello everyone, and welcome to Becker's Healthcare Podcast. I'm Scott King, thrilled today to be joined by a very special guest, Heather Tamborino, Chief Financial Officer with Emblem Health. Heather, how you doing? Thanks so much for joining us.
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C
I'm great. Thanks so much for letting me join you today. I'm so excited.
- [00:51]
B
Of course we have, you know, a new year, some same issues in health care and with health plans and, and some, some new ones as well. But before we jump into all that, I was wondering if you could please tell us a little bit about your background and your career journey.
- [01:06]
C
Sure thing. I've been here now with Emblem Health as the Chief Financial officer for the last five years and that entails what you would expect it to entail. Controllership, actuarial FP and a treasury, the norm. And my background's a bit of a mixed bag. You know, I started with Deloitte in the traditional accounting, moved into working in enterprise risk management and performance management and have bounced around in both IT spaces, operational performance spaces, and both profit and nonprofit. Probably my last 20 years has been in the nonprofit space with a variety of blues, and now here at Emblem Health.
- [01:56]
B
Well, excellent. Thank you so much for sharing all that info, Heather. Really appreciate it. You've come in from a lot of different experience and perspectives there. The first topic I wanted to get to, how are your relationships with providers changing as both sides face cost pressure and workforce shortages?
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C
Yeah, it's as you said, it's always been a question. But as with the more recent challenges, it can be a little challenging now. But our goal is to continue to move, focus on the relationship and move to value based and really focus on integration in a cost efficient manner. But you know, it's strained with those pressures. All that said, I think what we're continuing to do is look at opportunities to really think about unique contracting opportunities, you know, hybrid contracts, you know, blending fee for service versus pure value based and really focus on what is the common goal for both the payer and the provider. And that's putting our Members and patients right at the middle, right at the center. And we're working on engaging on a number of fronts, really focusing on educating our provider partners on, you know, what can drive premium incentive dollars and sharing actionable info in a really consultative way and show them how that improves the outcome not only for the patient, but for their reimbursement and financials. We're also doing things like providing predictive analytics to our providers so we can help catch rising risk and again allow both the payer and the provider side to nudge members towards lifestyle or engagement channels and changes. And the other thing we're trying to do with our providers is when we think about contracting, it's how do we take a multi year view on measures and improvements. So we're not asking a provider to step immediately into a new reimbursement methodology or something when they're struggling with other cost and revenue challenges. And we think as long as we take these multi year views on measures and improvements that can help with chronic care management, that can help with both outcome improvement on the payer and provider side. Last I would say we're in a slightly unique position at EMBLEM because we have our own provider group and given that many of our members are tied to our own provider group, that's advantage care physicians. This gives us a great opportunity to really incubate and sort of test and pilot new solutions, new capabilities, technologies that really support the long term management of our member needs. And then we can work to extend those capabilities to our provider, our broader provider base, because we've had the opportunity to test them and that can help minimize cost and investment to the providers when we're all trying to manage through this pressured period.
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B
Where do you see the biggest gap today between payer strategy and operational execution?
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C
I think if you focus on fundamental strategies on the payer side, it's really going to be around member engagement and outcomes. And when you think about the gap, it sort of takes two to tango, you know, in that support of the member and getting that outcome and engagement. Payer strategies focused on partnership with the providers are going to continue to be critical to deliver the care and quality that our members need. Emblem's focus, our focus is to continue to prioritize how do we engage these providers through sharing data and technologies, easing administrative processes, creating capabilities that really support shared decisions regarding care and patient engagement. But when you think about that, that's our, that's our focus to close that operational gap. You got to do that in an efficient sort of cost effective manner. We just talked about all the pressures both the payers and providers are facing. One place you're going to see people focusing is on AI capabilities. But we really need to be artful and thoughtful in our strategies of AI utilization. So we're focusing on areas that specifically ease the administrative burden regarding the integration of process with the payer and the provider. So this creates an opportunity for clinicians and administrators to spend time and resources really focused on patient care and engagement versus back office. When we think about where we need to invest, that's where we have to invest capabilities that meet our common goals and really focus on operational execution. It's meeting those common goals and then both sides can come to the dance floor in a real way for our members.
- [07:03]
B
Heather, could you dive a little deeper maybe into what Emblem is kind of looking to focus on in regards to AI in 2026?
- [07:12]
C
I would say it is one of the key investments that most of the payers or providers that you'd be talking about would be addressing. If I look at it from our provider side, it's around revenue cycle. They're looking at AI opportunities there. I think if you look at it on the health plan side and again, this is one of our most critical initiatives we have to go beyond. I think many payers are going to focus on what's the most advantageous to the health plan itself. And I think our initiatives will need to go beyond those internal operations of the health plan and focus on how do we extract data, focus on driving it to the payer in a way that's easy for them to digest into their systems.
- [08:05]
B
Absolutely. Heather, let me ask you, what's one investment or initiative you believe will most reshape how health plans operate over the next two to three years?
- [08:17]
C
I mean, we started to talk about it, right? We started to talk about AI and I think that is going to be one of the ways. But again, that AI focus and investment focus really around the integration with providers, deepening both sides, technical capabilities and common goals. It doesn't have to just be AI, right? It can be looking to say, how do we leverage data integration? How do we leverage other components that allows us to drive actionable activities to the providers in such a way that they can utilize it in a fashion that's where we're spending a lot of our time. Interoperability, engagement of data. And as we continue to see these escalating costs and these diminishing revenue levers, partnership in these initiatives for data exchanges that really manage outcomes and risk and reduce system wide administrative costs will be the Key to ongoing longevity. There's an increasing urgency here again, leveraging our provider practice, acp. It's a good way to test the interaction systemically between the two, the payer and the provider, and make sure that as we're deploying these investments, we can make sure that it works in real time and then we can lever that to some of our other provider partners.
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B
If you could change one regulatory or industry practice tomorrow to improve affordability and access, what would it be and why?
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C
Well, if you're only giving me one, I would say. And we sort of. I think I keep coming back to a similar theme. It really would be how do we focus on a framework, can be an industry framework, but a framework that really allows us to integrate decision support right in the electronic health record. How do we provide actionable data and feedback at the point of encounter so that it helps deliver improved quality and improved outcomes? This framework can leverage provider data and payer data to allow providers to close care gaps immediately. This can eliminate this back and forth post visit with the provider. Limiting that follow up between the health plans and their partners helps with the overall cost structure that we've been talking about. It helps align incentives. It makes transparency better. You said one. If you were going to let me pick an additional area of opportunity, you hear about it all the time. But how do we think differently about prior authorization, the goal between a payer and a provider? It's the same. We want to make sure that we're delivering the right care at the right time and location. Location is important to us. And at Emblem, that's what we're focused on today. We continue to iterate and ideate on how do we provide more immediate electronic feedback, ease the entire process electronically, only seek to address areas of most critical need and then this really helps avoid the delay in care that is a constant point of friction. But more than friction, trust for all parties, whether you're the member or the provider or the payer. So I picked two. One really around actionable, common framework in the electronic health record that we can support each other. And then the second one really around how do we think. Continue to think differently about where and how to do prior authorization, but do it in a way that's really efficient and immediate.
- [12:14]
B
I'm glad you broke the rules and picked two, because prior authorization is a very big deal. I appreciate your thoughts on it there. Heather, the last question I have for you. What issue is putting the most pressure on health plan margins right now? And how are you responding differently or are going to respond differently in 2026.
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C
It's interesting you ask that because you could pick five or six things that are putting pressure on health plan margins right now. One thing that I would say we're explicitly focused on and I bet if you ask many payers or providers, it's a common item. It's really around pharmacy costs because I think anything you look at or read, whether you're a national for profit, not for profit, pick a product segment. Pharmacy costs today are continuing to rise and continuing to be a pressure point. What are we doing differently? Really important thing, and we started this back in 2024. We reevaluated our PBM and we selected a partner that we thought really had a similar mission and goals that we had with and a real focus on transparency and growth. So Emblem Health recently announced that we did pick a new pharmacy benefit collaboration with Prime Therapeutics and we think there's an opportunity to really provide a more transparent and affordable pharmacy experience for our members. And I think it's more really focusing on giving members within a construct more choice and convenience in how they access their medications, including real time competitive referrals for specialty prescription drugs and fast home delivery through Amazon Pharmacy. This is a time when both health care and pharmacy costs are rising. That's putting pressure on our margins. But we're trying to introduce innovative solutions that give our members real time information, clear picture of the cost for them and convenience for them that puts their needs right in front. And we think by putting our members more in the driver's seat of their pharmacy experience, we can potentially remove some of the friction points that tend to lead towards non adherence missed doses and poor health outcomes. That drives cost into the entire system for everybody. The transparency components that we're working through as well with prime also puts us in a position where we can more actively manage the cost. We know where they're driving their margin, we know how to get the most affordable outcomes. So it's a bit of a win win for all of us. And that was critical in our choice. The last little bit on that. When you think about pharmacy beyond what we've discussed, it's really about the gene therapies, right? As more and more gene therapies emerge, we don't have all the answers, nor does the rest of the industry. But there is a real need to address thoughtful care management and look at risk transfer arrangements that work for all the parties. When you're talking about these drugs that are really critical to improving member health, but also come in two and $3 million price tags per dosage. So those would be the couple of key things that I would highlight. We're really focusing on in 2026 as one of the pressure points on our health plan margins.
- [15:59]
B
Heather, thanks so much for joining us on the podcast. It was a great conversation. We're really looking forward to you speaking at the Spring Payer Issues Roundtable.
- [16:07]
C
Thank you so much for inviting me. Happy to participate and and I think it's going to be great fun when we get together at the roundtable.
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B
Definitely will be.