Podcast Summary: Navigating Cost Pressures and Data Driven Partnerships at EmblemHealth

Podcast: Becker’s Healthcare Podcast
Host: Scott King (B)
Guest: Heather Tamborino (CFO, EmblemHealth)
Date: January 24, 2026

Episode Overview

This episode of Becker’s Healthcare Podcast features a discussion with Heather Tamborino, Chief Financial Officer at EmblemHealth. The conversation centers around how health plans and providers are confronting mounting cost pressures, evolving provider partnerships, and rapidly advancing data-driven and AI-enabled strategies. The episode also touches on regulatory challenges, operational gaps, and practical innovations aimed at improving both affordability and access across the healthcare system.

Key Discussion Points & Insights

1. Heather Tamborino’s Background & Approach

• Heather's Experience: Over 20 years in nonprofit health, broad experience spanning accounting, risk management, IT, and operational performance (01:05).
• Unique Perspective: Experience in both profit and nonprofit sectors, which shapes her holistic, pragmatic approach.

2. Evolving Provider-Payer Relationships under Cost Pressures

• Shift to Value-Based Care: EmblemHealth is focusing on relationship building, unique contracting, and blending fee-for-service with value-based models to keep members at the center (02:11).
• Provider Engagement Strategies:
  • Educate providers on premium incentive drivers through actionable data and consultative approaches.
  • Use predictive analytics to help providers catch rising risk and promote member lifestyle engagement.
  • Implement multi-year views in contracting to support providers transitioning to new reimbursement methodologies, recognizing the pressures they face.
  • Experiment with innovative solutions within EmblemHealth's own provider group (Advantage Care Physicians) before extending to broader networks.
• Notable Quote:

  "We're working on engaging on a number of fronts, really focusing on educating our provider partners...show them how that improves the outcome not only for the patient, but for their reimbursement and financials." — Heather Tamborino (03:12)

3. Bridging the Strategy-Execution Gap

• Operational Challenges:
  • Main gap is between payer focus on strategy vs. actual member engagement and clinical outcomes (05:09).
  • Effective execution requires “two to tango”—close partnership and shared goals between payers and providers.
• Efficiency & Technology:
  • Sharing data, easing administration, and creating tools for shared decision-making drives execution.
  • Investment in technologies, especially AI, is critical, but must directly reduce admin burden and enable clinicians to focus on care.
• AI Use:
  • EmblemHealth is focused on AI applications for revenue cycle on the provider side and streamlining administrative processes on the plan side, always with a goal to benefit both parties (07:11).
• Notable Quote:

  "We really need to be artful and thoughtful in our strategies of AI utilization... specifically ease the administrative burden." — Heather Tamborino (06:23)

4. Investments & Initiatives Shaping Future Health Plans

• AI & Data Integration:
  • AI is essential, but equally important is interoperability and seamless data exchange between payers and providers (08:17).
  • Testing new tech and data-sharing approaches within ACP before scaling.
  • Goal is actionable insights for providers, promoting risk management, reducing admin costs, and ensuring sustainability.
• Notable Quote:

  "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." — Heather Tamborino (08:55)

5. Regulatory Improvements for Affordability & Access

• Primary Ask:
  • An industry-wide framework to integrate actionable decision support in the EHR at the point of care—enabling immediate feedback and gap closure.
  • Goal: Eliminate back-and-forth with providers post-encounter, thereby improving cost, incentives, and transparency (09:56).
• Prior Authorization Reform:
  • Simplify and digitize the process, focusing only on critical needs to reduce delays, friction, and trust issues (11:35).
• Notable Quote:

  "How do we provide actionable data and feedback at the point of encounter so that it helps deliver improved quality and improved outcomes?" — Heather Tamborino (10:08)
  "How do we provide more immediate electronic feedback, ease the entire process electronically, only seek to address areas of most critical need..." — Heather Tamborino (11:35)

6. Biggest Pressures on Health Plan Margins & Responses

• Pharmacy Costs Rising:
  • Pharmacy spend is the top pressure, compelling reevaluation of PBM partnerships and benefit design (12:33).
  • In 2024, EmblemHealth shifted to Prime Therapeutics to prioritize transparency and bring members real-time, affordable options, including Amazon Pharmacy access for specialty and home delivery (13:15).
• Gene Therapies as a Cost Challenge:
  • $2-$3 million price tags per dose create industry-wide need for new care and risk management models.
  • Exploring risk transfer and care management for these therapies.
• Notable Quote:

  "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." — Heather Tamborino (14:14)
  "As more and more gene therapies emerge...there is a real need to address thoughtful care management and look at risk transfer arrangements that work for all the parties." — Heather Tamborino (15:23)

Notable Quotes & Memorable Moments

• On evolving provider partnerships:

  "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." (02:15)

• On AI's role:

  "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." (06:45)

• On the future of data:

  "How do we leverage data integration...to drive actionable activities to providers in such a way that they can utilize it in a fashion that's where we're spending a lot of our time." (08:35)

• On pharmacy innovation:

  "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." (14:41)

Timestamps for Key Segments

• 01:05 – Heather Tamborino’s background and EmblemHealth overview
• 02:11 – Changing provider-payer relationships amid cost pressure
• 05:09 – Gaps between strategy and operational execution
• 07:11 – Emblem’s focus areas for AI and data in 2026
• 08:17 – Investments that will reshape health plans in coming years
• 09:56 – Regulatory changes needed for affordability and access
• 12:33 – Pressures on health plan margins: pharmacy and PBM partnerships
• 14:14 – Innovation in pharmacy benefits and gene therapy risk

Conclusion

This episode features a candid, pragmatic conversation with EmblemHealth’s CFO on today’s most pressing challenges in health plan operations—cost pressures, technology integration, pharmacy spend, and the evolving provider landscape. The discussion is anchored in actionable strategies, data-driven partnerships, and the belief that sustainable innovation must always keep the member at the center.