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Brain: Hi, everyone. This is Brian Zimmerman with Becker's Healthcare. For today's podcast, I'm excited to be joined by Nirnay Patel, EVP and GM Benefits1™, Chief Digital Officer, Simplify Healthcare. Thank you so much for joining us today. (0:00)

Nirnay: Thank you, Brian. Thank you for having me here.

Brain: All right, Nirnay. So, let's get started with a simple introduction. I want you to share a few details about your background and the work you're doing. (0:18)

Nirnay: Yeah, of course. So, I am excited to be at the intersection of healthcare and technology. I have been in the healthcare space for about 15 years, and then in tech for pretty much all of my career. At Simplify Healthcare, we are solving two problem areas. The problem of benefits management from an end-to-end value proposition for payers, and the problem of provider data management. These are the two areas we focus on, and we have an incredible set of capabilities for customers, which solve these problems across different markets. So, we specialize in how do we solve this for Medicare, Medicaid, commercial, and all the markets involved.  

Brain: Yeah, that data management challenge, I'm sure, can create some silos from time to time. So, from your point of view, how are payers doing this really well? How are they breaking down operational silos between insurance and care delivery? (1:04)

Nirnay: Yeah, I think that’s a great question. You know, at a very macro level, the way we see it is that there are two aspects of care. There is what I call the design of care, and then there is the delivery of care. And I think where most successful payers and even payviders are increasingly going towards is how can we bridge that gap? Because at the end of the day, the continuum of care for a member would require these two areas to be highly integrated. 

 

So, for example, when you’re designing the care, you will be looking for what are some of the shared risk models from a delivery of care you would like to incentivize the member. So, the designing of care would mean what are your strategies with respect to your network? Are there vertical integration options if you’re taking shared risk and capitation models? What kind of member experience you want to deliver before you onboard the member? And what kind of personalization you want to deliver after you onboard the members, in particular, during their care delivery process?  

 

So, when we look at these silos, there are common denominators, right? Benefits is a common denominator. You would want to know when you’re shopping for your insurance plan, how much it’s going to cost. And you would want to know the same question when you’re in the middle of a care episode. So, benefit is one kind of data layer that we believe is a common denominator, that threads the needle between designing the care and delivering the care. The last thing you want is to create a fragmented data source for such an important layer, which is the problem we are trying to solve. We enable a source of truth for benefits, so that all different stakeholders from actuary to product design development, to your customer service, to your claims team, to the care delivery providers who need access to those benefits, they all are essentially getting a consistent view of benefits because it’s sourced from the same source of truth. So those are some of the value propositions we bring to the table. And essentially, you kind of break down the silos by building an integrated layer across the continuum of care.  

Brain: Yeah, and that tie-in or that bridge, so to speak, is that the benefits information serves as that bridge, like you said, between design of care and delivery of care. And of course, you know, we're talking about healthcare in 2025. So I got to ask you, when doing that work with benefits and shaping that member experience as you put it, what role is AI and analytics playing in helping make this a connected experience from benefit navigation to the proactive care. I believe, you know, the idea here is to get to a place where there's more proactive care. (3:34)

Nirnay: Yeah, yeah, yeah. Well, you know, we are in this incredible wave of AI here at Becker’s, right? It’s hard to even walk 10 steps without hearing AI. 

 

So, it’s very exciting. We have taken the mandate of Applied AI on two fronts. The first one is, how can we make access to knowledge easier? That becomes more along the lines of how we can personalize what’s important on the benefits level. So, we recently launched an AI assistant feature on the Benefits1™ platform. We call it BNi (Ben-ny), which is Benefits Native Intelligence. And essentially, the mandate for BNi is how can we make sure that you have access to all different kinds of benefits information we house within our platform, almost in a natural language manner.  

 

So, things like, “Hey, I’m about to have a broken bone injury, what it might cost me?” Now, to answer that question today, you may be on the phone with a customer service rep, right? And you will be dealing with calls or multiple checkpoints where you would try to get that information; BNi would make it easier because we would source it directly from where the care was designed again. So, this is a perfect example of how the delivery of care and design of care are eating from the same bucket. And that removes the human error, it removes the silos, it takes the friction and the rate limiters away, and it gets you to the source of information and the knowledge as fast as possible, as natural as possible. So that’s one use case of AI where we can deliver a lot more personalized experience on the frontline by limiting the distance from the source of truth.  

 

The second one will be more on the back-office side, where you would want to do a lot more automation. So, for example, if you want to match your member benefits, right, with incoming data sources. You would want to automate the end-to-end workflows using an agentic layer to take care of your back office functions. As it comes to benefits and providers, those are the areas that we are also looking at. So, you can talk to BNi in the future, right, and say, ” Hey, I would like to renew this plan for next year. Show me what are some plan recommendations I should be making as I look into the design of care for next year.” Now, when you have that level of sophistication, you will be able to create, compile, and design a plan. So, your starting point of that process is incredibly sophisticated, and that would mean that you would save a lot of time and cost, and you can spend more time designing the care, versus dealing with a lot more manual processes that exist today. 

Brain: Yeah, I want to come back to BNi, and I'm thinking about that sort of capability. It's come up, being on site at Becker's payer issues round table, comes up a lot. The demand for such a tool is high, and the need for it for members is high. When you think about how complex insurance can be to the average member, being able to cut through the noise, not have to be on hold, and have a direct answer. Am I reading that correctly from the rooms I've been in during the conference? (7:05)

Nirnay: Yeah, absolutely. We have multiple solution options at Simplify Healthcare. BNi essentially solves the problem of exposing benefits information to the product design, actuary, document management, and compliance— a lot of the stakeholders we have. We also have a benefit inquiry solution that empowers the day in the life of a customer service representative and the member. So again, it’s all the same source of truth information.  

 

The demand is high because, as we both know, Brian, it’s a team sport. The moment you are about to embark upon an episode of care, you are talking to, at least interacting with, anywhere between 18 and 25 people. And that’s the simplest form of care. And as your care delivery needs get more complicated, you have more stakeholders, right? You not only have doctors, but you also have to schedule appointments. You have to talk to insurance companies about how much you will pay for it. If you are prescribed, let’s say, a pharmacy, now you have a pharmacist. So now you will go back to your formularies and understand, hey, what, what is this drug type, tier one, tier two, tier three.  

 

So again, this pendulum keeps swinging between those who designed the care, which is more along the lines of payers, and those who deliver the care, which is more on the providers and the pharmacy. But as a member, I would be talking to both of these because I’m trying to take care of the episode of care right for myself. So, we see an incredible demand here for bridging this gap because at the end of the day, one common goal across both of these entities is how can we improve the life of a member, and how can we make sure that they are meeting the healthy outcomes we all intend for?  

Brain: Yeah. And speaking about that, what you just shared kind of gets at this, but to zero in even closer, but maybe a finer point on it, what are the most important moments that shape a member's perception of the benefits they're getting and the value of their plan? (9:16)

Nirnay: Yeah, I think it’s almost like the perception of the member is so intertwined with the market or the care access channel, which they’re coming from, and what I meant for the moments that matter for a Medicare member would be different than a Medicaid member, which will be different from a commercial member. If you look at Medicare members, for example, every year they have an opportunity to shop. And that would mean that every year there is just an extreme hyper focus on access to care, experience to care, because you would want, like, anywhere from onboarding and retaining a member all the way to making sure that you know that their care needs are met. And a Medicare member in an urban Chicago versus a Medicare member in a rural Illinois could have very different needs, right. So, I think moments that matter for a Medicare member would be how good your broker network system is, which can educate the member, how aware you are of their current care needs, and how accessible that care is. And the problem for Medicaid would be completely different. What are the social determinants? They are much more amplified, right, for Medicaid. Versus with commercial, you’re talking about, hey, what employer are we talking about? What kind of benefits does the employer subscribe to? So the moments that matter for the member are onboarding and educating the member. I think there is a common theme there across all markets. Customer service becomes an important one. And then access to care and provider experience become an important one. So across all three markets, those are the common denominators, but there are so many nuances, as you can imagine, onboarding a Medicare member would be very, very different than onboarding a commercial member. So the devil is really in the details. You know, one may think that, yes, these are the areas we want to improve and get more sophisticated on, but the playbook for each one of these market is extremely nuanced and different. And those are the areas where we essentially offer a lot more value for our customers.  

Brain: Considering everything we've talked about so far, Nirnay, what do you believe should be at the top of the innovation agenda this year for payers? (11:48)

Nirnay: Yeah, it’s really enabling a more integrated, connected journey for the members and your internal stakeholders alike. So, personalization of benefits, which allows you to meet more competitive needs in the marketplace, and much more member-facing needs in the marketplace; partnerships with providers and different entities, especially on value-based and other shared risk arrangements, that start shifting the output to the outcomes conversation. So we’re excited about that trend line.  

 

But at a macro level, we believe that the more bridging the silos happen between design and the delivery of the care, that’s the shared space, where it’s a win -win -win. And when I say win-win-win, and there are three stakeholders here, there are members, payers, and providers. So, how can we get these three wins? It’s really founded on how well we can integrate the delivery and design of care. AI is making a lot more of these use-cases much easier, faster, and more accessible. We have use-cases like how can we recommend a plan for a particular member of a particular market? So, your journey of onboarding a member becomes a lot smarter, knowing what the delivery of care formula was that worked for that member. So, with all the data available between payers and providers, some of these use cases of enabling a connected journey have become much easier. And those are the value propositions we bring to the table at Simplify Healthcare.  

Brain: Yeah. I think that's an important point. Maybe we can go even deeper for our final question here, which is really about, either payers are going to have to partner, obviously, here, or they're going to have to build solutions of their own to get to this future state, fill this need that members have, and the payers that do this are going to be the ones that thrive in the future. So the final question is what they should be looking for in partners, or what kind of capabilities they should be looking for as they go to build their own, so that they can get to this future state of a more connected future for members. (11:44)

Nirnay: Yeah, I think that’s a great question. So there are two constraints, which we see. The first one is really investing and improving upon personalizing your experience for your members. On the other hand, there is incredible pressure to do that at scale without adding a lot more cost. And if you look at these two constraints, it’s inevitable for you not to leverage platforms. And what platforms bring to the table, and what platform thinking brings to the table. The technology that comes into picture here can allow you to kill two birds with one stone. So, on the front line and your digital front doors, it can enable a personalized experience for the member because it’s using the data to create a much more integrated and accessible story for your members. And for your back office teams, it brings incredible automations. So your manual silos goes away which is exactly where there is a lot more admin and cost savings and a lot more exhaustion, frankly speaking, because these are highly regulated environments with timelines which are high pressure. There are just a lot of customers who try to endure. So having a platform that allows you to improve on personalizing for your members at scale, at the same time, not adding more cost. Like we have a story with our customer where they improved their NPS score by 12 points without adding any person to their employee staff. Now, it cannot be possible because as you grow geographically in more markets, as you add on more members, if you’re not adding more admin cost, it’s a litmus test, right, on how the degree of automation and sophistication you have in your operating protocols and those are the areas which we think are going to be important for journey onwards. 

Brain: Yeah, it's very easy to conceptualize the way you put it: This becomes a litmus test in terms of how effective the technology is. Nirnay, it was a Pleasure speaking with you today. Thank you so much for coming on the podcast. (16:30)

Nirnay: Yeah, sounds good. Likewise, thank you so much and have a nice day.  

Brain: Yeah, absolutely. I also want to thank Simplify Healthcare for sponsoring today’s podcast. I hope you all have a wonderful rest of your day. 

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