Thriving in a dynamic health insurance landscape

Joining us in this episode, Dr. Tommy Ibrahim, M.D., Executive Vice President, President and CEO of Sanford Health Plan, talks with Molly Smith, Group Vice President, Public Policy at the American Hospital Association (AHA). Together they'll discuss the future of care and coverage in rural America, including enhanced premium tax credits, drug pricing, the future of Medicare Advantage (MA) and bold, innovative models that could improve accessibility and affordability while making health care more personalized. 

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Transcript

Courtney Collen (Announcer):

Reimagining Rural Health, a conversation series brought to you by Sanford Health. In this series, Sanford Health leaders and expert guests share insights, innovations and real-world solutions to the toughest challenges in health care today. Each episode explores the ideas, tools and partnerships advancing rural health care and strength in care in communities across the country. Joining us in this episode is Molly Smith, Group Vice President, Public Policy at the American Hospital Association (AHA), alongside Dr. Tommy Ibrahim, M.D., Executive Vice President, President and CEO of Sanford Health Plan. Together they'll discuss the future of care and coverage in rural America, including enhanced premium tax credits, drug pricing, the future of Medicare Advantage (MA) and bold, innovative models that could improve accessibility and affordability while making health care more personalized.

Dr. Tommy Ibrahim (Host):

Molly, hey, it's wonderful to see you again. Thank you so much for agreeing to do this. You've been such a great supporter of Sanford. We loved having you at our Rural Health Summit this past October. And have really appreciated everything that you've done to advocate on behalf of Sanford, on behalf of Sanford Health Plan and for all the great work that you do at the AHA to support our care and coverage strategy. So, we'll dive right in and I really wanted to just maybe start with a little bit of background. So you've been at the AHA for quite a bit now and you've done some tremendous work around care and coverage strategies, care and coverage policy reform. I would love to maybe hear a little bit about the work that you're doing today, and maybe just a little bit about you personally.

Molly Smith (Guest):

Yeah, sure. Absolutely. So thank you so much for having me. Always a pleasure to work with Sanford. And just really, I think your broader focus on rural health care across the nation, I think showing a lot of leadership there, we really, really value that. So, as you mentioned, I work at the American Hospital Association. We are sort of hospitals’ national representatives in Washington. We have about 5,000 member hospitals. Everything from kind of your larger academic medical centers all the way down to frontier hospitals. So a really wide range of different organizations, but frankly, who all share the same mission, which is to provide really high quality care to their communities. And as you know, hospitals provide the highest acuity care. They are unique in that responsibility, and so it's just been a real honor over the last 10 years to get to represent hospitals. And it's been obviously a wild ride. Health care is always a very top priority for policy makers, for really good reason. It affects all of us on a day-to-day basis. It has a big impact on our federal budget. So, there's just always a lot going on, and really looking forward to talking to you about particularly what federal policy makers are thinking in terms of the health care space and how it is impacting rural providers specifically.

Dr. Tommy Ibrahim (Host):

Yeah, no, I love that, Molly, and I think you've heard me say obviously with the focus on hospitals that the AHA has, I think you specifically, your broader teams have done a fantastic job to also keep the lens on provider-led health plans as well that might be part of sort of those larger integrated health care delivery systems and advocate on our behalf as well. Sort of apart from kind of that broader payer landscape that often coincides with a lot of the work that AHA does. So you guys have done a phenomenal job there. We'd really love to just kind of understand, particularly something that's shaped your perspective around rural health care and coverage, particularly for provider-led health plans and integrated health care delivery systems like us.

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Molly Smith (Guest):

There's a little bit of it in my blood, I guess you'd say. Both of my parents worked for the Indian Health Service (IHS) and were both, they actually met and got married in a definitely a very, what we would call a frontier hospital 20 miles above the Arctic Circle in Alaska. Despite not being American Indian by blood, I actually was born in an IHS hospital, and that's simply because my mother went into labor while she was in an IHS hospital. And so there you have it. So there's an aspect of this that has sort of been in my family, and I grew up getting to hear the stories of the importance and the need for health care access in all of our communities because we've got Americans everywhere and people who have joined us in this country, and everybody needs health care. And as we know, getting access to care can be very time sensitive, and so the need to have providers sort of on the ground, bricks and mortar, and workforce who are ready to care for people in even sort of the most far-flung places is really important to this country and it's definitely one of our values, is sort of taking care of our communities, and certainly hospitals are a fundamental part of that. So actually that sort of was in my blood, and both my parents having worked for the government in that capacity really sort of opened my eyes to what the opportunities were. And I actually began my career at the U.S. Department of Health and Human Services within the Centers for Medicare and Medicaid Services (CMS). And that of course is the agency in Washington, or at least at the national level, that runs the Medicare and the Medicaid programs. So that's where I first got myself professionally introduced to the world of hospitals. And in fact, my career started in hospital payment policy. So kind of goes back. But to your point about the role of hospitals and health systems that have kind of gone all the way down the value chain to become, to get an insurance license and offer kind of insurance products and sell plans is one of, I think, the proudest innovations, and one of maybe the more exciting innovations that we've seen over the last 10, 15, 20 years. So Sanford is in good company. There are about a hundred or so hospital systems around the country that do have health plans, and one of the things that I think this really aligns with, one of the main drivers of policymakers right now, and I think a lot of stakeholders, which is really trying to get the best value for the money that we are spending in health care and recognizing that when a provider is able to do that, when they're able to take on risk, financial risk in that way, it also actually opens up a lot of flexibility for them to really care for a patient population perhaps in different ways. So we certainly have seen a lot of innovation in that space. The government has clearly prioritized and has said that they would like to see more of that happening. Of course, it doesn't necessarily mean that every organization can go all the way down the chain, and so we're seeing sort of an evolution we call it, but it's a huge success story and I think something we want to see more of.

Dr. Tommy Ibrahim (Host):

Yeah, no, I love that. And you know where I stand on that, Molly, I mean, we're as an integrated health care delivery system, it's the language that we speak. You know, we're constantly looking about how do we differentiate for our members and for our communities and bringing a provider-led health plan and sort of that full suite of capabilities is really what we believe is going to be the future of how we manage the populations that we’re privileged to serve. So thanks for sharing that. Thanks for sharing your personal story. I mean, I've known you for so many years already, and I didn't know that about you. So that personal connectivity to rural health care obviously translates into all the work that you do and are so passionate about. So maybe switching gears just a tad, staying obviously on the policy front, a lot of focus right now going into the premium tax credits and how that's going to shake out over the course of the next couple of weeks that set to expire here on December 31st. Obviously this was sort of the genesis of the prolonged and the sort of the longest historical you know, government shutdown in our nation's history, and continues to obviously create a lot of uncertainty for people that are anticipating hopefully continuing coverage into next year. The estimations are pretty drastic, right? I mean millions of people will lose coverage effective January 1st. And obviously that has a ripple effect throughout our industry, throughout the communities that we serve. So really would love to kind of get your take on where you see all this going, and particularly, do you see a light at the end of the tunnel for an extension of some kind?

Molly Smith (Guest):

At the point in time where we're speaking, I think that it is probably fair to say that that the extension is not going to happen this year. And frankly, that's something that we're all concerned about. And for exactly the reasons that you mentioned. There will be several million consumers who will see an increase in their premiums as well as some of their, potentially their cost sharing as well. And, you know, the government itself has estimated that those increases are going to be so significant that there are going to be people who either cannot afford to continue paying or simply choose not to given other priorities within their budget. So it is a very, very real likelihood that millions of additional people will be going without what we consider comprehensive coverage in 2026. That being said, there is still a lot of discussion here in Washington about whether this is something that can be picked back up in the new year. In fact, just yesterday a number of Republicans sort of crossed the aisle, if you will, and joined with the Democrats in the House to sign onto a discharge petition to bring this back up in the House in January. So, the issue is not totally dead, but I will say I think that there is a lot of interest to, among many policy makers, looking to the future and looking to what this means for other options for getting coverage. So there's a growing kind of conversation out there about alternatives. We can certainly get into that, but I think for now, the advance premium tax credit extension is something that unfortunately will not get resolved in the next two-and-a-half weeks or so.

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Dr. Tommy Ibrahim (Host):

It's unfortunate, obviously something that we're continuing to watch very closely, and getting a lot of calls about from our members with just incredible amounts of questions that we're trying to walk them through and obviously support them through as well. So we'll keep close touch on that as I'm sure you guys will as well. Let's stay maybe on that topic of affordability. Obviously having health insurance is sort of step number one to getting access to care and affordable coverage and affordable care at that. But it seems like there's a sort of a growing trend and obviously a bigger discussion about affordability coming out of Washington, D.C., which is important particularly in sort of these economic times. A lot of what I'm hearing about some of the kind of bolder models that are being proposed, the access model that was just recently launched, or actually thrown out by CMS as a potential opportunity, seemed to be somewhat encouraging. Sort of aligned with value-based care, all focused obviously on controlling total cost of care over time. Would love to kind of get your initial thoughts on where you stand and AHA stands with those programs.

Molly Smith (Guest):

Yeah, absolutely. So you're certainly right. I think affordability is going to be the key word, and not just word obviously, but the key motivator for policymakers in 2026. Although I think it's worth noting that it has been a priority for a number of years. Obviously there have been some competing priorities, if you will, whether it was to expand coverage or frankly, to deal with the pandemic. But I think there have been longstanding concerns about whether or not the health care system that we have in this country is affordable, whether it's for individual patients, whether it is for the government or for employers who of course pay a significant amount into the system. But I do think that we're going to see efforts maybe really accelerate. And so I think there's a couple of different ways that policymakers are thinking about this, and you've really hit on probably one of the more exciting, which is where can we lean into innovations, whether it's innovations in the way that we help people manage their health, which is really what the access model is about, and we'll come back to that. Or just innovation and how we organize and deliver health care services in ways that we can do it more efficiently or take costs out of the system. So in that bucket of innovating to try to help people better manage their health. So for those listeners who may not be familiar with the access model, that is really around supporting providers in using technologies, whether it's like wearables, like watches, and all of these kind of tools that now exist that a lot of people rely on already to kind of look at some of their own health statistics. But really providing a vehicle, or a financial vehicle, as well as sort of thinking about how providers can actually engage with their patients around leveraging that information that's being collected to better manage their health. There's a lot of other work I would say going into the whole MAHA movement around Make America Healthy Again. So really trying to get people sort of more knowledgeable about what are the different factors that actually are the underlying drivers of poor health that then ends up driving a lot of utilization and illness that is very costly to take care of. So that is definitely a huge priority for this administration, and I think Secretary Kennedy in particular has really sort of been a big champion of a lot of that work. But, you know, there are a lot of other things on the affordability options list, if you will, and some of those are kind of more, again, in that realm of innovation, and how do we think about, for example, paying for care and can we move more providers into what we've sort of traditionally thought of as accountability or value-based models where they take more of the financial risk for managing the health of a particular patient population. They are moving very, very quickly to try to get even more providers into those relationships. Particularly through the innovation center out of CMS, we have just seen a ton of models, and one of the consistent themes, I think, across those is the mandatory nature of most of them. I think for many, many years the government tried to entice providers to participate in these with various different programs and various different carrots. And I think now, not that there's an intention to be punitive at all, but I think there's a real message coming across which is like, ‘OK, the time is really now actually, there's no more sort of sitting on the sidelines to this. We need to really get everybody into these new reimbursement models,’ which frankly, an organization like Sanford is just incredibly well-positioned because Sanford, with a health plan, already has both sort of an expertise and a technological infrastructure, and frankly, sort of mentality among the workforce about what it means to actually manage and be accountable to the premium dollar in that case, but in some of these other models that will really serve you well. But there's a lot of work to be done, though, to bring other providers and frankly, even other plans along who maybe have not really thought about managing population health to drive their financial sustainability and success, but rather have used other tools, whether it's just like rate reductions, or cutting benefits or something like that. So I think there's a lot of work to be done, but clearly a message from the government that everybody needs to get on board.

Dr. Tommy Ibrahim (Host):

Yeah, I know for sure, we see it as well. And to your point, about 50% of our members here at Sanford Health Plan actually get their care, all of their care, most of their care within a Sanford facility. So we are really well structured to kind of provide that end-to-end continuum of coverage. Let's stick on the topic of innovation. Obviously, there's been a really impressive pivot. I would say to your point about sort of CMS, CMOI, really looking at new alternative care delivery models through the use of technology. There appears to be sort of a growing relationship that's developing with the venture capital ecosystem and you know, leveraging sort of the newest technologies in the market. We're sort of excited about that trend, obviously. And particularly with the rural health transformation fund that's being proposed and some of the potential funding capabilities that are out there, looking at ways to also tap into some of those areas to continue to drive that strategy forward, because we do fundamentally believe that the two really need to be intertwined. Tell me a little bit about your thoughts about the rural health transformation fund in particular, and where you see some of those dollars flowing, which programs will probably get the most support for those dollars.

Molly Smith (Guest):

Yeah, so it's really interesting, and hopefully soon, in a couple of weeks, we'll have even more information. But this is a $50 billion fund that Congress included in HR-1 or the One Big Beautiful Bill. And the intent behind this $50 billion is exactly as its name, to help transform access to care in rural areas. I think there is a broad recognition among policymakers that rural areas are particularly vulnerable to, some of the destabilizing forces. Whether it's insufficient population to financially maintain clinical services, or recruiting the workforce to come and live full-time in rural areas. There are a number of just particularly kind of unique challenges. So the way that Congress designed the program is that every state had an opportunity to apply, and in fact, all states did apply. It doesn't necessarily mean that everyone will have a winning application, but let's presume that there are rural areas all across the nation, and most states will be able to tap into this. But the administration, when putting out the applications, was pretty clear about some of the things that they thought were going to be most impactful and that they wanted to see. And to your point, technology was clearly high on the list. I think, again, there's just, a huge recognition that whether it is telehealth, and telehealth that kind of directly can connect patients with providers in various places, or frankly even connect providers to providers. So, for example, if you've got an advanced practice nurse or a physician assistant in a rural area, but they need to tap into the expertise of a psychiatrist or someone else who's maybe not available in that community, that you could use these technologies. But unfortunately, we still have a lot of gaps in access to those technologies, whether it's because they're expensive to adopt or because the connectivity doesn't exist. So we do expect for a number of states to receive funds to try to bolster the technical infrastructure and the deployment of some of these tools. But I would say another really big thing was around workforce, and really around how do we make sure that we've got an appropriate minimum level of services in rural communities, but then can also either bring in the right workforce or frankly move people out. So that's also another thing that the government was really interested in is, are there different models of organizing the delivery system? And one thing in particular they talked about was like, these hub and spoke models. So would it make sense for, in some rural communities, to have one anchor institution, maybe in a more suburban or urban area, but that could support a constellation of rural facilities that could, again, either quickly transport patients if needed or simply tap into their expertise when needed. So those are the types of things that we are expecting and frankly, were reflected in states applications. And now what I think remains to be seen is how the money is going to get divvied up. And then, the government has been very clear that one, they want results in year one, and those results are really going to be the key to unlocking future years’ allocations. So I think that this is something that we're going to be seeing quick movement on in in 2026, and it is going to be really exciting to watch.

Dr. Tommy Ibrahim (Host):

Yeah, no, that's super insightful. Very helpful. And I think consistent with what we're seeing as well and targeting also in terms of some of the projects that we're exploring. Let's maybe talk a little bit about Medicare Advantage. Obviously a huge topic of discussion over the course of the past year. There's a number of wonderful aspects to the program that we continue to be really bullish on as an organization. Obviously with sort of the growing trend of that over-65 demographic continuing the preferential sort of drive of seniors to opt for a Medicare Advantage program as opposed to traditional Medicare continues to expand and grow. And particularly in rural markets like ourselves, there always is seemingly an under penetration of Medicare Advantage relative to traditional, which I think poses some long-term growth prospects for MA in rural America, which is something that we get excited about as a health plan. Having said that, the economics have been incredibly challenging, as you know. I mean, the utilization rates are incredibly high. You know, we're seeing a lot of inflationary pressures, cost pressures, driven by higher utilization, higher medical and surgical claims. Pharmaceutical spend continuing to really be disproportionately escalating with many other sort of regulatory factors and uncertainties abound. So how do you see that market progressing in the future with some of what you know about all of the regulatory questions that are out there around risk adjustments? Where do you see all of this going for MA participants?

Molly Smith (Guest):

I think this program is going to survive and frankly continue to thrive. And there are really two primary reasons for that. One is that, to your point, Medicare enrollees are choosing Medicare Advantage. It looks a lot more, it looks very similar to what they are used to from their job-based coverage. Oftentimes in fact, there's sort of a pretty easy transition between maybe the way in which they were getting covered and the companies that they were using when they were employed into a Medicare Advantage product. And I do think that that will continue. So the consumers will drive it. But I think the other reason is some of what we've already touched on, which is this kind of inherent value proposition around creating incentives for the MA plan to really try to manage the care better, and to really ensure that they're driving to the best health outcomes for their enrollees. I think all stakeholders continue to really believe that aligning these financial incentives and creating also the flexibility through these alternative ways of paying, are really what is needed to make providers able to do these things, to better care for their populations. So given that kind of commitment to those models, and again, I think a really fundamental belief that those are ultimately the right ones, we will figure it out. But it is clearly a very uncertain period right now for Medicare Advantage plans. There is a lot of concern in Washington that the program, the participants, the companies that serve the program have been overpaid by the government. And it is true that the federal government spends more on the Medicare Advantage program than it does if those enrollees fulfill the fee-for-service program. There are a lot of reasons for that, but there's been particular concern by policy makers that there's been some level of gaming by certain payers in particular. Certainly not universal. I think the biggest challenge that we have before us is how do we address those very valid concerns where there is problematic behavior, but not lose access to this really important program that a lot of beneficiaries rely on, that they want, and that is working again to really align incentives. So I think here at the American Hospital Association, one of the things that's so important for us is to really tap into our members that have health plans to really understand what are the dynamics that are happening, what is working in the program, where do you think some of this gaming might be happening, and how do we isolate that? Because frankly, a lot of hospitals who don't have plans are really frustrated for good reason with some of the really big national MA carriers. And so it's easy to sort of say, you know, there's been abuse of prior authorization, or there's been abuse of the risk adjustment program, and they're getting more money than they deserve, you know, let's throw the program out. I think that for us, we feel a real responsibility to try to do right by the health care system to try to figure it out and get it right, which is just an incredible opportunity for us to partner with organizations like Sanford to figure that out.

Dr. Tommy Ibrahim (Host):

Yeah. No, I love that. Thanks for saying that. I mean, I think you're absolutely right. I mean, provider-led health plans often get pulled into that broader narrative when we try to always sort of play by the rules and do what's best for seniors. And you know, I also see the other side of it too. I mean, on the care delivery side, we've also had some of those frustrations that you note with other MA carriers. And given the fact that we obviously own our own health plan and operate a pretty significant Medicare Advantage line of business, can see sort of the flip side of it, and are more sympathetic to sort of the variations that happen there. You know, sticking with that theme though, I have been very impressed with you know, CMS's willingness to sort of have an open door policy and have a conversation about some of these things. To take a look at the variations between some of the larger payers that are out there and smaller plans like ourselves. And they express sort of a willingness to listen and address some of the variables that impact us maybe adversely than they would other plans. I mean, just recently, I know you guys had a little bit of a role to play in this, Alliance of Community Health Plans (ACHP) was involved as well, but CMS actually did make a pretty large concession to move away from the health equity index, which is absolutely well-intentioned but would've adversely impacted smaller plans like ourselves that wouldn't just meet some of the basic requirements to qualify for that particular measure and replaced it with the reward factor. So thanks to you and your leadership in AHA for really diving into some of that, but that seems like a really positive win for smaller plans like ourselves. Would you agree?

Molly Smith (Guest):

Yeah, absolutely. And I think that to your point, well-intentioned policy, but at the end of the day, I think that one of the biggest challenges with a policy like that, and frankly this can happen a lot, is that the way that it was structured really was, just by de facto, sort of benefited bigger plans that had millions and millions and millions more beneficiaries who could perhaps even qualify them to participate. So that's one example of kind of a specific aspect of that program, which was just, which plans are eligible for this new kind of incentive financial award. And the reality is some of the highest quality plans in the country, which are smaller provider-led health plans, didn't even qualify just because they don't have millions and millions of ...

Dr. Tommy Ibrahim (Host):

Population. Yeah.

Molly Smith (Guest):

Exactly. And so that is a perfect example of one area where we really need to be a lot more thoughtful when we're making policy about not stifling competition by making it so that only these behemoths can play in the market. I mean, we already have a lot of consolidation in the insurance space. I think most Americans can name kind of the top five insurers off the top of their, like on one hand. But what I think that, again has been so exciting has been these newer, smaller entrants who are deeply embedded in their communities. I mean, you have physical infrastructure, your workforce is in the community, you're not going anywhere. And what I think we've seen from provider-led health plans is that they bring competition to Medicare Advantage markets. They bring stability. There's a lot less kind of coming and going from markets, because you're really committed to the population and not just necessarily the returns that you might get in a given year. And frankly, we've actually looked at the performance, the quality ratings that CMS does of health plans, and we've been able to segment out the provider-led health plans, and they do meaningfully actually perform better as well on the metrics of things like access to care and timeliness of care, and frankly, patient satisfaction with their coverage. So just given all of those reasons, I think it's just so important. And I'm very optimistic that the government does recognize that and has an open mind for what other changes need to be made. Because frankly, there are some other changes that need to be made to continue to make this like a viable market for smaller more regional plans.

Dr. Tommy Ibrahim (Host):

Yeah, I totally agree with that statement, obviously. And we've been thinking about how do we sort of keep the momentum going now that the conversation's been started and sort of a realization that we are very different. In keeping with that, other policy reforms, I know there's a lot of focus obviously on prior authorization and denial rates and how we manage some of those back office processes that get in the way between care and the member. Tell me a little bit about what you think we could be doing right now to continue to advocate on behalf of smaller plans like ourselves and to continue to get that differentiation narrative out to sort of a broader audience.

Molly Smith (Guest):

One, we need to be always sort of elevating the story of how provider health plans kind of do things differently. And frankly, there's probably no one better to tell that story than your enrollees themselves. And as I mentioned, they're already telling it through the surveys that they do of their satisfaction with the plans, and we really need to elevate that. But I mean, you mentioned prior authorization. I think this is such a great example of where an integrated delivery system has just such a different opportunity to do things differently. To really take a look at, I mean, we're always going to have prior authorization. It's totally appropriate that we have a mechanism for health plans to, one, to make sure that the care that is being sort of recommended for their enrollee is actually covered by the health plan. I mean, it would be terrible if there was no mechanism for that, and then all of a sudden you got something that you otherwise couldn't afford and you didn't know in advance. So there are reasons. What I think has happened now is that it's become just a very, very blunt tool that some payers use when they realize they can't meet their financial targets, and all of a sudden they start squeezing on prior authorization. Where we see it work very differently in our members that have plans, is that they're able to sit down, the provider kind of side of the house, if you will, and the plan side of the house and say, ‘OK, what is what is the care that needs to be delivered for patients with whatever the condition is?’ Let's take our, like hypertensives, let's take those with Chronic Obstructive Pulmonary Disease (COPD), whatever the condition is, what is the right care pathway for them? Do we have that enabled? Where are there places where we can say what we don't need? We know this is all covered. We all are aware of what the rules are. Providers kind of go forth. But also there's access to information and data that is just easier and kind of safer to access when you're all part of one system. So I think that those are some of the inherent benefits of being an integrated delivery system. And again, I think this is just why the performance is bearing out when CMS or when the surveyors ask consumers what they think about their plans, or frankly, when we look at disenrollment information, and we do know that Medicare Advantage beneficiaries are two and a half times more likely to leave one of the big traditional kind of commercial insurers than if they're enrolled in a provider-led health plan. I mean, I think that speaks volumes. I think that we need to continue to kind of elevate not only the performance results, but the stories about how and frankly also I think the stories about how maybe will help others kind of learn how to do things better too.

Dr. Tommy Ibrahim (Host):

Yeah, totally agree. And I like that statistic that you shared about seniors opting for smaller regional plans, a lot like ourselves. We believe that our reputation and sort of the loyal base that we've established here really does sort of lean in that direction. So this has been an absolutely fantastic conversation. Always insightful, Molly, to connect with you. I mean, there's a lot going on right now in the health insurance space. There's a lot going on in sort of the hospital industry overall. Maybe just a couple of pearls of wisdom from you, like where do you see the next two to three years going here and what would you sort of recommend to provider-led health plans like ourselves as we look at differentiation, as we look at continuing to evolve our model amid all of the industry challenges? What would you suggest to us?

Molly Smith (Guest):

Yeah, so I think one of the most interesting things that's happening right now, and we haven't touched on this a bunch, but there's all these new access points for care that are springing up. So whether it is direct-to-consumer primary care, or concierge primary care, there are just like this ever proliferation of websites now where people can go and speak to a clinician and get a prescription for any range of drugs. And in fact that's something that is being encouraged by the administration in terms of working with some of the large pharmaceutical companies to offer more direct-to-consumer offerings. I think this is both, it's fascinating. It potentially could be transformative for populations that otherwise have really struggled to get access to care, which really could include a lot of rural populations. But it introduces a real change, a potential change, to kind of the traditional business model of insurance. I mean, I think that historically, the insurance model has really been predicated on establishing a provider network where you can, and this is whether it's provider-led or it's a big traditional insurer, you establish a provider network where you negotiate rates and then you try to manage utilization. Like we were just talking about, you either maybe try to do it in a way that is more driven towards like actually managing population health, or you just throw on prior auth on everything and just try to like, manage it that way. But in any event, it seems clear that people are going to increasingly access care outside of their traditional kind of network. So I think one of the things that's going to be really important for provider-led health plans, but frankly probably any health plan, is to really be watching and talking to their enrollees about what they want in terms of access to care, and then helping them meet it, whether it is building it yourself, building the access points that they want or partnering as appropriate. But it's going to really take, for many organizations, a different look at the way that they organize their benefits, the providers with whom they contract. So all of that I think is really both exciting, but it could be a little challenging because it really could disrupt some of the traditional ways that health plans have sort of managed their business model. So I think that's sort of one really interesting thing, and I think it's going to move. I mean, it's already moving and it's been moving so fast. And the last thing I do think that we just need to double, triple, quadruple down on, this value kind of adoption. And I think in the rural space in particular, what I think is incredibly exciting and we need to continue to learn from is that the traditional way of thinking was that managing risk didn't work in rural areas because there wasn't a big enough population to sort of spread risk. But organizations like Sanford and others around the country have clearly proven that wrong, and in fact have really been innovative in thinking about how do they even build more kind of risk and accountability into individual providers in rural areas? That has really seemed to work, including to bring stability actually through more sort of stable financing mechanisms of rural providers. So I think that that is just a huge, huge opportunity for us nationally. And one really where we really need to learn from the Sanford’s of the world and then export that more around the country.

Dr. Tommy Ibrahim (Host):

Yeah, I appreciate that very much. I think you brought us full circle back to sort of the foundational concept of just member centricity, right? Listening to our members, really optimizing for an ideal experience for them, trying to drive affordability, quality and service. And that is sort of the thesis that we are centering our strategy around as well. So I appreciate you validating that. Molly, this has just been awesome. I appreciate the time that you've given us today. Thank you for sharing your expertise and your insights. On behalf of Sanford, on behalf of the entire organization, thanks for all you do for us and for how you represent us with the AHA. It really is an important relationship and a partnership that we value.

Courtney Collen (Announcer):

Thank you for listening to Reimagining Rural Health, a conversation series brought to you by Sanford Health. Hear more episodes in this series or other Sanford Health Series on Apple, Spotify or news.sanfordhealth.org