Latest / Becker’s Payer Issues Podcast / Affordability and the Role of Regional Nonprofit Health Plans at Point32Health with Patrick Gilligan

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Affordability and the Role of Regional Nonprofit Health Plans at Point32Health with Patrick Gilligan · Becker’s Payer Issues Podcast

• 0:02
  This is where health insurance leadership comes together.
• 0:05
  Becker's fourth annual spring payer issues roundtable brings
• 0:08
  together over 400
• 0:10
  payer and health plan executives
• 0:12
  and more than 100 speakers to Chicago April.
• 0:16
  This year's event includes keynote conversations with the
• 0:19
  industry's top leaders and former president George w
• 0:23
  Bush. For the full agenda and event details,
• 0:25
  visit beckershospitalreview.com
• 0:27
  and click on the events tab in the
• 0:29
  upper right. We're looking forward to hosting you
• 0:31
  here in Chicago.
• 0:33
  Hello, everyone. This is Jacob Emerson with the
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  Becker's Payer Issues podcast. Thrilled today to be
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  joined by Patrick Gilligan, who serves as the
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  president and CEO of Point thirty two Health,
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  which is the parent company of Harvard Pilgrim
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  Health Care and Tufts Health Plan. Pat, thanks
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  so much for taking the time to be
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  with me on the podcast today. Really happy
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  to be with you, Jacob. Thank you. Likewise.
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  And before we dive into everything we wanna
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  talk with you about today, Pat, can you
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  first tell us a little bit more about
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  yourself, your background in health care, and what
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  it is that you do today at Point
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  thirty two Health?
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  Yeah. Great. Well, appreciate this opportunity to be
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  with you. Again, my name is Pat Gilligan,
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  president and CEO of Point thirty two Health.
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  We are a,
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  New England based health plan. I have been
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  living in New England my whole career
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  and have done more than 30 working in
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  health care, in the New England space mostly
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  for not for profits.
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  I spent a long time at a local
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  academic medical center,
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  where I ran contracting with the with the
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  payers
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  and did that for a long time. I
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  then actually moved. I'm an actuary by training,
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  and wanted some payer experience. So then I
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  moved to, Local Blue Plan,
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  where I actually did the provider negotiations. So
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  I've done both sides of that and focused,
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  very heavily on aligning incentives between payers and
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  providers,
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  whenever I could.
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  I did take a short break and work
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  for
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  a for profit, CVS,
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  which is also a New England company,
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  but then went back to the local Blues
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  plans to become the chief commercial officer
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  and to run sales, marketing, and product.
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  So I've been on the provider side. I've
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  been on the payer side, focused on providers,
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  and I've been on the payer side
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  focused on,
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  employers and our customers.
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  So having that experience, I was, doing some
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  consulting,
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  for a couple years,
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  which I was enjoying,
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  but then have the opportunity to talk to
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  the board here at point thirty two health.
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  So we're the parent company of Harvard Pilgrim
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  Health Care and Tufts Health Plan.
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  And
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  we operate in five of the six, New
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  England states,
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  and we're a regional not for profit.
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  And I
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  believe
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  very much in not for profit, both health
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  care delivery
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  and,
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  on the health plan side. It doesn't mean
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  that other models don't work or are problematic.
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  I just think these are very important,
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  to the industry, and it was important me
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  to join this company and to see these
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  two brands thrive. So that's why I'm here.
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  Absolutely. And let's talk a little bit more
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  about that, Pat, in terms of, you know,
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  what you've experienced across the industry
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  during your career, the types of companies you
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  worked for, the parts of the industry you've
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  worked in,
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  because point thirty two Health, as you know,
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  you now serve
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  around 2,000,000 people across New England. And so
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  I wonder
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  if if you're looking at at the current
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  health care landscape
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  and everything that's going on right now,
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  what's the value prop of of a regional
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  nonprofit
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  plan
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  in an industry where we're we're increasingly seen
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  dominated by national for profit insurers, really just
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  a handful of companies?
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  Companies. And do you think that your model
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  comes with any trade offs, whether that's in
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  scale, in resources, in financial resilience? How are
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  you thinking about this right now?
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  Yeah. It's a really important question. And, again,
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  I think the for profit certainly play their
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  role, and there are certain customers that really
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  want that, more more national presence.
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  But I would just remind us all that
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  health care, you know, despite technology and telemedicine,
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  you know, health care, especially on the delivery
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  side, is still very, very local.
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  And the way that we get our care
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  is with our local,
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  providers, our local pharmacy,
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  and local hospitals.
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  And as a truly independent, not for profit
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  health plan,
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  we can focus on our members in a
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  different way than some of our competitors are.
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  What's the difference? So
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  many
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  the national for profits
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  obviously have shareholders that they have to worry
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  about, and they have to worry about their
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  earnings calls. That's not something we have to
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  worry about.
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  Many of our local competitors in this market
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  are smaller,
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  health plans that are also not for profit,
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  but they're owned by providers.
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  And so with that provider focus,
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  they have different priorities maybe than what we
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  have. And then there's also, of course, the
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  blue system across the country.
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  But the blues, you know, need to work
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  with each other in certain way and don't
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  always have the independence that we have as
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  a regional plan.
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  So at Harvard Pilgrim Health Care and Tufts
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  Health Plan,
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  when I say we're truly independent,
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  we are independent. We we have our board,
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  but we don't have to worry about all
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  these other aspects that our competitors have to
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  worry about.
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  And what does that mean? It means that
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  we focus on our customers, that's employers,
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  and individuals who buy our products and all
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  of our members.
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  And we literally view them as our shareholders.
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  Our members and our customers are our shareholders.
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  Our purpose is to guide and empower healthier
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  lives,
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  and we create a culture here at PointThirtyTwoHealth
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  that's myopically focused
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  on that that purpose.
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  What does that mean when we're dealing, with
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  folks in the marketplace?
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  One is we're local for our employers,
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  which they really appreciate, and we get to
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  know them. But we have very unique relationships
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  with our providers as well because we can
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  go visit them, and we can meet with
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  them, easier and spend more time and try
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  to get aligned with them and what we're
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  trying to do.
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  We also,
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  as as a set of plans,
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  we participate in in all markets
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  of health plans. Meaning, we're in the commercial
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  market, Medicare.
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  We're in Medicaid in in several states, and
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  we're in the duals program.
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  So
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  we have a much more,
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  intertwined relationship
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  with our local providers, and they appreciate that.
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  No. I absolutely, Pat. And I
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  so basically,
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  you're you're saying that at the end of
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  the day, you know, you are beholden to
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  your customers and to your members,
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  from the get go.
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  And, you know, you're you're really still relatively
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  new to the role. You stepped into,
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  the CEO role just last year. And so
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  I wonder, given your your long experience now
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  in the industry,
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  is are there any new challenges that you're
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  seeing right now either for the company specifically
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  or for your local health care markets?
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  Really, has anything surprised you since you took
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  on this top role?
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  Well, I will say, it didn't surprise me
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  from when I took on the role. But
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  if I go back to 2024
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  when I was doing consulting,
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  as I as I said at the beginning,
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  I've been in this business for thirty years.
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  So the biggest surprise over the last three
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  years is just the unrelenting,
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  trend in medical costs and whether that's,
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  the outpatient side or the pharmacy side or
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  other places. And this is not unique to
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  us. It's not unique to our region. This
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  is a national trend right now, and all
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  payers and providers are needing to deal,
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  with this issue.
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  And so that's probably been a challenge my
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  whole career. It has never been as acute
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  it as it is right now.
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  And I came into this role
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  knowing that that was gonna be the biggest
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  challenge
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  and something that we are very focused on
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  on taking on that challenge.
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  The cost issue that we have
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  is
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  not just around providers. I wanna be clear
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  about that.
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  Health plans need to manage their costs as
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  well if we're gonna provide, better value
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  to our employers.
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  So at PointThirtyTwoHealth,
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  we're focused on our own costs and how
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  we deliver
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  our services and our coverage more efficiently. We're
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  focused on the total cost of care and
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  how we manage,
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  medical
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  and pharmacy care, and we're focused on the
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  long term around how we align incentives
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  to bring down trend and manage costs more
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  effectively over time.
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  And, Pat, let's let's dive into that a
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  little bit more in terms of the affordability
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  crisis that, we're we're hearing about all over
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  the country right now from from pretty much
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  every insurer.
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  You're sitting in
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  one of the most expensive health care markets
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  in the country, Massachusetts
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  specifically.
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  How are you thinking about Point thirty two
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  Health's role in all of this,
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  and what levers do you actually have to
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  to help bring down some of these costs,
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  both for for providers and your members?
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  Yeah. Well, first of all, I just wanna
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  point out that,
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  it's not an overstatement that this is a
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  crisis. I I really think we are at
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  a crisis point.
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  And what I mean by that is that
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  employers,
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  and and members slash patients
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  are really suffering around affordability.
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  Health care in many respects is just not
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  affordable. The premiums are too high. The deductibles
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  are too high. The medical debt that we're
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  seeing,
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  insured people have is too high. And so
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  there's an imperative for us to deliver for
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  our customers,
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  a better experience,
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  and better pricing.
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  There's a lot we can do and that
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  we are doing,
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  to manage,
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  overall cost and to focus on affordability.
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  One of the things, first of all, is
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  just educating providers,
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  about that.
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  The providers for a long time
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  have been rate takers when it comes to
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  Medicare and Medicaid
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  and then try to set their own prices
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  with commercial
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  without really full understanding or regard to what
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  that's doing to local businesses that are around
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  them. And so that's one of the things
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  that we focus on is that education.
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  And then I'll go back to what I
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  said before, Jacob, is that,
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  we have a cost problem in health care.
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  It's not a revenue problem. And whether it's
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  regulators
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  or legislators
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  or,
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  pharma companies,
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  there's, for whatever reason, a huge bias to
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  focus on the revenue side of health care.
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  We need to focus on the cost. We
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  are doing that as a company. We are
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  looking at our overhead costs and our FTE
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  count. We are managing our vendors in different
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  ways to get more efficient,
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  and then we are managing
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  the cost of care on behalf of our
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  customers, which is, our responsibility.
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  By the way, when I say this is
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  a crisis, we're going to we're going to
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  manage
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  as much of this as possible. And I
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  feel much better that we are getting it
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  under control with what we know about right
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  now. But I wanna remind us all that
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  there are other,
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  pressures that will be coming as we think
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  about new therapies,
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  cell and gene therapy in particular,
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  really
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  significant costs with meaningful clinical outcomes that we
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  are gonna wanna provide for our members and
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  for our patients. But we need to start
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  taking on the cost problem now to get
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  ready for the cost problems of the future.
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  Absolutely. It's a really astute point, Pat. And
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  I I wonder, you know, obviously, you are
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  very affected by policy changes at the state
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  and federal levels, multiple states for for point
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  thirty two health. I wonder, you know, given
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  your your expertise and your your experience,
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  for for a long time now throughout the
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  industry from provider negotiations,
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  commercial insurance, consulting, like you mentioned,
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  if you had a magic wand and and
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  you had all those perspectives in mind, what's
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  one specific thing you you would fix immediately
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  if you could? Is is it a policy
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  thing? Is it something that, you know, the
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  company what what what would you do, to
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  make things just a little bit different?
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  So the thing that I would like to
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  do, and I think all of the players
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  in health coverage and health care need to
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  do,
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  is to think about
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  how do we design and orient care
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  around the patient.
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  One of the things that I learned being
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  on the provider side and why I wanted
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  to get over to the payer side and
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  understand the customer more is that so many
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  times from the provider perspective, we organize the
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  care and the delivery through the provider lens.
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  And we need to totally reverse that and
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  do it through the patient lens, which will
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  give you a much different outcome.
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  How do we do that?
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  We're gonna do it by partnering much more
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  closely with the delivery system.
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  And whether that's pharma,
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  or physicians,
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  or hospitals,
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  really creating stronger partnerships that are aligning incentives
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  around both cost,
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  quality,
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  and experience.
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  We've talked about the fact that health care
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  is way too expensive.
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  It's also has a terrible experience for members
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  and patients.
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  Many when my, when I learn about friends
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  or family members who have someone in the
• 13:25
  hospital,
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  as much as I know the delivery system,
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  you know, here in New England, I always
• 13:30
  say, make sure you go in and and
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  check on that,
• 13:34
  on your family member and make sure that
• 13:36
  you support them. We need to do that
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  because health care is so complicated.
• 13:41
  We see stories of people getting to the
• 13:44
  pharmacy to pick up a prescription,
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  and it's not ready because some glitch in
• 13:48
  the system, and they really need that medication.
• 13:51
  There is so much opportunity
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  for us to reduce,
• 13:55
  waste and to focus on, you know, better
• 13:58
  experience that will actually lower cost. And I
• 14:00
  think the way we do that, Jacob, is,
• 14:02
  again, focusing on the patient and their experience,
• 14:06
  rather than any any any other actor in
• 14:08
  the system.
• 14:10
  Absolutely. So you would really target and improve
• 14:13
  the member experience. I I love that answer,
• 14:15
  Pat. And I think that really ties back
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  to what you were saying earlier in terms
• 14:19
  of who you and the company
• 14:21
  ultimately serve.
• 14:23
  So I really appreciate that answer.
• 14:26
  Before we go, is there anything else that
• 14:27
  we're missing, anything else you wanna make sure
• 14:29
  that we hit on, or or any other
• 14:31
  advice you wanna share,
• 14:33
  while you have the ears of a lot
• 14:35
  of other health plan leaders from around the
• 14:37
  country. Yeah. I think I just end with
• 14:39
  two points. You know, one is in the
• 14:41
  last question, you asked me about, you know,
• 14:44
  regulators.
• 14:44
  And,
• 14:45
  by the way, I think there are a
• 14:47
  lot of policy issues that can help support
• 14:49
  what I just went through and how do
• 14:50
  we make, put the patient at the center.
• 14:53
  And
• 14:54
  there's,
• 14:55
  so many, interactions that happen in health care
• 14:58
  that are clunky, and I think any policies
• 15:01
  that can help providers and payers work better
• 15:03
  together,
• 15:05
  to be patient focused is, very, very welcome,
• 15:09
  both at the local, and at the national
• 15:11
  level.
• 15:12
  And then finally, I would just say, you
• 15:14
  know, I appreciate being here, Jacob, and being
• 15:16
  being able to share my perspectives.
• 15:19
  I've been in this business long enough to
• 15:21
  know that one health plan is not gonna
• 15:23
  fix this on their own. One provider is
• 15:25
  not gonna fix this on their own.
• 15:28
  We need everyone to lean into this problem,
• 15:30
  and so I appreciate the opportunity to share
• 15:32
  my
• 15:34
  perspective,
• 15:35
  with my colleagues here and look forward to
• 15:36
  learning, their ideas around how we may care,
• 15:40
  just better for everyone.
• 15:42
  Well, Pat, I I speak on behalf of
• 15:44
  all of us here at Becker's. We're thankful
• 15:46
  that you,
• 15:47
  decided to to take the time to chat
• 15:49
  with us and to share a little bit
• 15:51
  about all the important work that you and
• 15:53
  and your teams at point thirty two Health
• 15:55
  are doing. We really appreciate it, and and
• 15:57
  we appreciate you sharing your insights with us.
• 15:59
  So thank you. Thanks, Jake. It's so nice
• 16:01
  to be with you. Yeah. And to our
• 16:03
  audience, if you'd like to listen to more
• 16:05
  podcasts from Becker's HealthCare, you can visit beckershospitalreview.com.