Latest / Becker’s Healthcare Podcast / Value Based Care, Data Gaps, and Cost Pressures in Health Plans with Howard Brill

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Value Based Care, Data Gaps, and Cost Pressures in Health Plans with Howard Brill · Becker’s Healthcare 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 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.
0:34
Hello, everyone, and welcome to Becker's Health Care
0:36
Podcast. I'm Scott King. Thrilled today to be
0:39
joined by a very special guest, Howard Brill,
0:41
senior vice president, population health and quality over
0:44
at Monroe plan for medical care. Howard, how
0:46
are you doing today? Thanks so much for
0:47
joining us. Thank you. I'm doing very well.
0:50
Wonderful. You know, we have a lot of
0:52
big topics to dive into as we're, you
0:53
know, kinda getting started here in 2026. Already
0:56
a lot going on in health plan, world
0:59
and health plan side of things. But before
1:00
we jump into that discussion, I was wondering
1:02
if you could please tell us a little
1:04
bit about your background and your career journey.
1:07
Yeah. Sure.
1:08
And and first, just one thing to clarify.
1:10
We we are a at risk provider organization.
1:14
So we're located
1:16
in, Western New York, and we focus exclusively
1:21
on public programs, Medicaid,
1:24
and child health plus.
1:27
So my background,
1:29
I actually,
1:31
started
1:32
with a
1:34
software development
1:35
company that was developing
1:38
risk adjustment,
1:40
and stratification
1:41
software
1:42
for,
1:44
evaluating
1:46
health plan and provider,
1:48
performance.
1:50
And,
1:51
from that,
1:52
move to
1:54
working for a Monroe plan,
1:57
initially starting again in a IT,
2:01
role and in evaluating,
2:04
health programs that,
2:06
Monroe plan had
2:08
and then and eventually,
2:10
moved into
2:11
a leadership role,
2:13
in population
2:14
health.
2:15
My background includes a PhD in sociology.
2:19
I focused on
2:21
health care, and, I had written a dissertation
2:24
on transformations
2:25
in the health care system in the in
2:28
the nineteen thirties.
2:30
Thanks so much for sharing your background information
2:32
there, Howard. I I think it's so interesting
2:33
that you worked for a software development company
2:36
that, you know, analyzed
2:37
health plan, performance. I just, you know, from
2:40
that experience to what you're doing now, like,
2:43
I mean, how effective
2:45
are you when they kinda analyzing where things
2:47
are and what needs tweaking? And how much
2:49
time does that save, you know, your your
2:51
prior experience and the way it ties into
2:53
everything?
2:54
Well, you you the, company I was working
2:56
for had developed,
2:58
early,
2:59
at the time. It wasn't yet called that,
3:02
but was essentially predictive modeling tools.
3:06
And so,
3:07
you know, obviously, predictive modeling
3:09
has become much more
3:12
important since then.
3:14
And,
3:15
it certainly gave me
3:17
insight into
3:19
what drives,
3:22
performance and,
3:24
understanding,
3:26
some of the
3:27
conditions and contextual elements
3:31
that underlie
3:32
variation
3:33
in provider performance,
3:35
including
3:37
the,
3:38
the the kinds of patients they are seeing,
3:40
the net and the networks,
3:42
that they are in.
3:44
And getting to some of the trends kind
3:46
of happening today, you know, it's it's a
3:47
time where,
3:49
obviously,
3:50
on a provider side, there's a lot of
3:51
regulatory pressure
3:53
and same with the payer side of things.
3:55
So
3:56
my question for you is how are your
3:58
relationships with providers
4:00
changing as both sides face
4:02
cost pressure and and workforce shortages in particular?
4:06
Yeah. So so as a at risk provider
4:09
organization
4:11
with with the health plan,
4:13
that we work with,
4:14
we have a value based,
4:16
arrangement.
4:18
And in turn, our with our network,
4:21
we for the for the larger
4:24
providers in our network,
4:25
we have, value based,
4:28
contracts too.
4:29
We do also have some providers
4:33
in our network who who just have,
4:37
who who who don't have, value based contracts.
4:40
But but, essentially,
4:41
you have a an environment where we have
4:44
a a a nested,
4:46
value based arrangements. So we
4:50
work under a value based arrangement, and in
4:52
turn, the large part of our network
4:54
that we contract with also have a value
4:57
based arrangement.
4:58
As, you know, you're asking, there is a
5:01
tremendous cost pressure,
5:03
in the environment right now.
5:05
For us, that,
5:07
means that fee schedules,
5:09
are being held flat and in some cases,
5:13
decreasing.
5:15
We see,
5:16
the health plan,
5:19
increasing audits
5:21
of provider billing
5:22
and,
5:23
scrutinizing
5:24
for potential upcoding of services at at,
5:28
you know, more
5:30
more intensely than they've have in, recent years.
5:34
An important aspect
5:36
of what we do in terms of our
5:38
value based,
5:40
arrangements
5:41
is that we do,
5:43
a variety of administrative advances,
5:45
and we provide other support,
5:48
for quality improvement purposes.
5:51
Those can range
5:54
from,
5:55
staff,
5:56
support and assistance
5:58
to
5:59
tools that we make available.
6:01
One of the things that the increased cost
6:04
pressure means is that there
6:06
is a lot closer scrutiny
6:09
of those kinds of
6:11
activities and initiatives,
6:14
and the costs around them and the range
6:16
of initiatives
6:18
that we introduce on the quality side.
6:20
Outside of our network relationships,
6:23
we see a tightening
6:24
of,
6:25
utilization management,
6:27
And,
6:28
we see an increased effort,
6:30
overall in the region for value based contracts,
6:35
to include both,
6:36
upside and downside risk.
6:39
Howard, where do you see the biggest gap
6:41
today between
6:42
payer strategy and then operational execution?
6:46
Yeah. And, you know, I I I think
6:48
it's helpful when talking about that to, again,
6:51
understand the broader historical context.
6:54
And, you know, this is not news to
6:56
anyone, but for at least forty years,
6:59
fee for service reimbursement
7:01
has been largely,
7:03
acknowledged as a fundamental structural problem,
7:06
in the cost of health care in The
7:08
US.
7:09
For the past
7:10
ten
7:11
to fifteen years, value based care arrangements
7:15
between payers and providers have been seen as,
7:19
the strategic framework,
7:22
for managing,
7:23
the impact of fee for service
7:25
reimbursement
7:27
and,
7:28
and for creating a pathway for,
7:31
alternative reimbursement
7:32
models.
7:35
The the the gap today
7:37
is that efforts to reduce,
7:40
cost
7:41
through value based
7:42
contracting,
7:44
appear to be falling short,
7:47
and,
7:47
that's straining relationships
7:49
between payers and providers
7:52
and, tending to shift the focus from quality
7:56
to,
7:57
cost of care.
7:59
So there you there's there's multiple
8:02
reasons for that. A continuing,
8:05
issue,
8:06
that limits the effectiveness of value based arrangements
8:10
is a is a lack
8:12
of real time data and fragmentation
8:16
across,
8:17
the continuum of care.
8:20
Their the the ability,
8:22
to receive and analyze data in real time,
8:26
versus experiencing
8:27
lags.
8:29
It inhibits,
8:30
the ability of at risk organizations
8:33
to,
8:34
work with providers and members to manage
8:38
care and,
8:40
and control costs.
8:43
Another aspect,
8:44
although there's been
8:46
substantial substantial
8:47
consolidation
8:49
among,
8:50
providers,
8:52
This often has not,
8:54
been reflected in integration,
8:57
of care.
8:58
It was thought,
9:00
that consolidation
9:01
would improve,
9:03
and ease integration.
9:06
And, there's certainly,
9:08
over the past ten to fifteen years, sometimes
9:10
very, very large,
9:14
EHR projects
9:16
who were
9:18
promoted and and intended to promote,
9:21
that,
9:22
integration.
9:24
And at least, in some cases, if not
9:27
many cases,
9:29
the actual care integration that emerged
9:32
was much less than promised and hoped.
9:35
So I I I I think that
9:38
again, I would see that biggest gap between
9:40
strategy and execution
9:43
is between
9:46
is between value based
9:48
care as a strategy
9:51
and the ability to successfully
9:53
execute on that through integration
9:58
is the the biggest gap. And, you know,
10:00
it falls along number of lines,
10:03
not least of which is,
10:06
effectively,
10:07
integrating,
10:10
data and care.
10:12
What's one investment or initiative you believe will
10:14
most
10:15
reshape how health plans operate over the next
10:17
two to three years?
10:18
Yeah. And I I have a a bit
10:20
of a complex answer,
10:22
to that.
10:25
So what one of the, major drivers
10:28
of costs
10:29
is wage increases experienced,
10:32
by provider organizations.
10:34
That's reflected,
10:36
several years of, workforce shortages,
10:40
which were certainly
10:41
exacerbated
10:42
by,
10:43
the pandemic burnout
10:45
and,
10:46
longer term problems in the workforce pipe pipeline.
10:51
Although that's that's not easily articulated
10:54
as a health plan or provider organization investment
10:58
or initiative,
10:59
and it's certainly not short term.
11:02
There is a need for initiatives and an
11:04
investment
11:05
in
11:06
workforce development.
11:09
I, of course, and, you know, I I
11:11
I I you probably
11:13
heard this several times.
11:16
AI projects,
11:17
you know, do have a significant opportunity,
11:21
to reshape operational practice,
11:24
through altering,
11:25
administrative processes and workflow.
11:28
One of the things,
11:30
that
11:31
health plans and provider organizations still experience
11:34
is a significant burden
11:37
of legacy systems and manual processes.
11:41
Projects involving traditional databases,
11:45
to improve workflows,
11:48
encounter very high costs and implementation failure,
11:52
because there there's still a very large volume
11:55
of unstructured
11:56
data
11:57
involved in contracts,
11:59
member interactions,
12:00
and,
12:01
medical records.
12:03
I mean, in the short term, in that
12:05
one to three year
12:06
time frame, AI tools
12:09
have potential
12:10
to reduce the cost of workflow projects that
12:13
involve,
12:15
that unstructured,
12:16
data.
12:17
I think, you know, there there's certainly
12:20
significant attention to alternative reimbursement
12:23
models, different kinds of bundled and episodic payments.
12:28
There is also,
12:30
significant attention to,
12:33
changes in care management and
12:36
population health initiatives.
12:37
There is a lot of rethinking going on,
12:41
in the population,
12:43
health space,
12:44
too, but the
12:46
one to three years might be
12:48
a,
12:49
too short of a time frame, to see
12:51
the impact of that.
12:53
Yeah. Alright. You made a great point. I
12:55
I think, you know, several great points. I
12:56
think, you you know, with all the advancements
12:58
we've seen with the emerging tech,
13:01
it seems the data still is one of
13:03
the main things that that needs improvement.
13:06
Is that kind of is that kinda how
13:08
you feel and what you say? You know,
13:10
I
13:10
the interesting thing, I I just, a few
13:13
hours ago, I was just,
13:15
got off a meeting,
13:16
a project management meeting around a
13:19
AI project,
13:20
that we have.
13:22
We,
13:23
among other things, we do provide some,
13:27
services to health plans. And one of the
13:29
things we we do is,
13:31
a utilization utilization
13:33
management,
13:34
services.
13:36
And,
13:37
I was just you know, the amount of
13:39
unstructured
13:40
data and manual processes
13:43
still in involved
13:45
in those are could be, breathtaking.
13:49
And so while,
13:51
you know, there's been,
13:53
decades of investment
13:55
in IT projects,
13:57
there is a still a substantial
13:59
amount of work
14:02
that,
14:03
depends on very manual,
14:06
processes.
14:07
And
14:08
in in some respects, some of the,
14:12
the,
14:13
if you will, the low hanging fruit on
14:15
AI is just just being able to,
14:20
reduce,
14:22
the
14:23
investment and time required
14:26
to make, long overdue
14:28
workflow improvements,
14:31
that handle,
14:33
the, the unstructured data involved in those processes
14:37
in much better ways
14:39
than they could be,
14:41
using,
14:42
traditional databases.
14:44
Yeah. A 100%. I I hope we I
14:46
hope we do see the the data get
14:47
cleaned up soon. Something else I wanted to
14:50
ask you, Howard,
14:51
is that if you could change one
14:53
regulatory or industry practice tomorrow
14:56
to improve affordability and access, what would it
14:59
be and why?
15:00
Yeah. I and and and sorry for,
15:03
perhaps a bit more complex answer to that.
15:05
It's okay. Yeah. There there are several,
15:08
regulatory changes
15:10
that that affected affordability and access.
15:13
So in New York state, there was a
15:16
waiver,
15:17
for the essential plan that allowed it to
15:20
expand,
15:20
coverage,
15:22
to people of higher incomes.
15:24
With, the OBAA
15:26
changes, New York will have to back out
15:28
of that,
15:29
waiver,
15:31
that allowed it to expand essential plan coverage
15:34
for those with
15:36
moderate incomes. And and, again, it gets a
15:38
a bit complicated.
15:40
So,
15:42
although,
15:42
OVA,
15:44
the changes were related to restrictions on eligible
15:46
immigrants,
15:47
it has a broader impact than that in
15:49
New York
15:50
due to,
15:52
the state having constitutional
15:54
requirements related to
15:56
immigrants. So the there was an expansion for
15:58
higher income people,
16:00
and that,
16:02
appears that, yeah, that that,
16:04
would have to be pulled back.
16:06
So that that is just an immediate issue
16:09
on affordability and access.
16:11
So, in terms of perhaps other,
16:15
broader issues
16:16
outside of New York State
16:18
related to the to the the the whole
16:21
the whole,
16:22
structural,
16:24
problems around for fee for service reimbursement.
16:28
Prior authorization
16:30
is a key industry practice,
16:32
to manage utilization.
16:35
The level of administrative effort
16:37
on both the payer and provider side
16:40
misdirects resources
16:42
and does,
16:43
impede access.
16:44
I mean, the the unfortunately, the trap is
16:47
is that it becomes a key practice
16:50
to, manage you to adverse utilization.
16:54
But in doing so, it does create a
16:57
a a high degree of administrative effort, which
17:00
is just, you know, not not really
17:05
serving consumers,
17:07
very well.
17:09
Absolutely.
17:10
And the last thing I would ask you,
17:12
Howard, is what issue is putting the most
17:14
pressure on health plan margins right now,
17:17
and how are you responding differently in in
17:19
2026?
17:21
Yeah. So,
17:23
again, because,
17:25
I I I'm within a New York State
17:27
Medicaid,
17:29
context.
17:30
Pharmacy
17:31
is currently
17:33
carved out,
17:35
for us.
17:36
So that's gonna be a different answer than
17:38
what you'll find in the commercial world.
17:41
Certainly, what we see,
17:44
outside of, you know, our space,
17:46
it
17:47
is GLP one drugs are putting the
17:51
the most immediate,
17:52
pressure
17:53
on,
17:54
health plans.
17:56
Now in in our in our space, in
17:58
the New York State Medicaid environment,
18:01
biologics
18:02
and infusion drugs are significant,
18:05
although we are seeing broad cost
18:08
increases,
18:09
generally.
18:11
Also,
18:12
within the Medicaid space, and in particular,
18:15
New York, we are
18:17
seeing pressure from some very unique specialized services,
18:21
related to consumer directed,
18:24
personal care services.
18:26
But that, that that's probably very unique to
18:29
the way those are,
18:31
those are set up into that particular,
18:34
benefit.
18:36
Howard, thanks so much for joining the podcast
18:38
and for all your insight. We're really looking
18:39
forward to having you speak at the spring
18:41
payer issues roundtable in April. Thank you very
18:43
much.