This is where health insurance leadership comes together.
Becker's fourth annual spring payer issues roundtable brings
together over 400 payer and health plan executives
and more than 100 speakers to Chicago April.
This year's event includes keynote conversations with the
industry's top leaders and former president George W.
Bush. For the full agenda and event details,
visit beckershospitalreview.com
and click on the events tab in the
upper right. We're looking forward to hosting you
here in Chicago.
Hello, everyone, and welcome to Becker's Health Care
Podcast. I'm Scott King. Thrilled today to be
joined by a very special guest, Howard Brill,
senior vice president, population health and quality over
at Monroe plan for medical care. Howard, how
are you doing today? Thanks so much for
joining us. Thank you. I'm doing very well.
Wonderful. You know, we have a lot of
big topics to dive into as we're, you
know, kinda getting started here in 2026. Already
a lot going on in health plan, world
and health plan side of things. But before
we jump into that discussion, I was wondering
if you could please tell us a little
bit about your background and your career journey.
Yeah. Sure.
And and first, just one thing to clarify.
We we are a at risk provider organization.
So we're located
in, Western New York, and we focus exclusively
on public programs, Medicaid,
and child health plus.
So my background,
I actually,
started
with a
software development
company that was developing
risk adjustment,
and stratification
software
for,
evaluating
health plan and provider,
performance.
And,
from that,
move to
working for a Monroe plan,
initially starting again in a IT,
role and in evaluating,
health programs that,
Monroe plan had
and then and eventually,
moved into
a leadership role,
in population
health.
My background includes a PhD in sociology.
I focused on
health care, and, I had written a dissertation
on transformations
in the health care system in the in
the nineteen thirties.
Thanks so much for sharing your background information
there, Howard. I I think it's so interesting
that you worked for a software development company
that, you know, analyzed
health plan, performance. I just, you know, from
that experience to what you're doing now, like,
I mean, how effective
are you when they kinda analyzing where things
are and what needs tweaking? And how much
time does that save, you know, your your
prior experience and the way it ties into
everything?
Well, you you the, company I was working
for had developed,
early,
at the time. It wasn't yet called that,
but was essentially predictive modeling tools.
And so,
you know, obviously, predictive modeling
has become much more
important since then.
And,
it certainly gave me
insight into
what drives,
performance and,
understanding,
some of the
conditions and contextual elements
that underlie
variation
in provider performance,
including
the,
the the kinds of patients they are seeing,
the net and the networks,
that they are in.
And getting to some of the trends kind
of happening today, you know, it's it's a
time where,
obviously,
on a provider side, there's a lot of
regulatory pressure
and same with the payer side of things.
So
my question for you is how are your
relationships with providers
changing as both sides face
cost pressure and and workforce shortages in particular?
Yeah. So so as a at risk provider
organization
with with the health plan,
that we work with,
we have a value based,
arrangement.
And in turn, our with our network,
we for the for the larger
providers in our network,
we have, value based,
contracts too.
We do also have some providers
in our network who who just have,
who who who don't have, value based contracts.
But but, essentially,
you have a an environment where we have
a a a nested,
value based arrangements. So we
work under a value based arrangement, and in
turn, the large part of our network
that we contract with also have a value
based arrangement.
As, you know, you're asking, there is a
tremendous cost pressure,
in the environment right now.
For us, that,
means that fee schedules,
are being held flat and in some cases,
decreasing.
We see,
the health plan,
increasing audits
of provider billing
and,
scrutinizing
for potential upcoding of services at at,
you know, more
more intensely than they've have in, recent years.
An important aspect
of what we do in terms of our
value based,
arrangements
is that we do,
a variety of administrative advances,
and we provide other support,
for quality improvement purposes.
Those can range
from,
staff,
support and assistance
to
tools that we make available.
One of the things that the increased cost
pressure means is that there
is a lot closer scrutiny
of those kinds of
activities and initiatives,
and the costs around them and the range
of initiatives
that we introduce on the quality side.
Outside of our network relationships,
we see a tightening
of,
utilization management,
And,
we see an increased effort,
overall in the region for value based contracts,
to include both,
upside and downside risk.
Howard, where do you see the biggest gap
today between
payer strategy and then operational execution?
Yeah. And, you know, I I I think
it's helpful when talking about that to, again,
understand the broader historical context.
And, you know, this is not news to
anyone, but for at least forty years,
fee for service reimbursement
has been largely,
acknowledged as a fundamental structural problem,
in the cost of health care in The
US.
For the past
ten
to fifteen years, value based care arrangements
between payers and providers have been seen as,
the strategic framework,
for managing,
the impact of fee for service
reimbursement
and,
and for creating a pathway for,
alternative reimbursement
models.
The the the gap today
is that efforts to reduce,
cost
through value based
contracting,
appear to be falling short,
and,
that's straining relationships
between payers and providers
and, tending to shift the focus from quality
to,
cost of care.
So there you there's there's multiple
reasons for that. A continuing,
issue,
that limits the effectiveness of value based arrangements
is a is a lack
of real time data and fragmentation
across,
the continuum of care.
Their the the ability,
to receive and analyze data in real time,
versus experiencing
lags.
It inhibits,
the ability of at risk organizations
to,
work with providers and members to manage
care and,
and control costs.
Another aspect,
although there's been
substantial substantial
consolidation
among,
providers,
This often has not,
been reflected in integration,
of care.
It was thought,
that consolidation
would improve,
and ease integration.
And, there's certainly,
over the past ten to fifteen years, sometimes
very, very large,
EHR projects
who were
promoted and and intended to promote,
that,
integration.
And at least, in some cases, if not
many cases,
the actual care integration that emerged
was much less than promised and hoped.
So I I I I think that
again, I would see that biggest gap between
strategy and execution
is between
is between value based
care as a strategy
and the ability to successfully
execute on that through integration
is the the biggest gap. And, you know,
it falls along number of lines,
not least of which is,
effectively,
integrating,
data and care.
What's one investment or initiative you believe will
most
reshape how health plans operate over the next
two to three years?
Yeah. And I I have a a bit
of a complex answer,
to that.
So what one of the, major drivers
of costs
is wage increases experienced,
by provider organizations.
That's reflected,
several years of, workforce shortages,
which were certainly
exacerbated
by,
the pandemic burnout
and,
longer term problems in the workforce pipe pipeline.
Although that's that's not easily articulated
as a health plan or provider organization investment
or initiative,
and it's certainly not short term.
There is a need for initiatives and an
investment
in
workforce development.
I, of course, and, you know, I I
I I you probably
heard this several times.
AI projects,
you know, do have a significant opportunity,
to reshape operational practice,
through altering,
administrative processes and workflow.
One of the things,
that
health plans and provider organizations still experience
is a significant burden
of legacy systems and manual processes.
Projects involving traditional databases,
to improve workflows,
encounter very high costs and implementation failure,
because there there's still a very large volume
of unstructured
data
involved in contracts,
member interactions,
and,
medical records.
I mean, in the short term, in that
one to three year
time frame, AI tools
have potential
to reduce the cost of workflow projects that
involve,
that unstructured,
data.
I think, you know, there there's certainly
significant attention to alternative reimbursement
models, different kinds of bundled and episodic payments.
There is also,
significant attention to,
changes in care management and
population health initiatives.
There is a lot of rethinking going on,
in the population,
health space,
too, but the
one to three years might be
a,
too short of a time frame, to see
the impact of that.
Yeah. Alright. You made a great point. I
I think, you know, several great points. I
think, you you know, with all the advancements
we've seen with the emerging tech,
it seems the data still is one of
the main things that that needs improvement.
Is that kind of is that kinda how
you feel and what you say? You know,
I
the interesting thing, I I just, a few
hours ago, I was just,
got off a meeting,
a project management meeting around a
AI project,
that we have.
We,
among other things, we do provide some,
services to health plans. And one of the
things we we do is,
a utilization utilization
management,
services.
And,
I was just you know, the amount of
unstructured
data and manual processes
still in involved
in those are could be, breathtaking.
And so while,
you know, there's been,
decades of investment
in IT projects,
there is a still a substantial
amount of work
that,
depends on very manual,
processes.
And
in in some respects, some of the,
the,
if you will, the low hanging fruit on
AI is just just being able to,
reduce,
the
investment and time required
to make, long overdue
workflow improvements,
that handle,
the, the unstructured data involved in those processes
in much better ways
than they could be,
using,
traditional databases.
Yeah. A 100%. I I hope we I
hope we do see the the data get
cleaned up soon. Something else I wanted to
ask you, Howard,
is that if you could change one
regulatory or industry practice tomorrow
to improve affordability and access, what would it
be and why?
Yeah. I and and and sorry for,
perhaps a bit more complex answer to that.
It's okay. Yeah. There there are several,
regulatory changes
that that affected affordability and access.
So in New York state, there was a
waiver,
for the essential plan that allowed it to
expand,
coverage,
to people of higher incomes.
With, the OBAA
changes, New York will have to back out
of that,
waiver,
that allowed it to expand essential plan coverage
for those with
moderate incomes. And and, again, it gets a
a bit complicated.
So,
although,
OVA,
the changes were related to restrictions on eligible
immigrants,
it has a broader impact than that in
New York
due to,
the state having constitutional
requirements related to
immigrants. So the there was an expansion for
higher income people,
and that,
appears that, yeah, that that,
would have to be pulled back.
So that that is just an immediate issue
on affordability and access.
So, in terms of perhaps other,
broader issues
outside of New York State
related to the to the the the whole
the whole,
structural,
problems around for fee for service reimbursement.
Prior authorization
is a key industry practice,
to manage utilization.
The level of administrative effort
on both the payer and provider side
misdirects resources
and does,
impede access.
I mean, the the unfortunately, the trap is
is that it becomes a key practice
to, manage you to adverse utilization.
But in doing so, it does create a
a a high degree of administrative effort, which
is just, you know, not not really
serving consumers,
very well.
Absolutely.
And the last thing I would ask you,
Howard, is what issue is putting the most
pressure on health plan margins right now,
and how are you responding differently in in
2026?
Yeah. So,
again, because,
I I I'm within a New York State
Medicaid,
context.
Pharmacy
is currently
carved out,
for us.
So that's gonna be a different answer than
what you'll find in the commercial world.
Certainly, what we see,
outside of, you know, our space,
it
is GLP one drugs are putting the
the most immediate,
pressure
on,
health plans.
Now in in our in our space, in
the New York State Medicaid environment,
biologics
and infusion drugs are significant,
although we are seeing broad cost
increases,
generally.
Also,
within the Medicaid space, and in particular,
New York, we are
seeing pressure from some very unique specialized services,
related to consumer directed,
personal care services.
But that, that that's probably very unique to
the way those are,
those are set up into that particular,
benefit.
Howard, thanks so much for joining the podcast
and for all your insight. We're really looking
forward to having you speak at the spring
payer issues roundtable in April. Thank you very
much.