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This is where health insurance leadership comes together.

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Becker's fourth annual spring payer issues roundtable brings

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together over 400 payer and health plan executives

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and more than 100 speakers to Chicago April.

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This year's event includes keynote conversations with the

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industry's top leaders and former president George W.

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Bush. For the full agenda and event details,

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visit beckershospitalreview.com

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and click on the events tab in the

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upper right. We're looking forward to hosting you

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here in Chicago.

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Hello, everyone, and welcome to Becker's Health Care

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Podcast. I'm Scott King. Thrilled today to be

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joined by a very special guest, Howard Brill,

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senior vice president, population health and quality over

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at Monroe plan for medical care. Howard, how

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are you doing today? Thanks so much for

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joining us. Thank you. I'm doing very well.

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Wonderful. You know, we have a lot of

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big topics to dive into as we're, you

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know, kinda getting started here in 2026. Already

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a lot going on in health plan, world

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and health plan side of things. But before

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we jump into that discussion, I was wondering

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if you could please tell us a little

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bit about your background and your career journey.

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Yeah. Sure.

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And and first, just one thing to clarify.

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We we are a at risk provider organization.

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So we're located

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in, Western New York, and we focus exclusively

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on public programs, Medicaid,

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and child health plus.

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So my background,

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I actually,

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started

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with a

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software development

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company that was developing

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risk adjustment,

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and stratification

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software

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for,

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evaluating

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health plan and provider,

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performance.

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And,

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from that,

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move to

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working for a Monroe plan,

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initially starting again in a IT,

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role and in evaluating,

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health programs that,

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Monroe plan had

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and then and eventually,

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moved into

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a leadership role,

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in population

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health.

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My background includes a PhD in sociology.

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I focused on

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health care, and, I had written a dissertation

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on transformations

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in the health care system in the in

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the nineteen thirties.

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Thanks so much for sharing your background information

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there, Howard. I I think it's so interesting

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that you worked for a software development company

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that, you know, analyzed

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health plan, performance. I just, you know, from

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that experience to what you're doing now, like,

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I mean, how effective

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are you when they kinda analyzing where things

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are and what needs tweaking? And how much

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time does that save, you know, your your

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prior experience and the way it ties into

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everything?

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Well, you you the, company I was working

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for had developed,

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early,

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at the time. It wasn't yet called that,

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but was essentially predictive modeling tools.

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And so,

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you know, obviously, predictive modeling

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has become much more

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important since then.

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And,

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it certainly gave me

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insight into

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what drives,

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performance and,

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understanding,

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some of the

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conditions and contextual elements

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that underlie

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variation

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in provider performance,

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including

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the,

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the the kinds of patients they are seeing,

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the net and the networks,

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that they are in.

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And getting to some of the trends kind

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of happening today, you know, it's it's a

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time where,

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obviously,

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on a provider side, there's a lot of

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regulatory pressure

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and same with the payer side of things.

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So

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my question for you is how are your

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relationships with providers

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changing as both sides face

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cost pressure and and workforce shortages in particular?

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Yeah. So so as a at risk provider

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organization

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with with the health plan,

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that we work with,

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we have a value based,

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arrangement.

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And in turn, our with our network,

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we for the for the larger

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providers in our network,

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we have, value based,

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contracts too.

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We do also have some providers

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in our network who who just have,

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who who who don't have, value based contracts.

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But but, essentially,

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you have a an environment where we have

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a a a nested,

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value based arrangements. So we

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work under a value based arrangement, and in

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turn, the large part of our network

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that we contract with also have a value

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based arrangement.

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As, you know, you're asking, there is a

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tremendous cost pressure,

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in the environment right now.

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For us, that,

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means that fee schedules,

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are being held flat and in some cases,

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decreasing.

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We see,

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the health plan,

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increasing audits

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of provider billing

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and,

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scrutinizing

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for potential upcoding of services at at,

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you know, more

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more intensely than they've have in, recent years.

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An important aspect

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of what we do in terms of our

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value based,

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arrangements

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is that we do,

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a variety of administrative advances,

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and we provide other support,

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for quality improvement purposes.

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Those can range

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from,

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staff,

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support and assistance

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to

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tools that we make available.

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One of the things that the increased cost

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pressure means is that there

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is a lot closer scrutiny

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of those kinds of

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activities and initiatives,

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and the costs around them and the range

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of initiatives

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that we introduce on the quality side.

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Outside of our network relationships,

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we see a tightening

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of,

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utilization management,

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And,

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we see an increased effort,

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overall in the region for value based contracts,

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to include both,

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upside and downside risk.

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Howard, where do you see the biggest gap

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today between

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payer strategy and then operational execution?

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Yeah. And, you know, I I I think

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it's helpful when talking about that to, again,

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understand the broader historical context.

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And, you know, this is not news to

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anyone, but for at least forty years,

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fee for service reimbursement

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has been largely,

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acknowledged as a fundamental structural problem,

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in the cost of health care in The

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US.

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For the past

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ten

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to fifteen years, value based care arrangements

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between payers and providers have been seen as,

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the strategic framework,

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for managing,

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the impact of fee for service

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reimbursement

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and,

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and for creating a pathway for,

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alternative reimbursement

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models.

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The the the gap today

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is that efforts to reduce,

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cost

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through value based

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contracting,

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appear to be falling short,

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and,

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that's straining relationships

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between payers and providers

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and, tending to shift the focus from quality

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to,

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cost of care.

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So there you there's there's multiple

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reasons for that. A continuing,

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issue,

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that limits the effectiveness of value based arrangements

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is a is a lack

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of real time data and fragmentation

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across,

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the continuum of care.

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Their the the ability,

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to receive and analyze data in real time,

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versus experiencing

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lags.

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It inhibits,

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the ability of at risk organizations

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to,

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work with providers and members to manage

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care and,

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and control costs.

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Another aspect,

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although there's been

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substantial substantial

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consolidation

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among,

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providers,

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This often has not,

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been reflected in integration,

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of care.

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It was thought,

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that consolidation

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would improve,

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and ease integration.

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And, there's certainly,

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over the past ten to fifteen years, sometimes

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very, very large,

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EHR projects

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who were

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promoted and and intended to promote,

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that,

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integration.

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And at least, in some cases, if not

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many cases,

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the actual care integration that emerged

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was much less than promised and hoped.

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So I I I I think that

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again, I would see that biggest gap between

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strategy and execution

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is between

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is between value based

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care as a strategy

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and the ability to successfully

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execute on that through integration

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is the the biggest gap. And, you know,

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it falls along number of lines,

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not least of which is,

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effectively,

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integrating,

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data and care.

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What's one investment or initiative you believe will

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most

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reshape how health plans operate over the next

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two to three years?

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Yeah. And I I have a a bit

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of a complex answer,

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to that.

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So what one of the, major drivers

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of costs

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is wage increases experienced,

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by provider organizations.

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That's reflected,

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several years of, workforce shortages,

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which were certainly

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exacerbated

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by,

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the pandemic burnout

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and,

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00:10:46,764 --> 00:10:50,464
longer term problems in the workforce pipe pipeline.

297
00:10:51,710 --> 00:10:54,129
Although that's that's not easily articulated

298
00:10:54,430 --> 00:10:58,050
as a health plan or provider organization investment

299
00:10:58,110 --> 00:10:58,769
or initiative,

300
00:10:59,230 --> 00:11:01,250
and it's certainly not short term.

301
00:11:02,190 --> 00:11:04,110
There is a need for initiatives and an

302
00:11:04,110 --> 00:11:04,610
investment

303
00:11:05,149 --> 00:11:05,649
in

304
00:11:06,705 --> 00:11:07,764
workforce development.

305
00:11:09,345 --> 00:11:11,745
I, of course, and, you know, I I

306
00:11:11,745 --> 00:11:13,365
I I you probably

307
00:11:13,745 --> 00:11:15,285
heard this several times.

308
00:11:16,225 --> 00:11:17,285
AI projects,

309
00:11:17,825 --> 00:11:20,004
you know, do have a significant opportunity,

310
00:11:21,184 --> 00:11:23,100
to reshape operational practice,

311
00:11:24,440 --> 00:11:25,259
through altering,

312
00:11:25,960 --> 00:11:28,139
administrative processes and workflow.

313
00:11:28,919 --> 00:11:29,980
One of the things,

314
00:11:30,440 --> 00:11:30,940
that

315
00:11:31,399 --> 00:11:34,299
health plans and provider organizations still experience

316
00:11:34,679 --> 00:11:36,700
is a significant burden

317
00:11:37,495 --> 00:11:40,235
of legacy systems and manual processes.

318
00:11:41,254 --> 00:11:43,355
Projects involving traditional databases,

319
00:11:45,975 --> 00:11:47,115
to improve workflows,

320
00:11:48,214 --> 00:11:51,194
encounter very high costs and implementation failure,

321
00:11:52,690 --> 00:11:55,169
because there there's still a very large volume

322
00:11:55,169 --> 00:11:55,909
of unstructured

323
00:11:56,210 --> 00:11:56,710
data

324
00:11:57,090 --> 00:11:58,710
involved in contracts,

325
00:11:59,090 --> 00:12:00,070
member interactions,

326
00:12:00,529 --> 00:12:01,029
and,

327
00:12:01,970 --> 00:12:03,029
medical records.

328
00:12:03,490 --> 00:12:05,169
I mean, in the short term, in that

329
00:12:05,169 --> 00:12:06,309
one to three year

330
00:12:06,774 --> 00:12:08,554
time frame, AI tools

331
00:12:09,654 --> 00:12:10,394
have potential

332
00:12:10,934 --> 00:12:13,654
to reduce the cost of workflow projects that

333
00:12:13,654 --> 00:12:14,154
involve,

334
00:12:15,254 --> 00:12:15,995
that unstructured,

335
00:12:16,774 --> 00:12:17,274
data.

336
00:12:17,735 --> 00:12:19,595
I think, you know, there there's certainly

337
00:12:20,289 --> 00:12:22,789
significant attention to alternative reimbursement

338
00:12:23,250 --> 00:12:27,190
models, different kinds of bundled and episodic payments.

339
00:12:28,529 --> 00:12:29,750
There is also,

340
00:12:30,929 --> 00:12:32,529
significant attention to,

341
00:12:33,009 --> 00:12:35,269
changes in care management and

342
00:12:36,014 --> 00:12:37,315
population health initiatives.

343
00:12:37,934 --> 00:12:40,514
There is a lot of rethinking going on,

344
00:12:41,295 --> 00:12:42,274
in the population,

345
00:12:43,295 --> 00:12:44,195
health space,

346
00:12:44,575 --> 00:12:45,715
too, but the

347
00:12:46,095 --> 00:12:47,634
one to three years might be

348
00:12:48,589 --> 00:12:49,089
a,

349
00:12:49,470 --> 00:12:51,709
too short of a time frame, to see

350
00:12:51,709 --> 00:12:52,850
the impact of that.

351
00:12:53,709 --> 00:12:55,309
Yeah. Alright. You made a great point. I

352
00:12:55,309 --> 00:12:56,829
I think, you know, several great points. I

353
00:12:56,829 --> 00:12:58,850
think, you you know, with all the advancements

354
00:12:58,909 --> 00:13:00,850
we've seen with the emerging tech,

355
00:13:01,625 --> 00:13:03,544
it seems the data still is one of

356
00:13:03,544 --> 00:13:05,804
the main things that that needs improvement.

357
00:13:06,825 --> 00:13:08,424
Is that kind of is that kinda how

358
00:13:08,424 --> 00:13:10,105
you feel and what you say? You know,

359
00:13:10,105 --> 00:13:10,264
I

360
00:13:10,985 --> 00:13:13,384
the interesting thing, I I just, a few

361
00:13:13,384 --> 00:13:14,580
hours ago, I was just,

362
00:13:15,540 --> 00:13:16,600
got off a meeting,

363
00:13:16,980 --> 00:13:19,080
a project management meeting around a

364
00:13:19,700 --> 00:13:20,440
AI project,

365
00:13:20,980 --> 00:13:21,940
that we have.

366
00:13:22,340 --> 00:13:22,840
We,

367
00:13:23,620 --> 00:13:26,279
among other things, we do provide some,

368
00:13:27,139 --> 00:13:29,299
services to health plans. And one of the

369
00:13:29,299 --> 00:13:31,084
things we we do is,

370
00:13:31,865 --> 00:13:33,084
a utilization utilization

371
00:13:33,384 --> 00:13:33,884
management,

372
00:13:34,664 --> 00:13:35,164
services.

373
00:13:36,024 --> 00:13:36,504
And,

374
00:13:37,065 --> 00:13:39,544
I was just you know, the amount of

375
00:13:39,544 --> 00:13:40,044
unstructured

376
00:13:40,904 --> 00:13:42,524
data and manual processes

377
00:13:43,384 --> 00:13:44,764
still in involved

378
00:13:45,600 --> 00:13:47,940
in those are could be, breathtaking.

379
00:13:49,279 --> 00:13:50,419
And so while,

380
00:13:51,440 --> 00:13:52,740
you know, there's been,

381
00:13:53,679 --> 00:13:54,820
decades of investment

382
00:13:55,360 --> 00:13:56,740
in IT projects,

383
00:13:57,120 --> 00:13:59,220
there is a still a substantial

384
00:13:59,679 --> 00:14:00,659
amount of work

385
00:14:02,245 --> 00:14:02,644
that,

386
00:14:03,445 --> 00:14:04,985
depends on very manual,

387
00:14:06,165 --> 00:14:06,665
processes.

388
00:14:07,285 --> 00:14:07,785
And

389
00:14:08,245 --> 00:14:10,264
in in some respects, some of the,

390
00:14:12,004 --> 00:14:12,404
the,

391
00:14:13,610 --> 00:14:15,929
if you will, the low hanging fruit on

392
00:14:15,929 --> 00:14:19,470
AI is just just being able to,

393
00:14:20,409 --> 00:14:20,909
reduce,

394
00:14:22,490 --> 00:14:22,990
the

395
00:14:23,850 --> 00:14:25,709
investment and time required

396
00:14:26,285 --> 00:14:27,985
to make, long overdue

397
00:14:28,365 --> 00:14:29,504
workflow improvements,

398
00:14:31,004 --> 00:14:32,144
that handle,

399
00:14:33,644 --> 00:14:37,504
the, the unstructured data involved in those processes

400
00:14:37,644 --> 00:14:38,865
in much better ways

401
00:14:39,389 --> 00:14:40,690
than they could be,

402
00:14:41,309 --> 00:14:41,790
using,

403
00:14:42,269 --> 00:14:43,330
traditional databases.

404
00:14:44,430 --> 00:14:46,350
Yeah. A 100%. I I hope we I

405
00:14:46,350 --> 00:14:47,629
hope we do see the the data get

406
00:14:47,629 --> 00:14:50,190
cleaned up soon. Something else I wanted to

407
00:14:50,190 --> 00:14:51,090
ask you, Howard,

408
00:14:51,394 --> 00:14:53,254
is that if you could change one

409
00:14:53,794 --> 00:14:56,215
regulatory or industry practice tomorrow

410
00:14:56,835 --> 00:14:59,154
to improve affordability and access, what would it

411
00:14:59,154 --> 00:14:59,975
be and why?

412
00:15:00,835 --> 00:15:02,754
Yeah. I and and and sorry for,

413
00:15:03,154 --> 00:15:05,735
perhaps a bit more complex answer to that.

414
00:15:05,875 --> 00:15:08,250
It's okay. Yeah. There there are several,

415
00:15:08,730 --> 00:15:09,950
regulatory changes

416
00:15:10,330 --> 00:15:12,910
that that affected affordability and access.

417
00:15:13,529 --> 00:15:16,090
So in New York state, there was a

418
00:15:16,090 --> 00:15:16,590
waiver,

419
00:15:17,129 --> 00:15:20,009
for the essential plan that allowed it to

420
00:15:20,009 --> 00:15:20,509
expand,

421
00:15:20,970 --> 00:15:21,470
coverage,

422
00:15:22,334 --> 00:15:23,875
to people of higher incomes.

423
00:15:24,575 --> 00:15:25,794
With, the OBAA

424
00:15:26,174 --> 00:15:28,334
changes, New York will have to back out

425
00:15:28,334 --> 00:15:28,815
of that,

426
00:15:29,534 --> 00:15:30,034
waiver,

427
00:15:31,134 --> 00:15:34,034
that allowed it to expand essential plan coverage

428
00:15:34,095 --> 00:15:35,075
for those with

429
00:15:36,000 --> 00:15:38,240
moderate incomes. And and, again, it gets a

430
00:15:38,240 --> 00:15:39,139
a bit complicated.

431
00:15:40,639 --> 00:15:41,139
So,

432
00:15:42,000 --> 00:15:42,500
although,

433
00:15:42,879 --> 00:15:43,379
OVA,

434
00:15:44,160 --> 00:15:46,580
the changes were related to restrictions on eligible

435
00:15:46,720 --> 00:15:47,220
immigrants,

436
00:15:47,679 --> 00:15:49,759
it has a broader impact than that in

437
00:15:49,759 --> 00:15:50,419
New York

438
00:15:50,934 --> 00:15:51,754
due to,

439
00:15:52,375 --> 00:15:53,674
the state having constitutional

440
00:15:54,134 --> 00:15:55,754
requirements related to

441
00:15:56,134 --> 00:15:58,934
immigrants. So the there was an expansion for

442
00:15:58,934 --> 00:16:00,154
higher income people,

443
00:16:00,774 --> 00:16:01,514
and that,

444
00:16:02,454 --> 00:16:04,214
appears that, yeah, that that,

445
00:16:04,615 --> 00:16:06,154
would have to be pulled back.

446
00:16:06,830 --> 00:16:09,070
So that that is just an immediate issue

447
00:16:09,070 --> 00:16:10,690
on affordability and access.

448
00:16:11,950 --> 00:16:14,529
So, in terms of perhaps other,

449
00:16:15,149 --> 00:16:16,049
broader issues

450
00:16:16,509 --> 00:16:17,970
outside of New York State

451
00:16:18,509 --> 00:16:21,455
related to the to the the the whole

452
00:16:21,674 --> 00:16:22,394
the whole,

453
00:16:22,875 --> 00:16:23,375
structural,

454
00:16:24,715 --> 00:16:27,294
problems around for fee for service reimbursement.

455
00:16:28,715 --> 00:16:29,615
Prior authorization

456
00:16:30,475 --> 00:16:32,254
is a key industry practice,

457
00:16:32,875 --> 00:16:34,095
to manage utilization.

458
00:16:35,480 --> 00:16:37,500
The level of administrative effort

459
00:16:37,960 --> 00:16:40,059
on both the payer and provider side

460
00:16:40,600 --> 00:16:41,899
misdirects resources

461
00:16:42,440 --> 00:16:43,159
and does,

462
00:16:43,559 --> 00:16:44,460
impede access.

463
00:16:44,839 --> 00:16:47,159
I mean, the the unfortunately, the trap is

464
00:16:47,159 --> 00:16:48,940
is that it becomes a key practice

465
00:16:50,764 --> 00:16:53,504
to, manage you to adverse utilization.

466
00:16:54,605 --> 00:16:57,404
But in doing so, it does create a

467
00:16:57,444 --> 00:17:00,605
a a high degree of administrative effort, which

468
00:17:00,605 --> 00:17:03,184
is just, you know, not not really

469
00:17:05,869 --> 00:17:06,929
serving consumers,

470
00:17:07,630 --> 00:17:08,529
very well.

471
00:17:09,630 --> 00:17:10,130
Absolutely.

472
00:17:10,829 --> 00:17:12,509
And the last thing I would ask you,

473
00:17:12,509 --> 00:17:14,429
Howard, is what issue is putting the most

474
00:17:14,429 --> 00:17:17,170
pressure on health plan margins right now,

475
00:17:17,654 --> 00:17:19,654
and how are you responding differently in in

476
00:17:19,654 --> 00:17:20,715
2026?

477
00:17:21,494 --> 00:17:22,394
Yeah. So,

478
00:17:23,575 --> 00:17:24,394
again, because,

479
00:17:25,414 --> 00:17:27,894
I I I'm within a New York State

480
00:17:27,894 --> 00:17:28,394
Medicaid,

481
00:17:29,975 --> 00:17:30,475
context.

482
00:17:30,934 --> 00:17:31,434
Pharmacy

483
00:17:31,815 --> 00:17:32,475
is currently

484
00:17:33,789 --> 00:17:34,609
carved out,

485
00:17:35,070 --> 00:17:35,809
for us.

486
00:17:36,509 --> 00:17:38,990
So that's gonna be a different answer than

487
00:17:38,990 --> 00:17:41,009
what you'll find in the commercial world.

488
00:17:41,630 --> 00:17:43,009
Certainly, what we see,

489
00:17:44,109 --> 00:17:46,369
outside of, you know, our space,

490
00:17:46,755 --> 00:17:47,255
it

491
00:17:47,714 --> 00:17:50,694
is GLP one drugs are putting the

492
00:17:51,394 --> 00:17:52,295
the most immediate,

493
00:17:52,994 --> 00:17:53,494
pressure

494
00:17:53,875 --> 00:17:54,194
on,

495
00:17:54,755 --> 00:17:55,654
health plans.

496
00:17:56,194 --> 00:17:58,674
Now in in our in our space, in

497
00:17:58,674 --> 00:18:00,454
the New York State Medicaid environment,

498
00:18:01,570 --> 00:18:02,070
biologics

499
00:18:02,450 --> 00:18:04,630
and infusion drugs are significant,

500
00:18:05,890 --> 00:18:07,910
although we are seeing broad cost

501
00:18:08,210 --> 00:18:08,710
increases,

502
00:18:09,410 --> 00:18:09,910
generally.

503
00:18:11,330 --> 00:18:11,830
Also,

504
00:18:12,210 --> 00:18:14,869
within the Medicaid space, and in particular,

505
00:18:15,410 --> 00:18:16,484
New York, we are

506
00:18:17,365 --> 00:18:21,224
seeing pressure from some very unique specialized services,

507
00:18:21,924 --> 00:18:23,865
related to consumer directed,

508
00:18:24,325 --> 00:18:25,545
personal care services.

509
00:18:26,724 --> 00:18:29,525
But that, that that's probably very unique to

510
00:18:29,525 --> 00:18:30,825
the way those are,

511
00:18:31,740 --> 00:18:34,240
those are set up into that particular,

512
00:18:34,779 --> 00:18:35,279
benefit.

513
00:18:36,287 --> 00:18:38,047
Howard, thanks so much for joining the podcast

514
00:18:38,047 --> 00:18:39,647
and for all your insight. We're really looking

515
00:18:39,647 --> 00:18:41,007
forward to having you speak at the spring

516
00:18:41,007 --> 00:18:43,487
payer issues roundtable in April. Thank you very

517
00:18:43,487 --> 00:18:43,987
much.