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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

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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. 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

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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

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say, make sure you go in and and

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check on that,

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on your family member and make sure that

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you support them. We need to do that

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because health care is so complicated.

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We see stories of people getting to the

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pharmacy to pick up a prescription,

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and it's not ready because some glitch in

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the system, and they really need that medication.

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There is so much opportunity

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for us to reduce,

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waste and to focus on, you know, better

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experience that will actually lower cost. And I

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think the way we do that, Jacob, is,

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again, focusing on the patient and their experience,

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rather than any any any other actor in

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the system.

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Absolutely. So you would really target and improve

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the member experience. I I love that answer,

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Pat. And I think that really ties back

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to what you were saying earlier in terms

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of who you and the company

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ultimately serve.

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So I really appreciate that answer.

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Before we go, is there anything else that

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we're missing, anything else you wanna make sure

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00:14:29,855 --> 00:14:31,534
that we hit on, or or any other

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advice you wanna share,

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while you have the ears of a lot

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of other health plan leaders from around the

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country. Yeah. I think I just end with

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two points. You know, one is in the

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last question, you asked me about, you know,

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regulators.

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And,

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by the way, I think there are a

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lot of policy issues that can help support

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what I just went through and how do

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we make, put the patient at the center.

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And

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there's,

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so many, interactions that happen in health care

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that are clunky, and I think any policies

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that can help providers and payers work better

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together,

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to be patient focused is, very, very welcome,

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both at the local, and at the national

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level.

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And then finally, I would just say, you

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know, I appreciate being here, Jacob, and being

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being able to share my perspectives.

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I've been in this business long enough to

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know that one health plan is not gonna

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fix this on their own. One provider is

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00:15:25,945 --> 00:15:27,644
not gonna fix this on their own.

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We need everyone to lean into this problem,

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and so I appreciate the opportunity to share

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my

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perspective,

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with my colleagues here and look forward to

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00:15:36,799 --> 00:15:39,779
learning, their ideas around how we may care,

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just better for everyone.

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00:15:42,160 --> 00:15:44,240
Well, Pat, I I speak on behalf of

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00:15:44,240 --> 00:15:46,000
all of us here at Becker's. We're thankful

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00:15:46,000 --> 00:15:46,660
that you,

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00:15:47,335 --> 00:15:49,254
decided to to take the time to chat

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00:15:49,254 --> 00:15:51,735
with us and to share a little bit

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00:15:51,735 --> 00:15:53,735
about all the important work that you and

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00:15:53,735 --> 00:15:55,414
and your teams at point thirty two Health

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00:15:55,414 --> 00:15:57,414
are doing. We really appreciate it, and and

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00:15:57,414 --> 00:15:59,654
we appreciate you sharing your insights with us.

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00:15:59,654 --> 00:16:01,735
So thank you. Thanks, Jake. It's so nice

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00:16:01,735 --> 00:16:03,769
to be with you. Yeah. And to our

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00:16:03,769 --> 00:16:05,450
audience, if you'd like to listen to more

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00:16:05,450 --> 00:16:09,709
podcasts from Becker's HealthCare, you can visit beckershospitalreview.com.