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