Affordability and the Role of Regional Nonprofit Health Plans at Point32Health with Patrick Gilligan

Summary

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Podcast Summary: "Affordability and the Role of Regional Nonprofit Health Plans at Point32Health with Patrick Gilligan"

Podcast: Becker’s Healthcare Podcast
Date: February 15, 2026
Host: Jacob Emerson (Speaker A), Becker's Healthcare
Guest: Patrick (Pat) Gilligan (Speaker B), President & CEO, Point32Health

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Overview

This episode centers on the value and challenges of regional nonprofit health plans in the evolving U.S. healthcare landscape, with an emphasis on affordability and the unique role of Point32Health. Pat Gilligan, recently appointed CEO, shares his perspective on local versus national health insurance models, ongoing cost crises, and the imperative of patient-centered care.

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Key Discussion Topics and Insights

Pat Gilligan’s Background in Healthcare (01:06–03:09)

• Local Roots & Varied Experience: Pat summarizes his three-decade career in New England, having worked in both academic healthcare administration (provider side) and multiple payer roles, including an actuarial background. He has worked for not-for-profit academic medical centers, for-profit CVS, and regional Blue plans prior to leading Point32Health.

  • "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." (B, 01:46)

• Philosophy on Not-for-Profit Care: Expresses strong belief in the not-for-profit model for both delivery and health plans.

The Value Proposition of Regional Nonprofit Health Plans (03:09–06:42)

• Why Local Still Matters: Despite technological advances, healthcare delivery remains fundamentally local. Local plans foster closer relationships with both members and providers.

  • "Healthcare, especially on the delivery side, is still very, very local...as a truly independent, not for profit health plan, we can focus on our members in a different way than some of our competitors." (B, 04:05)

• Contrast with National For-Profit Insurers:

  • National insurers must account for shareholders and earnings calls, while Point32Health can "myopically" focus on their members’ needs.
  • Independence from larger systems means fewer conflicting priorities.
  • "Our members and our customers are our shareholders." (B, 05:17)

• Breadth of Participation: Point32Health operates across all market segments—commercial, Medicare, Medicaid, and the duals program—strengthening provider relationships.

  • “We participate in all markets of health plans...we have a much more intertwined relationship with our local providers.” (B, 06:27)

Pressing Challenges: The Rising Cost of Healthcare (07:21–08:49)

• Acute Cost Increases: Pat highlights the "unrelenting trend in medical costs" as the most significant shift in recent years, affecting not just providers, but also insurers.
  • "The biggest surprise over the last three years is just the unrelenting trend in medical costs." (B, 07:27)
• Company Response: Point32Health is examining internal expenses and working to align incentives to better manage costs in medical and pharmacy spending.

The Affordability Crisis and Cost Control Levers (08:49–11:38)

• Affordability at a Crisis Point:
  • Pat considers the issue a true crisis: "Premiums are too high, the deductibles are too high, the medical debt that we're seeing insured people have is too high." (B, 09:36)
• Education & Alignment: Emphasizes educating providers on the impact of commercial rate setting for local employers, and shifting focus from increasing revenue to reducing costs throughout the system.
• Readiness for Future Pressures: Preparing for costly new therapies—such as cell and gene therapies—by controlling costs now.

Patient-Centric System Design (12:17–14:10)

• Reframing Healthcare Around Patients:
  • Pat’s “magic wand” solution is to restructure healthcare delivery around patient rather than provider needs.
  • "We need to totally reverse that and do it through the patient lens, which will give you a much different outcome." (B, 12:36)
• Reducing Systemic Waste and Improving Experience: Identifies everyday friction points (e.g., pharmacy issues) as opportunities for improvement, advocating for stronger payer-provider partnerships aligned on cost, quality, and experience.

Policy, Collaboration, and Final Thoughts (14:38–15:42)

• Policy Support: Welcomes regulatory and policy changes to facilitate better patient-centered care and smoother provider-payer collaboration.
• Industry-wide Call to Action: Stresses that no single organization can solve these systemic problems alone.
  • "One health plan is not going to fix this on their own. One provider is not going to fix this on their own. We need everyone to lean into this problem." (B, 15:24)

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Notable Quotes & Memorable Moments

• On Member Focus:
  "Our members and our customers are our shareholders. Our purpose is to guide and empower healthier lives." (B, 05:17)

• On the Cost Crisis:
  "Employers and members, patients are really suffering around affordability. Healthcare in many respects is just not affordable." (B, 09:21)

• On Patient-Centric Care:
  "We need to totally reverse that and do it through the patient lens, which will give you a much different outcome." (B, 12:36)

• On Collaboration:
  "One health plan is not going to fix this on their own. One provider is not going to fix this on their own. We need everyone to lean into this problem." (B, 15:24)

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Timestamps for Important Segments

• Pat’s Background and Role – 01:06–03:09
• Value of Regional Nonprofit Plans – 03:09–06:42
• The Unprecedented Cost Trend – 07:21–08:49
• Responding to the Affordability Crisis – 08:49–11:38
• If He Had a Magic Wand: Patient-Centric Care – 12:17–14:10
• Policy and Industry Collaboration – 14:38–15:42

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Closing

The episode provides a deep dive into the challenges and unique strengths of local, nonprofit health plans, with particular emphasis on member focus and the urgent need to address the cost crisis. Pat Gilligan advocates strongly for patient-centric reforms, sustained cost management, and sector-wide collaboration, making this a compelling listen for health plan leaders and industry observers alike.

Transcript

[A]

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 13th and 14th. 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 32 Health, which is the parent company of Harvard Pilgrim Healthcare and Tufts Health Plan. Pat, thanks so much for taking the time to be with me on the podcast today.

[B]

Really happy to be with you Jacob. Thank you.

[A]

Likewise. And before we dive into everything we want to 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 32 health?

[B]

Yeah, great. Well appreciate this opportunity to be with you again. My name is Pat Gilligan, president and CEO of Point32 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 years 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 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 a 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 had the opportunity to talk to the board here at point 32 health. So we're the parent company of Harvard Pilgrim Healthcare 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 healthcare delivery and on the health plan side. It doesn't mean that other models don't work or 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.

[A]

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 32 Health, as you know, you now serve around 2 million people across New England. And so I wonder if, if you're looking at, at the current healthcare 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. And do you think that your model comes with any trade offs, whether that's in resources and financial resilience? How are you thinking about this right now?

[B]

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, healthcare, 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 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 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 Healthcare and Tufts Health Plan, when I say we're truly independent, we are independent. 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 point 32 health that's myopically focused on 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 a set of plans, we participate in all markets of health plans, meaning we're in the commercial market, Medicare, we're in Medicaid 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.

[A]

No, absolutely, Pat. So basically you're saying that at the end of the day, you are beholden to your customers and to your members from the get go. And, you know, you're really still relatively new to the role. You stepped into the CEO role just last year. And so I wonder, given your long experience now in the industry, are there any new challenges that you're seeing right now, either for the company specifically or for your local healthcare market? Really, has anything surprised you since you took on this top role?

[B]

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 30 years. So the biggest surprise over the last three years is just the unrelenting trend in medical costs. And whether that's on 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 as it is right now. And I came into this role knowing that that was going to be the biggest challenge and something that we are very focused on taking on that challenge. The cost issue that we have is not just around providers. I want to be clear about that. Health plans need to manage their costs as well if we're going to provide better value to our employers. So at Point 32 Health, 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.

[A]

And Pat, let's dive into that a little bit more in terms of the affordability crisis that we're hearing about all over the country right now from pretty much every insurer. You're sitting in one of the most expensive healthcare markets in the country, Massachusetts, specifically. How are you thinking about 0.32 Health's role in all of this? And what levers do you actually have to help bring down some of these costs, both for providers and your.

[B]

Well, first of all, I just want to point out that it's not an overstatement that this is a crisis. I really think we are at a crisis point. And what I mean by that is that employers and members patients are really suffering around affordability. Healthcare 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 costs and to focus on affordability. One of the things, first of all, is just educating providers about that. 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 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 healthcare. 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 a crisis, 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 want to 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 going to want to 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.

[A]

Absolutely. It's a really astute point, Pat. And I wonder, you know, obviously you are very affected by policy changes at the state and federal levels. Multiple states for 4.32 health. I wonder, you know, given your expertise and your experience for a long time now throughout the industry, from provider negotiations, commercial insurance consulting, like you mentioned, if you had a magic wand and you had all those perspectives in mind, what's one specific thing you would fix immediately if you could? Is it a policy thing? Is it something that, you know, the company? What would you do to make things just a little bit different?

[B]

So the thing that I would like to do, and I think all of the players in health coverage and healthcare 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 going to 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 a hospital, as much as I know the delivery system, you know, here in New England, I always say, make sure you go in and check on that on your family member and make sure that you support them. We need to do that because healthcare 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 other actor in the system.

[A]

Absolutely. So you would really target and improve the member experience. 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 want to make sure that we hit on or any other advice you want to share while you have the ears of a lot of other health plan leaders from around the country?

[B]

Yeah, I think I just end with two points. One is in the last question you asked me about 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 put the patient at the center? And. 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 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 able to share my perspectives. I've been in this business long enough to know that one health plan is not going to fix this on their own. One provider is not going to fix this on their own. We need everyone to lean into this problem. I appreciate the opportunity to share my perspective with my colleagues here and look forward to learning their ideas around how we make care just better for everyone.

[A]

Well, Pat, I speak on behalf of all of us here at Beckers. We're thankful that you decided to take the time to chat with us and to share a little bit about all the important work that you and your teams at point 32 health are doing. We really appreciate it, and we appreciate you sharing your insights with us. So thank you.

[B]

Thanks, Jake. It's so nice to be with you.

[A]

Yeah. And to our audience. If you'd like to listen to more podcasts from Becker's Healthcare, you can visit Beckershospitalreview.com.