Healthcare Upside / Down: Building a Better Payvider Model with MetroPlusHealth and ECG

Summary

Becker’s Healthcare Podcast: Episode Summary

Title: Healthcare Upside / Down: Building a Better Payvider Model with MetroPlusHealth and ECG
Host: Molly Gamble
Guests:

• Lila Benayoun, Chief Operating Officer, MetroPlusHealth
• Joe Mangram, Partner, ECG Management Consultants
  Release Date: June 16, 2025

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Introduction

In this insightful episode of Healthcare Upside Down, hosted by Molly Gamble of Becker's Healthcare, the discussion centers around the evolving payvider model in the U.S. healthcare landscape. Joining Molly are Lila Benayoun, COO of MetroPlusHealth, and Joe Mangram, a partner at ECG Management Consultants. The conversation delves into operational strategies, the acceleration of payvider models, their challenges, and future prospects.

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Guest Introductions

Molly Gamble opens the session by introducing her esteemed guests.

• Joe Mangram [00:31]: As a partner at ECG Management Consultants, Joe leads the payer practice, working primarily with regional and provider-sponsored health plans. He oversees various consulting engagements, including strategy and financial turnarounds, focusing on the internal operations of health plans.

• Lila Benayoun [01:18]: Serving as the COO at MetroPlusHealth, Lila manages plan operations for a diverse membership of approximately 700,000 across New York City's five boroughs. Her role ensures operational excellence, aiming to provide high-quality access to care for both members and providers.

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Operational Strategies for a Diverse Population

Molly probes into how MetroPlusHealth effectively serves a highly diverse and large population.

• Multilingual Support and Community Integration [02:10]:
  • Lila Benayoun emphasizes MetroPlusHealth's commitment to diversity: “Our staff speaks over 40 different languages. We are deeply embedded in our communities, participating in local events and partnering with community organizations to ensure integrated care” [02:10].
  • The organization maintains 14 concierge teams across the city to assist members with various inquiries, from enrollment to social determinants of health, ensuring agility and responsiveness [02:10].

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The Rise of the Payvider Model

Transitioning to the broader industry context, the discussion shifts to the payvider model—the integration of payer and provider functions.

• Acceleration Factors [03:38]:

  • Joe Mangram notes, “National insurers are steamrolling their competition, dictating terms for providers. In response, many providers are creating their own health plans to foster friendlier and more collaborative relationships” [03:38].
  • He highlights a common shortfall: health plans often remain siloed from their provider partners, hindering seamless integration [04:33].

• Integration Benefits [03:38 - 04:45]:

  • Molly Gamble underscores the importance of brand unification: “When a patient thinks of the brand, they're thinking of both the provider and the payer function, not just one domain or the other” [04:42].
  • Joe Mangram adds, “The care is a lot more seamless as well” [04:45], pointing to enhanced patient experiences through integrated services.

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Challenges in Implementing Payvider Models

The conversation delves into the hurdles faced in establishing effective payvider models.

• Leadership Expertise [06:20 - 08:31]:

  • Joe Mangram asserts the necessity of specialized leadership: “Executives must understand insurance—underwriting, risk adjustment, MLR scores are crucial” [06:20]. He emphasizes that leadership from the healthcare side alone may lack the requisite insurance acumen, likening it to running a bank without specific banking experience [08:31].

• Data Alignment [06:20 - 07:15]:

  • Joe Mangram highlights the critical role of data: “Good data alignment between the provider sponsor and the health plan is essential. There must be an easy and real-time exchange of information” [06:20].
  • Lila Benayoun concurs, adding that data integration “leads to better care coordination and reduces administrative burdens by eliminating duplicative processes” [07:15].

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Future of Payvider Integration

Exploring the next steps for payvider models, both guests provide forward-looking insights.

• Holistic and Proactive Care [05:08 - 06:05]:
  • Lila Benayoun envisions the future of payviders as focusing on holistic care: “Aligning financial incentives from both the provider and the payer is critical. Leveraging data and technology to manage population health and proactively address individual needs is where the healthcare landscape is heading” [05:08].

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Designing Sustainable Payvider Models

Joe offers practical advice on building successful payvider structures.

• Essential Features [06:20 - 07:10]:

  • Leadership with insurance expertise and robust data integration are non-negotiables for sustainable payvider models.

• Lila’s Perspective on Data Utilization [07:15 - 07:51]:

  • Effective data use enhances care coordination and minimizes administrative redundancies, leading to more integrated and efficient member care [07:15].

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Closing Remarks

The episode concludes with final thoughts from both guests.

• Lila Benayoun [08:51]:

  • Stresses the importance of adaptability in a fast-paced, consumer-oriented healthcare environment: “We must continue to transform our healthcare delivery system to provide holistic coverage and ensure access to care for all members” [08:51].
  • Emphasizes collaboration over competition between providers and payers [09:31].

• Joe Mangram [09:45]:

  • Advocates for the payvider model as a strategic response to dominant national insurers: “More health systems and hospitals should consider building or acquiring their own health plans” [09:45].

Molly Gamble wraps up by thanking Lila and Joe for their valuable insights, reinforcing the significance of integrated payvider models in advancing quality healthcare delivery.

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This episode of Healthcare Upside Down offers a comprehensive exploration of the payvider model, highlighting operational excellence, strategic integration, and the collaborative efforts necessary to enhance healthcare outcomes for diverse populations. Through the expertise of Lila Benayoun and Joe Mangram, listeners gain a deeper understanding of the challenges and opportunities in building sustainable, integrated healthcare models.

Transcript

[Molly Gamble]

Welcome to Healthcare Upside Down, a podcast by Becker's healthcare and ECG management consultants in which we'll explore the upsides and downsides of healthcare and the industry's most current trends. I'm Molly Gamble and today I'm thrilled to be joined by two guests. Lila Benayoun, chief operating officer with Metro Plus Health, and Joe Mangram, partner with ECG Management Consultants. Lila, Joe, thank you so much for joining me today and be my guests.

[Lila Benayoun]

Thank you for having me.

[Joe Mangram]

Thanks.

[Molly Gamble]

Great. So to begin, can you share a few pertinent details about your current role in your organization? Joe, let's turn to you first.

[Joe Mangram]

Sure. Hi everyone, my name is Joe Mangram. I'm a partner at ECG Management Consultants. We're a national healthcare consulting firm and at ECG I lead our payer practice. So my clients are typically regional and provider sponsored health plans. So excited to be talking with you today and especially with you, Lila, because I'm based in New York City, so Metro plus is a big part of the New York City community. And my team and I, we do all different types of consulting, engagements, strategy, financial turnarounds, you name it. Basically, if it's at the four walls of a health plan, we usually do it.

[Molly Gamble]

So that's great. Thanks, Joe. So not only a big provider sponsored health plan, but a neighbor to you with Lila. So, Lila, we'll turn to you next a few pertinent details about you and your organization.

[Lila Benayoun]

Hi, yes, I am the Chief Operating Officer at Metroplex Health. As Joe has just mentioned, we are a provider of unplanned. We service about 700,000 members through the five boroughs of new York City. And I focus on plan operations, making sure operational excellence. We want to make sure both our members and providers have an excellent experience and providing high quality access to care. And so very excited to be here today.

[Molly Gamble]

Thank you both so much. I'm going to turn to you, Lila, you just shared that Overview with us. 700,000 lives covered by Metro Plus Health. A highly, highly diverse population, largely Medicaid. I'm thinking of the five boroughs. How diverse it is. I know Queens. I think there was a stat. Still blows my mind. How many languages are spoken in Queens alone, for instance? Can you share some operational strategies that have proven most effective for improving access and outcomes for a population this diverse and this large?

[Lila Benayoun]

Yeah, so internally we have. Our staff speaks over 40 different languages. That's just because of the diverse nature of our population. Our operations are agile and nimble to make sure that we could address any of the needs of Our members ensuring they have access to care at their fingertips. We are really entrenched into our communities with our members and providers. We participate in low local events. We are in community organizations really partnering with New York City health and hospital corporations making sure that our members have integrated care. We do have a concierge team that are located in 14 different sites throughout the city to ensure that our members have a place to go whenever they have a question, whether it's a enrollment question, redetermination question, or just simply some sort of social determinants of health. Just making sure that we're nimble for them. That's key and really important for us.

[Molly Gamble]

Leah, thank you so much for touching on those things. What's really worked well, 40 plus languages spoken at your health plan, this cohesive integration with the community, offering resources for questions and also social determinant of life factors. Joe, let me turn to you here because ECG works with both traditional payers and emerging payviders. And from your perspective, I want to talk about the payvider models. More specifically, what's driving the acceleration of payviders right now and where do you see the model still continue to fall short or struggle?

[Joe Mangram]

So we all see national insurers are steamrolling their competition all across the country. I think that the result of that is that they essentially dictate terms for their providers. There's not a lot of negotiating with them anymore. And I think that a lot of providers, hospitals, health systems have said we'd rather sit across the table from a friendlier entity. And so they think one way to do that, and I agree, is to build their own provider sponsored health plan. I think that one place that is falling short though is once the plan gets built, they sort of keep it as a separate entity. So Lila had a great response about how Metroplus is so well integrated with its provider sponsor. I think that more plans should be doing that integrate well both on the financial, clinical and operational side.

[Molly Gamble]

So that way when a patient or consumer thinks of the brand, they're thinking of both the provider and the payer function, not just one domain or the other.

[Joe Mangram]

Right. And the care is a lot more seamless as well.

[Molly Gamble]

Sure. Let's talk about that a bit more. This integration between the care delivery side and the financing side, that is going to be key for value based transformation. Lila, if I had to turn to you for your thoughts here, what would you see as the next frontier for payvider integration? What does that look like? And then on the other side of that coin, what's actually playing out right now in reality.

[Lila Benayoun]

So I do think that the payvida model is really becoming more popular and resurging from the past because of the fact that we are really focusing on value based care. The way healthcare system is now, it's fragmented and we need to figure out a way so that we keep our members and just consumers in general the center of all care. And so it's really important to have integrated care. And so aligning financial incentives from both the provider and the payer is critical. It also brings everyone to the table to ensure how are we providing holistic care, whether that's from medications, behavioral health services, social determinants of health, medical. I do think that leveraging data and technology, managing population health and just trying to be more proactive of those individuals that are in our care than continuing to be reactive would be really groundbreaking and I think that's where the healthcare landscape's going.

[Molly Gamble]

Jo, let me turn to you here. If you had to design a truly sustainable pay vitor model based on what Lila just shared this, this idea of really closely aligned incentives, what are a couple specific features that you would consider non negotiables.

[Joe Mangram]

I'm sort of laughing to myself because my ECG colleagues are going to laugh at me for saying this because I say it all the time. So when you build a provider sponsored health plan, a lot of times what ends up happening is the provider instills its leadership from the provider side. You have to have executives who know understand insurance because again it's an insurance company. You have to know underwriting and risk adjustment and MLR scores. Right. So I would say that that's crucial. And then the second thing is data alignment. You, you really have to have good data between both the provider sponsor and the health plan. There has to be easy exchange of it and it has to be real time, sort of like Lila was saying, not reactive data.

[Molly Gamble]

Lila, are there any of those two points that you want to speak to, whether it's the leadership piece or the data alignment?

[Lila Benayoun]

I do, because I think with data you have better integrated care coordination and also removing the administrative burden. Because a lot of times what we see from our care managers is it's a lot of paperwork and as we move towards a more stronger relationship with our provider payer side, we could eliminate some of the duplicities that we are seeing or running into. And there's a lot of disconnects that are happening. Average reaction to medications and things of that nature. And I think that having more alignment between both the provider and payer is a really crucial point for our patients and members.

[Molly Gamble]

And Jo, I think the leadership point too is such a important one because this takes an entirely different skill set in some ways and different experiences to really lead a successful health plan or insurance model versus the provider side of things.

[Joe Mangram]

Yeah, absolutely. I think we see examples of, you know, a chief medical officer or somebody like that from the health system side who becomes the president or CEO of the health plan. They're obviously very capable, very knowledgeable in health care, clinical determinations, things like that. But it would sort of be analogous to me running a bank. I mean, I could take things that I've learned throughout my career and apply it to it, but it's a fundamentally different business.

[Molly Gamble]

It's a really great example. Lila, any closing thoughts to share with our listeners coming from your health plan? You had mentioned some really impressive statistics and stats at the beginning with your opening remarks. If this has been a really tumultuous time, I imagine with Medicaid redetermination still ongoing in many pockets of the country. Anything else you want to leave our listeners with in closing today?

[Lila Benayoun]

Sure. I do think we live in a very fast paced environment. It's very consumer oriented, digitized and I believe that we have to continue with the momentum and transform the way we look, look at healthcare, our delivery system and how we provide holistic coverage to our members to making sure that they have access to care. That has been a struggle across the nation making sure that the right behavioral health providers are available. And so I do think that we need to continue to stay focused and keep working together as a collaborative effort. It's not the provider versus the payer. This is a collaborative effort so that we can move forward in providing good quality care to our members.

[Molly Gamble]

Joe, same question for you in closing remarks. I appreciate your comments earlier about the big payers getting bigger in many ways and more faceless at times. The payvider model can be a really helpful contrast to that. Anything else you want to add as we wind down?

[Joe Mangram]

Yeah, I think for a lot of the reasons that we said, I think that the payvider model is the right model and I think that more health systems and hospitals should consider either building or acquiring their own health plan.

[Molly Gamble]

Terrific. Well, I want to thank you as my guests. We have Lila Bennyun listeners again. She's the chief operating officer with Metro plus Health and Joe Mangram, partner with ECG Management Consultants. Lila Joe, thank you again for this conversation today.

[Lila Benayoun]

Thank you for having us.

[Joe Mangram]

Thanks a lot.