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

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.

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.

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].

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.

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].

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].

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].

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.

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.