Episode Overview
Podcast: Becker’s Healthcare Podcast
Title: Value Based Care, Data Gaps, and Cost Pressures in Health Plans with Howard Brill
Air Date: February 2, 2026
Guest: Howard Brill, Senior Vice President, Population Health and Quality, Monroe Plan for Medical Care
Host: Scott King
This episode centers on the evolving landscape of value-based care, the persistent data and workflow challenges facing payers and providers, and the growing cost and margin pressures impacting public programs and health plans. Howard Brill shares insights from both operational and strategic perspectives, highlighting his experience with predictive analytics, hands-on leadership in Medicaid-focused organizations, and ongoing regulatory and workforce changes.
Key Discussion Points & Insights
1. Howard Brill’s Background & Perspective
- Provider Organization Focus: Monroe Plan is an "at risk provider organization" working exclusively with public programs (Medicaid, Child Health Plus) in western New York.
- Career Path: Started in software development for risk adjustment and predictive modeling, which evolved into IT and then population health leadership at Monroe Plan.
- Academic Lens: Holds a PhD in Sociology with a focus on healthcare system transformations.
“We are an at risk provider organization…we focus exclusively on public programs, Medicaid and Child Health Plus.”
— Howard Brill [01:07]
2. Impact of Predictive Analytics & Prior Experience
- Predictive Modeling: Early work gave Howard deep understanding of drivers behind provider performance, crucial for today’s value-based models.
- Importance of Context: Provider variation is often rooted in the types of patients served and network environments.
“Predictive modeling has become much more important since then. And it certainly gave me insight into what drives performance…”
— Howard Brill [02:54]
3. Changing Provider-Payer Relationships Amid Cost & Workforce Pressures
- Nested Value-Based Arrangements: Monroe Plan’s unique structure features back-to-back value-based contracts with both health plans and downstream network providers.
- Cost Scrutiny: Fee schedules are flat or declining; audits around upcoding are increasing; and administrative and quality improvement costs face greater scrutiny.
- Tighter Utilization Management: More contracts feature both upside and downside risk for providers.
“There is tremendous cost pressure in the environment right now…fee schedules are being held flat and in some cases decreasing… audits of provider billing and scrutinizing for potential upcoding…a lot closer scrutiny of those kinds of activities…”
— Howard Brill [04:20]
4. The Strategy-Execution Gap in Value-Based Care
- Persisting Fee-for-Service Problem: Value-based contracting was intended to reduce inefficiencies, but execution is falling short—cost, not quality, is the main focus.
- Fragmented, Lagging Data: Lack of real-time, integrated data across care settings prevents effective care coordination and cost control.
- Consolidation ≠ Integration: Despite provider consolidation and large EHR investments, actual care integration lags behind expectations.
“Efforts to reduce cost through value based contracting appear to be falling short and that’s straining relationships between payers and providers… A continuing issue...is a lack of real time data and fragmentation across the continuum of care.”
— Howard Brill [06:46, 07:48]
5. Investments That Could Reshape Health Plans
- Workforce Development: Ongoing shortages and wage pressure are a primary driver of costs; systemic investment is required but slow to yield results.
- AI & Workflow Automation: Legacy systems and manual processes still dominate. AI’s potential lies in automating workflows involving massive unstructured data, resulting in cost and efficiency gains, especially in the short-to-medium term.
- Population Health & Alternative Models: Interest is growing, but three years may be too short to see widespread impact.
“AI tools have potential to reduce the cost of workflow. Projects that [manage] unstructured data...the low hanging fruit on AI is just being able to reduce the investment and time required to make long overdue workflow improvements…”
— Howard Brill [10:18, 13:09]
6. Data: The Persistent Roadblock
- Manual Work Remains Rife: Decades of IT investment haven’t eliminated the need for hands-on data work, especially in utilization management and administrative tasks.
- AI’s Practical Advantage: Immediate gains from AI may come from tackling these manual processes rather than grand, transformative projects.
“There is still a substantial amount of work that depends on very manual processes...the low hanging fruit on AI is just...workflow improvements that handle the unstructured data involved in those processes in much better ways…”
— Howard Brill [13:26]
7. Regulatory & Industry Practice Changes for Affordability and Access
- State Waivers and Coverage: Regulatory changes can suddenly shift eligibility for coverage, as illustrated by New York’s need to reverse expansion of its Essential Plan.
- Prior Authorization Practices: Intended to control utilization, prior authorization now consumes excessive administrative resources and impedes access for consumers.
“The level of administrative effort on both the payer and provider side misdirects resources and does impede access. Unfortunately, the trap is that it becomes a key practice to manage adverse utilization, but...it does create a high degree of administrative effort…”
— Howard Brill [16:32]
8. Margin Pressures in Health Plans (2026 Outlook)
- Drug Costs Dominate:
- Commercial: GLP-1 drugs front-and-center as a margin pressure.
- Medicaid (NY): Biologics, infusion drugs, and consumer-directed personal care services are adding cost pressures.
- Cost Increases Broadly Felt: Both general increases and unique state-specific factors are at play.
“GLP1 drugs are putting the most immediate pressure on health plans now. In our space in the New York State Medicaid environment, biologics and infusion drugs are significant…”
— Howard Brill [17:32]
Notable Quotes & Memorable Moments
- On ongoing challenges in data:
“The amount of unstructured data and manual processes still involved in those are, can be breathtaking.”
— Howard Brill [13:26] - On regulatory priorities:
“Prior authorization is a key industry practice to manage utilization...in doing so it does create a high degree of administrative effort which is just, you know, not, not really serving consumers very well.”
— Howard Brill [16:29] - On AI’s near-term potential:
“Low hanging fruit on AI is just being able to reduce the investment and time required to make long overdue workflow improvements…”
— Howard Brill [13:38]
Key Segment Timestamps
- [01:06] — Howard Brill’s professional background
- [04:06] — How provider-payer relationships are shifting under cost/workforce pressure
- [06:46] — The biggest gap between strategy and execution for health plans
- [10:18] — Investment or initiative that could reshape health plans in the next 2-3 years
- [13:09] — The continuing struggle with data and manual processes
- [15:00] — Regulatory or industry change to improve access and affordability
- [17:21] — Pressures on health plan margins and Monroe Plan’s strategies
Conclusion
Howard Brill’s insights paint a clear picture: value-based care still struggles with the same data and integration challenges it’s faced for years, and new tools like AI may be more valuable for automating stubbornly manual workflows than for grand system overhauls—at least in the short run. Meanwhile, legacy practices like prior authorization are ripe for reform to improve access and reduce system waste, even as cost and workforce pressures mount on all sides. For Medicaid and other public plans, both regulatory shifts and high-cost drugs shape a landscape that demands agile, data-smart responses.