Value Based Care, Data Gaps, and Cost Pressures in Health Plans with Howard Brill

Summary

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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.

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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]

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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]

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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]

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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]

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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]

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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]

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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]

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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]

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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]

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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

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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.

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Transcript

[A]

This is where health insurance leadership comes together. Becker's 4th 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.

[B]

Hello, everyone, and welcome to Becker's Healthcare Podcast. I'm Scott King, thrilled today to be joined by a very special guest, Howard Brill, Senior Vice President, Population Health and Quality over at Monroe Plan for Medical Care. Howard, how you doing today? Thanks so much for joining us.

[C]

Thank you. I'm doing very well.

[B]

Wonderful. You know, we have a lot of big topics to dive into as we're, you know, just kind of getting started here and 2026 already a lot going on in the health plan world and health plan side of things. But before we jump into that discussion, Howard, wondering if you could please tell us a little bit about your background and your career journey.

[C]

Yeah, sure. And first, just one thing to clarify. We are an at risk provider organization, so we're located in western New York and we focus exclusively on public programs, Medicaid and child health plus. So my background, I actually started with a software development company that was developing risk adjustment and stratification software for evaluating health plan and provider performance. And from that move to working for Monroe Plan, initially starting again in a IT role and in evaluating health programs that Monroe Plan had and then eventually moved into a leadership role in population health. My background includes a PhD in Sociology. I focused on health care and I had written a dissertation on transformations in the healthcare system in the 1930s.

[B]

Thanks so much for sharing your background information there, Howard. I think it's so interesting that you worked for a software development company that analyzed health plan performance. Just from that experience to what you're doing now, how effective are you in the kind of analyzing where things are and what needs tweaking and how much time does that save, you know, your prior experience and the way it ties into everything?

[C]

Well, the company I was working for had developed early at the time, it wasn't yet called that, but was essentially predictive modeling tools. And so, you know, obviously predictive modeling has become much more important since then. And it certainly gave me insight into what drives performance and understanding some of the conditions and contextual elements that underlie variation in provider performance, including the kinds of patients they are seeing and the networks that they are in and getting.

[B]

To some of the trends kind of happening today. You know, it's, it's a time where obviously on the provider side there's a lot of regulatory pressure and same with the payer side of things. So my question for you is how are your relationships with providers changing as both sides face cost pressure and workforce shortages in particular?

[C]

Yeah. So as a at risk provider organization, with the health plan that we work with, we have a value based arrangement and in turn with our network, we, for the, for the larger providers in our network, we have value based contracts too. We do also have some providers in our network who will just have, who, who don't have value based contracts. But, but essentially you have a, an environment where we have a nested value based arrangement. So we work under a value based arrangement and in turn the large part of our network that we contract with also has a value based arrangement. As you know, you're asking, there is tremendous cost pressure in the environment right now. For us that means that fee schedules are being held flat and in some cases decreasing. We see the health plan increasing, audits of provider billing and scrutinizing for potential upcoding of services at more, more intensely than they have in recent years. An important aspect of what we do in terms of our value based arrangements is that we do a variety of administrative advances and we provide other support for quality improvement purposes. Those can range from staff support and assistance to tools that we make available. One of the things that the increased cost pressure means is that there is a lot closer scrutiny of those kinds of activities and initiatives and the costs around them and the range of initiatives that we introduce. On the quality side, outside of our network relationships, we see a tightening of utilization management and we see an increased effort overall in the region for value based contracts to include both upside and downside risk.

[B]

Howard, where do you see the biggest gap today between payer strategy and then operational execution?

[C]

Yeah, and you know, I, I, I think it's helpful when talking about that to again understand the broader historical context. And you know, this is not news to anyone, but for at least 40 years, fee for service reimbursement has been largely acknowledged as a fundamental structural problem in the cost of health care in the US for the past 10 to 15 years, value based care arrangements between payers and providers have been seen as the strategic framework for managing the impact of fee for service reimbursement and for creating a pathway for alternative reimbursement models. The gap today is that efforts to reduce cost through value based contracting appear to be falling short and that's straining relationships between payers and providers and tending to shift the focus from quality to cost of care. So there's multiple reasons for that. A continuing issue that limits the effectiveness of value based arrangements is a lack of real time data and fragmentation across the continuum of care. The ability to receive and analyze data in real time versus experiencing lags inhibits the ability of at risk organizations to work with providers and members to manage care and control costs. Another aspect, although there's been substantial, substantial consolidation among providers, this often has not been reflected in an integration of care. It was thought that consolidation would improve and ease integration. And there's certainly over the past 10 to 15 years, sometimes very, very large EHR projects who were promoted and intended to promote that integration. And at least in some cases, if not many cases, the actual care integration that emerged was much less than promised. And hope so. I think that again I would see that biggest gap between strategy and execution is between, is between value based care as a strategy and the ability to successfully execute on that through integration is the biggest gap. And you know, it falls along a number of lines, not least of which is effectively integrating data and care.

[B]

What's one investment or initiative you believe will most reshape how health plans operate over the next two to three years?

[C]

Yeah, and I have a bit of a complex answer to that. So one of the major drivers of costs is wage increases experienced by provider organizations. That's reflected several years of workforce shortages, which were certainly exacerbated by the pandemic burnout and longer term problems in the workforce pipeline. Although that's not easily articulated as a health plan or provider organization investment or initiative, and it's certainly not short term. There is a need for initiatives and investment in workforce development, of course, and you know, you probably heard this several times, AI projects, you know, do have a significant opportunity to reshape operational practice through altering administrative processes and workflow. One of the things that health plans and provider organizations still experience is a significant burden of legacy systems and manual processes. Projects involving traditional databases to improve workflows encounter very high costs and implementation failure because there's still a very large volume of unstructured data involved in contracts, member interactions and medical records. In the short term, in that one to three year time frame, AI tools have potential to reduce the cost of workflow. Projects that evolve that unstructured data, I think, you know, there's certainly significant attention to alternative reimbursement models, different kinds of bundled and episodic payments. There is also significant attention to changes in care management and population health initiatives. There is a lot of rethinking going on in the population health space too, but one to three years might be too short of a time frame to see the impact of that.

[B]

Yeah, you made a great point. I think, you know, several great points. I think, you know, with all the advancements we've seen with the emerging tech, it seems that data still is one of the main things that, that needs improvement. Is that kind of, is that kind of how you feel and what you see?

[C]

You know, I the interesting thing I just a few hours ago I was just got off a meeting of project management, meaning around a AI project that we have. We among other things we do provide some services to health plans. And one of the things we, we do is a utilization utilization management services. And I was just, you know, the amount of unstructured data and manual processes still involved in those are, can be breathtaking. And so while you know, there's been decades of investment in IT projects, there is a still a substantial amount of work that depends on very manual processes. And in some respects some of the, the, if you will, the low hanging fruit on AI is just just being able to reduce the investment and time required to make long overdue workflow improvements that handle the, the unstructured data involved in those processes in much better ways than they could be using non traditional databases.

[B]

Yeah, 100%. I hope we do see the data get cleaned up soon. Something else I want to ask you Howard, is that if you could change one regulatory or industry practice tomorrow to improve affordability and access, what would it be and why?

[C]

Yeah, and sorry for perhaps a bit more complex answer to that.

[B]

That's okay.

[C]

Yeah. There are several regulatory changes that affected affordability and access. So in New York State there was a waiver for the essential Plan that allowed it to expand coverage to people of higher incomes. With the OBA changes, New York will have to back out of that waiver that allowed it to expand essential plan coverage for those with moderate incomes. And again it gets a bit complicated. So although OBA the changes are related to restrictions on eligible immigrants, it has a broader impact than that in New York due to the state having constitutional requirements related to immigrants. So there was an expansion for higher income people in that appears to that that would have to be pulled back. So that, that is just an immediate issue on affordability and access. So in terms of perhaps other broader issues outside of New York State related to the, to the whole the whole structural problems around for fee for service reimbursement, prior authorization is a key industry practice to manage utilization. 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 in doing so it does create a high degree of administrative effort which is just, you know, not, not really serving consumers very well.

[B]

Absolutely. And the last thing I would ask you, Howard, is what issue is putting the most pressure on health plan margins right now and how are you responding differently in 2026?

[C]

Yeah, so again, because I'm within a New York State Medicaid context, pharmacy is currently carved out for us. So that's going to be a different answer than what you'll find in the commercial world. Certainly what we see outside of, you know, our space is 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, though we are seeing broad cost increases generally. Also within the Medicaid space and in particular New York, we are seeing pressure from some very unique specialized services related to consumer directed personal care services. But that, that, that's probably very unique to the way those are, those are set up and to that particular benefit.

[B]

Howard, thanks so much for joining the podcast and for all your insight. We're really looking forward to having you speak at the Spring Payer Issues Roundtable in April.

[C]

Thank you very much.