When Michael Genord, MD, received a call offering him an executive role at a health plan, his first question was: "Why would I do that?"
Dr. Genord was a practicing OB-GYN for 20 years before working in the payer industry. He has been the CEO of Health Alliance Plan, a Michigan payer owned by Henry Ford Health, since 2020.
"As I paused and reflected, [I realized] we need physician voices in every part of the healthcare system if we want it to be aligned with providers, their patients and members," Dr. Genord told Becker's. "I often complained about insurance companies doing things that seemed counterproductive to quality, and I thought maybe I could be a different voice on that side."
Mark Mugiishi, MD, spent nearly 30 years practicing surgery. He has been CEO of the Hawaii Medical Service Association, the Blue Cross Blue Shield affiliate in Hawaii, since 2020.
Dr. Mugiishi helped build the first ambulatory surgery centers in Hawaii, an experience that led him to shift his focus from caring for one patient at a time to caring for a population.
"It led me to the realization that there was a way to take my curiosity, my desire to improve the health of Hawaii, to a place where you could do that at a population level," he said. "That's what got me moving from my individual practice to a big payer."
Becker's spoke to four physicians who are chief executives at insurance companies about how their background shapes their leadership, and how payers and providers can work better together.
Leading with curiosity
John Espinola, MD, is the CEO of PacificSource Health Plans in Springfield, Ore. He previously held roles at UnitedHealth Group and Premera Blue Cross, and began his career as a geriatrician.
Dr. Espinola said empathy and curiosity are two key traits for a physician he applies in his role as CEO.
"We've got 2,000 employees. I have to think about their experience to be an effective leader. I have to listen to them. I have to be curious about it, and make sure that I'm relying on them to inform me along the way," Dr. Espinola said.
The years physician CEOs spent caring for patients also influence the projects they prioritize.
One of his first priorities when he assumed the executive role was to implement a value-based payment system for primary care physicians, Dr. Mugiishi told Becker's.
"I think coming from the provider community made it easier for me to design and convince our network on this new model," he said.
Dr. Genord said his experience as a physician helps him to have more open dialogue with providers. It also grants him perspective to "pressure test" which policies will be too burdensome for providers.
"When I first got here, we were designing a program that was going to take physician offices 20 or 30 minutes to input information for it to work. We were patting ourselves on the back because we were going to get all this data and information about our members," Dr. Genord said. "I looked at it, as a physician, and said, 'You designed that for us, not for physicians.' No physician is going to be spending 20 or 30 minutes — they're busy taking care of their patients."
Michael Cropp, MD, has been the CEO of Buffalo, N.Y.-based Independent Health since 2004.
Dr. Cropp told Becker's part of a payer's job is to enhance trust between patients and providers, and efforts in quality are one way to do that.
"I've always felt from my days practicing as a primary care physician, that what's at the core of making healthcare work is the trust that exists between the patient and provider," he said. "The primary care provider is really that first point of contact and the ultimate opportunity to create that trust and that bond."
Changing mindsets
Relationships between payers and providers can be difficult.
A 2022 survey by the American Hospital Association found 78% of hospitals said their relationships with commercial insurers were worsening. Tense contract negotiations are appearing in headlines more often.
Payer CEOs with experience as providers said more transparency and humanization could make these relationships more positive.
When Dr. Cropp began his tenure at Independent Health, there was an assumption that providers "are just in it for themselves," he said.
"I said, 'Let's shift our mindset a little bit,'" Dr. Cropp recalls. "That might be the case for a small percentage of providers, but why would we make a set of rules that applies to 3% of providers when 97% are in it for the right reasons, and doing the right things?"
The change in mindset affected the approach Independent Health took to prior authorizations and payments, Dr. Cropp said. Around 2013, the company shifted its approach further, and asked physicians what the ideal number of patients to see in a day was.
Independent Health designed a payment model to allow physicians to spend more time with patients, and better rationalize the use of specialty care, hospitals, imaging and other services.
"If you think 12 to 15 patients a day is manageable, and you have a practice that has 2,000 patients, our collective job is to figure out, how do we help you see the right 12 to 15 patients every day, and make sure the other 2,000 are getting the right touches by either you, us, or another part of the system."
The approach has paid off — Independent Health's Medicare Advantage plans have all received 5-star quality ratings from CMS, and the company is one of two commercial insurers to receive a 5-star rating from the National Committee for Quality Assurance.
Another key to better relationships between payers and providers is removing the "cloak of secrecy," Dr. Genord said.
"We have to share data. We have to be open with what we're seeing. We need to make [providers] partners in helping us solve problems, and move solutions closer to the physicians," Dr. Genord said.
Finding more physician leaders
Physician CEOs agreed — the insurance industry could use more clinicians in leadership.
Physicians can bring a balance and perspective to insurers, Dr. Mugiishi said, but there is a lot to learn when it comes to running a large organization that isn't taught in medical school.
"When I was a surgeon, everybody in the room was trying to help me, nobody from outside of the room was bothering me, and there was a beginning and an end. I don't have any of that now," he said.
For physicians considering a role with an insurer, it can take some soul-searching to decide to step away from clinical practice, Dr. Genord said, but their voices can be extremely valuable for insurers.
"What aspects of your clinical upbringing can you use to help change the larger system of healthcare, and still have that fulfillment, doing things that are so important to public health and community health," Dr. Genord said.
Insurers would do well to recruit more clinicians to be leaders, Dr. Espinola said, because they have a key role in keeping a focus on the moment of care.
"The more clinicians we have in leadership roles, the more likely we are to stay focused on the moment that matters. I think that's true of both the payer side and the provider side," he said.