Tommy Ibrahim, MD, joined Sioux Falls, S.D.-based Sanford Health Plan as president and CEO in January after serving as president and CEO of Cooperstown, N.Y.-based Bassett Healthcare Network.
He sat down with Becker's to share insights on the challenges and opportunities facing provider-led health plans, the state of Medicare Advantage, and payer-provider relationships in a rapidly evolving healthcare landscape.
Question: What's it been like going from health system CEO to leading an insurance company?
Dr. Tommy Ibrahim: It's been a blast. We've been on an exciting journey in the short time I've been at Sanford, and I’m really enjoying it. My background as a physician, working in hospitals for my entire career, and eventually running hospitals and health systems, is a completely different world from where I am today. Transitioning to the health plan side has been incredibly fulfilling because I'm now at the intersection of a strong, diverse, integrated healthcare delivery system, which offers tremendous opportunities. The chance to reshape clinical delivery models and explore alternative payment models, while working across the delivery system and the health plan, has been a remarkable opportunity.
Question: As part of an integrated system, where do you see the biggest opportunities for growth right now?
TI: This moment in time is a ripe opportunity for provider-led health plans to capitalize on the disruptions in the national payer space. There's significant change happening, and consumers are expecting more. Providers are also seeking alternative relationships with payers. All of this sets the stage for a resurgence of provider-led health plans. Our focus is on how we can further integrate our model and maximize the benefits of being a provider-led health plan. We aim to create a frictionless, seamless experience for our members, differentiating ourselves through an enhanced member experience. This, combined with market dynamics, positions us well for both organic and inorganic growth opportunities.
Question: We're about to enter the annual Medicare enrollment period, marked by a lot of big changes this year. What's it like navigating Medicare Advantage right now?
TI: Our Medicare Advantage plan is about three years old, and we’re relatively small. As we've seen disruption in the MA space, we’re focusing on how to redesign our plan for the future. Despite the national challenges, we’ve experienced little to no disruption because of our integrated model. We navigate our members through the system without the burdens of prior authorization and other denials that many face. For example, while we do have prior authorization processes, we developed them hand in hand with our providers, making the process less burdensome. For the few things we do require prior authorization for, we typically turn things around within 24 hours, and our denial rate is less than half of the national average. I even had a conversation with one of our physicians about further reducing prior authorization, and they pointed out that it’s necessary to ensure we're preserving quality and managing patients the best way possible. That was really eye-opening and reaffirming.
Question: Some hospitals and health systems are opting to end their contracts with MA plans over administrative challenges. What's your perspective on this trend?
TI: Unfortunately, I think the challenges in the Medicare Advantage environment will continue, with increasing regulatory constraints, decreasing reimbursement, and changes to the Star Ratings methodology. All of this affects revenue for payers, and we’re feeling it too on the Sanford Health Plan side. The larger for-profit payers, who are accountable to shareholders, have to balance administering the program and maintaining profits. As regulatory changes continue, we’ll likely see more strain in payer-provider relationships. In our market, a large carrier is pulling out, which creates a great opportunity for us. As a not-for-profit, integrated healthcare delivery system, we reinvest in our organization, members, and community, which gives us leverage to reduce some of the headaches and work well with our providers.
It's definitely where we're placing our bets. One of our key growth strategies is to find other like-minded health systems that are struggling with the traditional payer environment but have strengths in value-based care. We want to partner in a bigger way. We’re about to announce an exciting joint venture with a nearby organization where we’ll co-own and distribute a new product. Sanford Health Plan brings payer capabilities, while the health system brings clinical care and delivery assets. Together, we’ll design benefit programs and manage utilization and care to create a distinct model in the market.