Challenges and Trends with Value-Based Care Models Featuring Lili Brillstein of BCollaborative
During this episode of Real World Talk, host Emily Di Capua has a discussion with Lili Brillstein, the Chief Executive Officer of BCollaborative (Brillstein Collaborative Consulting). Lili works with Payers, Providers, Pharma, Start-Ups and other stakeholders to progress the movement from fee-for-service to patient-focused, value-based care models.
Lili opens the conversation by setting the stage for those who are unfamiliar with healthcare payment models. She discusses the dominant form of payments, which is a fee-for-service model. She then discusses the core components of the value-based care model.
Lili discusses how there are a lot of different models under an umbrella, which is value-based care. Terms often used include population health, bundled payments and episodes of care.
The goal of value-based care models is to really shift the focus from the care provided by one provider to all the care that’s rendered to one particular patient across the full continuum of care.
Lili talks about the model of value-based care that she’s most familiar with – the episodes of care model. This model really focuses on the specialists associated with a value based scenario and considers individuals who have some real clinical similarities.
There are three main components to value-based care models – improving outcomes, improving experiences and getting the most from limited resources.
Providers often don’t have a longitudinal view of a patient’s care because they’re just focused on what services they’ve delivered to the patient.
In many cases, you often associate episodes with orthopedic procedures such as hip replacements or knee replacements because these are scenarios that are easier to define. There’s a starting point and an end point.
Lili talks about how it’s important for providers and stakeholders to understand that payers are gigantic bureaucracies and are often sitting on systems that rely upon a fee for service model.
Lili talks about how her goal as a partner is too often “build something that is clinically meaningful and also administrable by the payer and not burdensome for the providers and the other partners.”
Lili’s best advice around providers looking to engage with payers on value-based care, is to engage with payers that have value based care activities already. One way to make this determination is by finding payers who have staff members with titles using words such as innovation, transformation, pophealth, etc.
Lili provides some background on specific examples of episode programs, most notably mentioning CMS’s OCM (oncology care management) model.
When considering the trends of value-based care, Lili feels it’ll involve more tweaks and an overall evolution versus a jump. The level of risk will be shifted between payers, providers and patients.
Lilii breaks down the components of a specialty care medical home model built around oncology – which was essentially a more hybrid model between the primary care medical home model and a specialty care episode model.
Lili talks about a model created at Horizon which involved a maternity episode. The model first focused on moms with low risk pregnancies and then shifted to higher risk patients.
When evaluating episodes, it’s important to go beyond claims data, and focus on what success is for the patient as well as the provider and payer. In order to do this, you need clinical data, claims data, social data and the technology to analyze the data.
Lili draws a distinction between fee for service and value-based care models, “Fee for service is a payment model that reimburses providers of care on a per service basis. So every service is paid for separate and apart from any other service that may be rendered to an individual patient. And reimbursement for the care provider then is increased when they provide them more services. So it…is a quantity over quality incentive in the model.”
Lili talks about some of the major drawbacks of the fee for service model, “There is this sort of perverse incentive around quantity rather than quality, for patient outcomes, which often results in fragmented and or unnecessary care for individuals and results in really, less than optimal outcomes. As we’ve seen medicine continue to evolve and people are living longer and with more complex diagnoses and co-morbidities the fragmented fee for service model really does not work effectively to support these patients and individuals with these situations and certainly not to produce optimal outcomes or a thoughtful use of limited resources.”
Lili mentions “And so one of the things I always say to providers and startups and tech vendors who are going in to talk to payers is you need to be thoughtful about what they can actually do and not do. And to listen to what they’re telling you because they may not be saying no because they don’t like your idea. They may be saying no because administratively it’s difficult.”
When discussing value-based care models and the pandemic, Lili states “We’re really interdependent upon one another to keep each other safe and protect ourselves. And those are precisely the principles at work in value-based care. It’s really about being respectful, and understanding that we all have a role to play in the care and the health care, of each of us.”