Lili Brillstein

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Transitioning to value-based care requires that healthcare system participants rethink how to deliver and compensate for healthcare. Under the current system, healthcare is delivered and paid for as incremental units of care by individual practitioners — the individual doctor’s visit, for example, or a procedure. In contrast, a value-based care system recasts the “unit” of focus as the individual patient and includes all the care that patient requires (i.e., not simply the care one provider delivers). This means that a provider must be thoughtful and clear, not only about the care they themselves deliver, but about all the up- and downstream care that others are giving to that patient. It means understanding how care affects a patient’s experience and outcome, across the full continuum of care, inside and outside of one’s particular office.

This holistic approach to care leads to the natural inclusion of a variety of providers, extending from the traditional (such as physicians, nurses and therapists) to the nontraditional (such as doulas, nutritionists and mindfulness instructors, among others). Value-based care is team-based care, and all providers must work collectively to ensure the holistic care of the patient.

But most commercial insurance companies design benefit plans within the confines of the prevailing fee-for-service methodology. Within this system, providers are reimbursed for each procedure, test and treatment, regardless of patient outcome. A low-cost or nontraditional option will generally not be considered, even if the patient would benefit, because it’s not a covered benefit and so will not be paid by the health plan. Value-based care models, on the other hand, create an opportunity to really reconsider what has the biggest impact on a patient’s outcomes, and not only what is or is not a covered benefit.

This leads to important considerations of compensation. Under value-based care, payment is based on patient outcomes and the efficient use of resources, not on any particular increment of care. Therefore, each stakeholder must understand all the care that is required and make good choices about who to work with across the continuum of care.

Consider paying for a car service. A commercial health plan paying a fee for service probably would not cover the cost of a car service to take a member to a healthcare appointment. The car service is not “care” in the traditional sense, but getting people to the doctor’s office can have a major influence on their outcomes.Under value-based care, outcomes becomes paramount. There is also new emphasis put on evidence about quality and cost-effectiveness because both quality and cost of care factor into what providers are paid. Many nontraditional practices, unlike traditional medical procedures, are low cost and high impact.

The need for collaboration and team-oriented decision-making extends beyond the continuum of providers. Payers bring valuable experience and data to the table; health plans maintain longitudinal claims data. But most health plans are large, bureaucratic-to-their-bones organizations, so the transition to value-based care payment is often slow and halting. Clinicians who approach payers with lofty ideals, but no understanding of their limitations, are likely to wind up frustrated. Likewise, technology vendors wooing payers with dazzling innovations for the care and payment system will probably be turned away if they are unable to show support of providers (preferably in the payer’s market).

Most payers today are interested in engaging in value-based care models. However, they cannot do it alone, and no one would want them to. But providers and payers have been more foe than friend traditionally. It is only when fists unclench and the focus shifts to what each side brings to the mix that real change can occur.

Value-based care requires collective and comprehensive planning and a healthy respect for one’s prospective partners in care delivery. Throw away your need to solve everything. Invite some prospective partners to brainstorm ideas that are outside the norm. What emerges may be new ways to create outstanding experiences and outcomes for your patients, all at a surprisingly lower cost.

Articles

Editorial piece by Managed Healthcare Executive's Editorial Advisory Board Member, Lili Brillstein. Brillstein is a nationally recognized expert on value-based care and the CEO of BCollaborative, a healthcare consulting company.

Value-based care: Rethink, unclench, invite 

As I sit at home, like most of you, I am amazed at how quickly the world has evolved from what we always knew and trusted to a new, unprecedented state of uncertainty in which we have no idea what the future will hold. In the six weeks that most of us have been sequestered in our homes, so much has happened. The whole world has seemingly closed down. In healthcare, we’ve seen a startling dichotomy: Emergency departments and ICUs in hot spot areas have been overrun, while elective surgeries have been canceled and hospitals and many physician offices avoided, except by individuals with COVID-19. 

The pandemic and the need for us to all be #alonetogether have accelerated the acceptance and implementation of many ideas and models that prior to COVID-19 were considered back burner - potentially helpful but hardly top priority. The current situation has highlighted what has always been true: Being in an environment with potential exposure to infection, including and especially hospitals and physician offices, can be dangerous to one’s health.

Now, more than ever, we must do everything we can to protect ourselves - and each other - from unnecessary exposure to infection.

To that end, an unprecedented amount of medical service has transitioned to telehealth. In the span of just days or weeks, many small and large practices with no prior telecare capability have pivoted to offering services via an electronic visit platform. They did so because the current situation of doing what we can to reduce transmission of the SARS-CoV-2 virus demanded it.

In further efforts to support patients, insurance companies are waiving copays, relaxing prior authorization and other processes used to manage inappropriate utilization, and providing easier and more access for patients throughout the country. The pandemic presents a difficult situation for these companies. While many businesses are struggling to pay their premiums, resulting in lost revenue, health plans are simultaneously being asked to provide multimillion-dollar loans to support physician practices that have been financially decimated by the lack of procedures and in-person visits.

Many of these dynamics are largely invisible to the American public. Except for those on the front lines, the rest of us are on computers in our home offices or dining rooms, juggling home-schooling kids while preparing for Zoom calls, quieting barking dogs, looking professional (at least on top; it may be pajamas on the bottom), trying to master the art of video visiting (and wondering why we have not done this before) ... the list goes on. We are attempting to maintain the normal in a situation that is anything but.

As a result, some remarkable things have happened. We have figured out creative ways to stay connected. We have softened. There’s more generosity of spirit, forgiveness, acceptance, understanding, compassion, gratitude - expressed all day, every day, in interactions between people all over the world. There’s laughter at our individual and collective lack of grace in figuring out how to manage in this time of uncertainty and use new (to many of us) technology.

We are cheering for healthcare workers, silently and out loud, alone but together. Every meeting begins with empathetic questions about how others are doing, and not just the toss-away “How are you?” of pre-COVID-19 times but a heartfelt “How are you, really?” And, in my experience, each meeting ends with genuine wishes of good health and safety. The outbreak has kindled a collective spirit.

We must, though, take care to protect those at greater risk and recognize that we are not all evenly affected by the virus. Those living with preexisting chronic and other conditions are at heightened risk, and older people, those living in nursing homes and African Americans have been disproportionately affected by suffering and death.

Let us remember the interconnectedness and dependency we feel today. And let us hold on to the generosity of spirit and the lessons we have learned as we move forward. We must bring both to our collective and ongoing work of managing healthcare. These respectful, thoughtful interactions are precisely what will spark our collaborative innovation and ensure the best care for all of us.  

Lili Brillstein is CEO of BCollaborative, which provides strategic advisory services to stakeholders across the healthcare continuum, and a member of the Managed Healthcare Executive® editorial advisory board.

Lili Brillstein, CEO of BCollaborative and member of the Managed Healthcare Executive® editorial advisory board discusses how the global shut-down and stay-at-home orders due to the COVID-19 pandemic have benefitted us in many ways.

Opinion: Let’s Remember That This Brought Out the Best in Us

Cancer is among the most frightening diagnoses for patients to receive.

It is a daunting challenge for oncology treatment specialists, and a persistent challenge for policy makers, payers, and other parties charged with ensuring that high-quality, evidence-based, cost-effective care is delivered consistently for all patients.

In addition to the physical manifestations of oncologic disease and the often very difficult treatment side-effects, many patients experience significant financial distress as a result of their diagnosis and treatment.

Patients are also often left to navigate a complex and unclear labyrinth of healthcare services on their own during a period of intense physical and emotional vulnerability-the disjointed care that is one of the most unfortunate results of the prevailing fee for service payment methodology.

In an attempt to address these issues, many experts are evaluating the potential for adoption of value-based, collaborative care payment models such as Episodes of Care/Bundled Payments as an alternative to fee for service. 

Value-based models are intended to improve patient outcomes and experiences.

They are also intended to reduce the overall cost of care by shifting focus from each unit of care rendered by every independent practitioner, also known as fee for service, to the comprehensive care rendered to each patient, across a full spectrum of providers.

The goal is to use a collaborative, multidisciplinary care model of providers who work to design practice guidelines and evidence-based algorithms that will reduce variation and optimize care, patient experiences and overall costs of care.

Success requires that all stakeholders involved, such as providers, payers and others, communicate and agree to their respective roles in delivering seamless, optimal care. 

Developing value-based reimbursement models to support patients with cancer is significantly more complicated than for other kinds of healthcare episodes or conditions.

Unlike patients who are having surgical procedures which typically are one-time procedures with discrete triggering events, patients with cancer have wide variability in disease state and progression, significant differences in treatment options and outcomes and varying start and end points of treatment.

Despite these complexities, it is possible to design effective models.

Like any other episode of care model, it needs to be structured to clearly define which criteria qualify a patient to be in the episode of care, what services are included in the model and what the start and end points are for the episode.

For example, in the case of a diagnosis of Stage 1 metastatic breast cancer, the episode could begin on the date of diagnosis, first date of treatment or on another point of care. The episode might end at the completion of an agreed upon treatment protocol and appropriate follow-up, usually using an easily administered end point such as one year after diagnosis or other starting point. 

One of the complicating factors in cancer is that stratification of the patient population requires more information than is typically on the claims data held by the payer. Because cancer-even of the same body part-is not a single diagnosis, it requires integrating clinical data with claims data in order to get to the bio-molecular level of disease-the precision required to allow clinicians to make meaningful decisions for patients with cancer.

This requires even more collaboration among clinicians and administrators than in other episodes. 

Collaborative partnerships between providers, payers and other stakeholders engaged in patients’ care are critical to ensure that models are designed to allow clinicians to make the most well-informed decisions based on patients’ specific conditions and genetic and social markers.

It also requires continuous and ongoing review and communication to revise the model as new therapies and treatment options become available.  

, according to the American Cancer Society, and total annual spending on cancer treatment in the United States 

 to exceed $170 billion by 2020, it is critical that we assiduously work to develop models that support patients as they navigate this difficult diagnosis.

In addition, it’s important they receive the precise treatment therapies for their particular disease states and situations using the most cost-effective options for care.

These models are designed to improve outcomes, patient experiences, and manage overall costs of care, and they require commitment, transparency, and collaboration among engaged stakeholders.

Lili Brillstein, an editorial advisor for Managed Healthcare Executive, is a nationally recognized thought leader in the advancement of Episodes of Care as a value-based approach for specialty care. 

She is the CEO of BCollaborative, which works with stakeholders across the healthcare continuum to successfully make the move from fee-for-service to value-based healthcare.

Predictable, seamless oncology care begins with an effective value-based reimbursement model.

Author | Lili Brillstein

Articles

Value-based care: Rethink, unclench, invite

Opinion: Let’s Remember That This Brought Out the Best in Us

Opinion: Navigating the Complexities of Value-Based Cancer Care