Meet the Board: Lili Brillstein, CEO of BCollaborative, Discusses Episodes of Care and the Transition of Fee for Service to Value-based Care

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Below is a brief Q&A from the interview. The text has been edited for clarity.

Q: I think you're pretty careful on using the term "episodes of care." Other people use the term "bundled payments". Why do you use the term "episodes of care?"

A: I don't use the term bundle payments very often. And there are really two reasons. The most important from my perspective is that these models are about improving quality and member experience and ultimately reducing the overall cost of care.

If you use the term bundled payment, the only thing you hear is the money. You don't hear anything about patient care and outcomes. I think we've just had so much of that in fee-for-service where all we focus on is the money, the unit cost, the unit of care. The second reason is also because in most cases, when somebody is talking about a true bundled payment, they're talking about a risk-based model, a prospective payment where a bundle of money is paid upfront. Most of the models in the country today are not prospective, there are some, but they're not many. I am a huge advocate of not starting in that space, but starting with retrospective models that don't shift risk too early. I think if you shift risk too early before you understand what the data shows, how to look at it, how to reorganize, how to communicate and collaborate, people could get hurt. Payers are at no greater risk in a retrospective upside only model than they are in fee-for-service.

Q: You say that it's very important providers and other entities who come to payers with a program, that it has to be something that the payer can administer. Can you unpack that a little bit? Also, what are the elements of the program?

A: Let me first clarify I just don't think it makes sense for payers to come to providers and other partners with a fully baked program, as well as I also I don't believe others should come to payers and other stakeholders with a completely fully baked program. I do think it's important to have a program and understand what the payer is looking for and how they're organized so you can figure out if your program fits in. I always sort of counsel my clients, as well as profit payers, if I'm working with them, to be open to the perspectives of others. Don't be too married to your program at the nth degree of your program. When you go in, be willing to listen and hear that there might be something that might make it better than you even could have thought of.

So to your question, in terms of what I think it has to have for the light bulb to go off for payers to administer that, I feel like there's two questions there: one is "what is it that needs to be there for the light bulb to go off for the payer to be tested first?" Second, "what needs to be there for the payer to be able to administer it?" For the first question, I think in terms of what the payers really want to see is that one of their primary goals is to create predictability of cost. They need to be managing their membership, make sure they have good consistent outcomes, and then they need to really manage the predictability of cost, which is why there's this initial attempt to shift the risk immediately. I think, to the extent, that the value proposition can describe for the payer, how you what the issue is, and what is the issue as it relates to the payer, which is typically what it means in terms of longer term care, longer term costs of care, what is the return and how quickly does that happen so that they can figure out.

I think to the administration question, I think it's a different question. We've all heard the jokes about "everybody's not a payer," thinking there are rooms that payers that have phones in them that just ring and nobody ever answers them and that payers just say no, because they feel like saying no. The truth is, payers often say no because either they don't really understand what you're asking them, or what you're asking of them can't be done in their systems. So as we move from fee-for-service into value-based care, we have to be really aware and thoughtful of the fact that the payer systems are all sitting on a fee for service chassis, so they can't get pay easily. Based on outcomes, they're still focused on outcomes, but the systems are focused on paying in increments. When I say it has to be administrable, I mean being thoughtful of where is the payer today. Just like the payers need to be thoughtful of where are the providers today. They're not ready to take risk, or they haven't been in a model where they don't understand the data. You have to be thoughtful about what the payer actually has to work with today so that you can get started.

I always talk about the move from fee-for-service to fee-or-value as a movement. I see it as a movement and I think we will see movement - slow steps - because the payers are big. But if you're able to speak a language, that means something to them. For me, that means always connecting the dots really well. You need to connect those dots so that the payer can actually follow your train of thought, because if you're presenting to a payer, you're not the first one that day. You're probably the fifth one that week. So make it easy for them and don't send 25 pages, send one page so they can at least understand what you're saying. Be mindful of what they have to work with.