CODE speaking with Lili Brillstein at the 4th Interdisciplinary Conference on Orthopedic Value Based Care 2020

Session Topics:

  • ASC Based Orthopedic Practice – The outpatient “evolution” in orthopedic surgery
  • Payers Perspective on Value-Based Contracting

Interviewee: 
Lili Brillstein, MPH
CEO, BCollaborative

Breanna Cunningham:
Hi there. This is Bre Cunningham with CODE Technology. I am here at the excellent OBVHC Conference, the 2020 conference. They keep changing up the acronyms, so it gets a little challenging there, but I’m excited to be here on behalf of Dr. Kain and very excited to be interviewing Lili Brillstein who is the CEO of BCollaborative, a world-renowned expert in bundles. She was dealing with episodes well before they were trendy. She has vast experience working with Blue Cross Blue Shield in New Jersey, Horizon Care, is that correct?

Lili Brillstein:
Right, yeah.

Breanna Cunningham:
For 14 years designing bundles in ortho and outside of ortho, and I’m so excited to talk with you Lili.

Lili Brillstein:
Thank you. It’s so nice to be here. Thanks for having me.

Breanna Cunningham:
So, my first question that I have for you is to tell me about your journey of your new company of BCollaborative and how that came about.

Lili Brillstein:
So, it’s great fun. I’m having the best time ever. I spent, actually, seven years at Horizon working as the Director of the Episodes of Care program, and I had the best time there. I loved it. I loved the work that we did and the spirit of the work. I come from a public health background, so being able to really do work that I know puts good into the world and improves outcomes for patients and their experience while also reducing the cost of care was my dream job. It was great fun.

Lili Brillstein:
And so I left, I was there for about seven years. I just left this past July to start BCollaborative. And really the reason was I wanted to … Well, let me say it differently, a lot of the time that I spent at Horizon, one of the ways I was able to grow the program was I was out a lot. I would talk to people, I would try to understand the needs of the various stakeholders and what was happening around the country and some other programs. I would share what we were doing and I would bring stuff back home.

And so through a lot of that discussion, we got a lot of press, a lot of awareness around the program. And I really, really wanted the opportunity because we’d created so much success at Horizon to be able to share that around the country with other payers and stakeholders, so that they could come into the models, right, and begin to participate in an active way in the movement from fee for service to fee for value.

So, I am so delighted to say that I’m working with payers and providers and Pharma and a number of startup companies really with all of them to craft their strategy around value based model design and engagement.

Breanna Cunningham:
Wow. So interesting and so needed with where we’re at in medicine today and the shift to alternative payment models. So you do work in ortho, which I think a lot of people are familiar with bundles and how that relates in the orthopedic space. But you also do a lot of work outside of ortho in different specialties. So, I’d love to hear from you some of the nuances, what’s similar between the two, what’s different and what are we still trying to figure out?

Lili Brillstein:
So, it’s a great question. Lots of places including Horizon start their episodes programs with ortho procedural episodes, hip replacement, knee replacement. And the reason for that is A, there are tons of them and there’s tons of variation in care and cost of care, but they’re also very easy to define, right? You have a surgical procedure, you have the prehab and you have the post-acute care portion of the episode. So, typically 120 days, something like that. And you can capture everything that happens to the patient related to that ortho procedure and then it’s over. The patient has the procedure and it’s over. And they’re easy to measure, right? They’re easy to measure what success looks like. So-

Breanna Cunningham:
It’s a great surgery too, we’ve got outcomes.

Lili Brillstein:
Exactly right. And, I always say with patient experience, you have to be careful how you ask and what you ask, right?

Breanna Cunningham:
Sure.

Lili Brillstein:
In ortho procedures patients are usually very happy, right? Because now they can walk when they might not have versus if they had cabbage, they can’t eat pizza anymore and maybe that doesn’t make them happy. So, you have to be thoughtful about what patient satisfaction looks like in each of these episodes. But talking about different kinds of episodes, so I’ve built models that are not just procedural but acute care and chronic condition episodes.

So, episodes around oncology, cardiology, GI, maternity, lots of things. And what happens is the things that are not surgical in nature are a little messier. They don’t lend themselves quite as easily to being so defined so crystal clear, but the criteria for the design is the same.

So, if you follow that methodology and you say, well what do I need? I need to understand what’s the criteria that land someone in the episode in the first place. Is it a diagnosis? If it’s oncology, is it the date of diagnosis? Is it the first date of chemotherapy? Is it a surgical date? What actually gets them in there? And then also what’s the first day we’re going to measure?

So again, are we measuring from the date of diagnosis, maybe a diagnosis of metastatic breast cancer is what qualifies a patient to be in the episode. But maybe the first day we measure is the first date of treatment or something. And then we have to figure out what’s the last day, how long do we measure it? Again, the same as in a procedural episode, it’s just, it’s a more natural end for the procedural episode as opposed to chronic where you need to figure out some sort of artificial way to create a time period where you have clinically similar patients in a clinically similar time of their disease state so that you know you’re measuring the apples against the apples essentially.

Breanna Cunningham:
Well, so your clients are early adopters outside of ortho of this. So, five years from now when we look back, what are the areas that are going to have released sophisticated bundles and alternative payment models that are like ortho, right? There’s BPCI, there’s CJ, there are government programs. I mean, we say it’s APM.. with ortho. What are we going to see in five years? What are the big patient populations where we’re going to have bundles nailed down? Episodes of care I should say.

Lili Brillstein:
Yes. I always call them episodes of care, I don’t like the term bundle payments.

Breanna Cunningham:
I know you don’t, I’m sorry.

Lili Brillstein:
No, no, it’s okay. It’s so funny, everybody’s always apologizing to me for that. The reason I don’t is because I think these models are so much about improving patient outcomes and the patient experience and if we use the term bundle payments, the only thing you hear is the money.

Breanna Cunningham:
Absolutely.

Lili Brillstein:
So that’s why, and typically people are talking about risk-based models when they’re talking about bundles, but the question is really interesting and my answer is different than it might’ve been a couple of years ago. So genuinely my advice would never start with chronic conditions. That just would not be where I would ever advise anyone to start because they’re hard, they’re more nuanced. They’re harder to define.

However, a lot of plans are extremely concerned around oncology, around a lot of rheumatology and other chronic conditions today, IBD. And so, they’re talking to me and they’re talking to their prospective partners about how to actually build Value Based Care models around chronic conditions because so many of their members, their patients are affected by it. The cost is astronomical. There are constantly new therapies and drugs being introduced and it’s very hard for plans to wrap their arms around that.

And one of the things these models do, particularly the risk-based models, is creating some predictability of cost, which is what the health plans want, right? That’s really important to their business model. And so, while I’m not a fan of starting with risk-based models, I’m a real fan of starting where there’s no additional risk shifted to the providers. So, you create a level playing field and an opportunity for everybody to learn together how to create success.

I do think in five years from now or so, we’re going to see a lot more chronic condition episodes than I would’ve thought we would have. And I think we’ll begin to see some thoughtful risk-based models that hopefully will have come after some numerous models so that the partnerships can be solidified, the collaboration. I think if you go too fast you lose the opportunity to really partner and collaborate, which is really important in these models.

Breanna Cunningham:
That surprises me. I thought you were going to say something more specific like cancer where there is a more clear trigger point. So, that’s interesting. So my final question for you-

Lili Brillstein:
Let me just say, I do think cancer is one of those. Yeah, I do think cancer is one of those.

Breanna Cunningham:
Okay. That makes sense. The rheumatoid and IBS, that’s huge. Because my final question for you is related to risk. So, when you’re dealing with providers that are new to, they’re switching from fee for service into an episode of care type contract, what did they need to know about risk?

Lili Brillstein:
So, that’s a great question, a really important one. There are lots of folks around the country. Actually I was challenged for many years around the country around why I was building models that really didn’t have a risk component. And the question was, isn’t it true that the only time you see real change is when the providers are at risk? And the answer from my perspective is no. That I have seen tremendous success in building models that have no additional risk shifted to the provider, which really means the payer continues to hold the risk just as they do today. They’re not in any more risk in these models.

Lili Brillstein:
And it provides an opportunity, as I said earlier, really for everybody to figure out together to study the data that gets shared by the provider, that longitudinal view of the patient and be able to understand … Lots of times every doc, mostly every doc wants to take the best care of their patients, but they don’t know that what they’re doing to their patients is different from what their partner is doing or is different from another practice. And they don’t know the impact that has on the outcomes or on the cost until they see the data. And that’s what the payer partner can bring to the table, right? They have that, that longitudinal view of both.

Breanna Cunningham:
It was, what do providers need to know new into this? And I also think it’s probably the first time they’d been exposed to this data like year one, right? They might think they know, but.

Lili Brillstein:
No, you’re exactly right. The providers haven’t seen the data, payers haven’t really been willing or able to share it. And, this all really requires a lot of transparency. What the docs need to see, the clinicians need to be able to see, when we’re talking about specialty care value based models, which is different than population health. In these models, in episodes, you’re talking about a clinically homogeneous population or a homogeneous population in some way, right? They’re stratified.

Lili Brillstein:
The idea is to reduce the variation in care and costs of care and optimize both of those. And that’s what the docs don’t, they don’t even know what exists until they see the data. And then there’s almost this immediate, oh we can address that, or oh we know how to … I didn’t realize that was happening, or oh we can use this drug or change to this side of service or not refer to this doc or.

Lili Brillstein:
So, they need the data and they need the data in a way that’s meaningful for them. So just to give them, provide an overall cost for an entire episode is not really meaningful. They need to be able to see in some sort of group by types of service, where are the costs, what’s driving those variations? Is it the inpatient, is it the outpatient, is it the meds, is it the prehab? What is it? So for sure it’s data and it’s data across the full continuum, I would say that is number one that they need to be able to see.

Breanna Cunningham:
That is great advice. Well, thank you so much Lili, this has been a pleasure.

Lili Brillstein:
Thank you.

Breanna Cunningham:
I look forward to following Bcollaborative and learning more about what you guys are doing and thank you for your time.

Lili Brillstein:
Thank you so much. I so appreciate it.

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