Chronic Medical ECRs
An Evidence-informed Case Rate™ (ECR®) is a risk-adjusted budget for an entire care episode which includes all covered services across all providers that would typically treat a patient for that condition.
Chronic medical ECRs are designed to promote coordination of care by having the entire range of services associated with the condition being derived from one bundled payment, with a reward incentive built in for physicians who deliver superior care.
PROMETHEUS Payment currently has seven chronic medical ECRs for the following conditions: Asthma, Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), Coronary Artery Disease (CAD), Diabetes, Hypertension (HTN), and Gastro-Esophageal Reflux Disease (GERD). These chronic medical ECRs are designed to span a one year time period.
ECRs are patient-specific, in that the patient's characteristics are analyzed and a payment amount is calculated based on factors such as a patient's age, risk factors, and co-morbidities. Patients with co-morbid chronic conditions are assigned to an ECR using the following hierarchy: CHF, diabetes, CAD, COPD, asthma, GERD, HTN. (i.e. A patient with both HTN and diabetes would be assigned to the diabetes ECR with HTN as a risk factor, which would be used to risk-adjust the ECR budget.)
Outpatient facility, professional and pharmacy claims are analyzed to determine a patient's condition and risk factors. These claims are then sorted into two types: typical claims and claims associated with Potentially Avoidable Complications (PACs). PACs are any events that negatively impact the patient and are potentially controllable by all of the clinicians who manage and co-manage the patient. Each ECR has an allowance to cover the cost for any PACs that occur. If PACs are reduced or eliminated, the leftover allowance is distributed amongst all providers for the patient as a bonus.
To read an example scenario of PROMETHEUS Payment in Practice relating to a Chronic Procedural ECR, click here.
Version 3.6 ECR Analytics® Freeware is available here for clinicians and practices who are interested in learning the number of eligible patients they have for any of the given chronic conditions, the breakdown of claims associated with the condition into typical services and PAC-related services, and their PAC rates.
The Chronic ECR playbooks are available below to provide detailed information regarding the outputs of the test dataset and how the ECRs are constructed.
Chronic ECR Playbooks: