Colorado Employers, Providers Embark on Three-Year Pilot Program to Implement PROMETHEUS Payment Model 

By Hans G. Wiik, FACHE, MPH, MHA, RPh

Some employers and health care providers in Colorado are developing a new strategy for controlling costs and improving health care quality. Recognizing the need to improve the delivery of care in Colorado, The Colorado Health Foundation (TCHF) began discussions two years ago to develop a new method of delivering and paying for health care. Earlier this year, TCHF awarded the Health Care Incentives Improvement Institute (HCI3) a three-year grant to implement the PROMETHEUS Payment model in three pilot sites. One site will be in the Boulder County-North Denver area. A second will be in Colorado Springs, and a third will be in rural Alamosa, Colorado.

The Colorado effort to implement the PROMETHEUS Payment model is unusual because it is a multistakeholder initiative. HCI3 is working with the Colorado Business Group on Health, a nonprofit coalition of large purchasers of health care services, and with the integrated Physician Network (iPN), a quality improvement collaborative and physician hospital organization in the North Denver region that has more than 25 independent mutispecialty medical practices with 160 providers in more than 30 practice sites. It is a sponsored partner with Centura Health, Colorado's largest nonprofit health system. The employers and providers will work with the state's health plans to implement this system.

In this first year of the grant, we are seeking to determine how purchasers can get the most value from the PROMETHEUS Payment model. To implement this payment model, we are taking four steps this year:

1. Collecting reliable data
2. Developing partnerships
3. Sharing the savings
4. Coordinating specialist care and the transitions of care with the sponsoring hospitals.

Collecting Reliable Data
Having reliable data is one of the key deliverables for the payers and the self-funded employers involved with this project. Reliable and validated data will give us a longitudinal look at what's happening to the cost of care from a clinical and claims perspective. At iPN, we have a robust common electronic medical record system in all of our practices that provides good clinical and decision-support data. But not all provider groups in this project have such systems. For practices using paper records, we're trying to determine how to easily aggregate and analyze the clinical data we need to evaluate how these physicians have performed.

But having the software or systems in place solves only 10% of the problem. Even in different practices, we need everyone to collect data in the same way. Are the practices using validated patient registries, for example, meaning their patients are still in the practice and haven't died or moved to another doctor? Having an accurate profile of each patient is critical to our success. Also the physicians, nurse practitioners, or medical assistants who enter the data must do so in a consistent manner for each patient.

Having accurate data will drive performance and we know from past efforts that if you put garbage in, you get garbage out. Or, as our Chief Medical Officer David Ehrenberger, MD, has said, "We want to put gold in and get gold out."

Developing Partnerships
The second step involves getting the key purchasers and payers such as Cigna, Aetna, Rocky Mountain Health Plans, UnitedHealthcare, and Anthem to participate. The health plans have the patient claims we can use as baseline data.

The large employers are participating because they recognize the opportunity to cut costs. For these self-funded employers, we will work with their third-party administrators to get the financial and longitudinal data we need.

Sharing the Savings
The third step will be developing a way to share savings. Currently, when physicians and hospitals deliver appropriate care, any savings often go to the health plans. In the first year of a shared-savings model with a large self-funded school district in Boulder, we are already working with a regional provider collaborative: the Boulder Valley Care Network of hospitals, IPAs and clinics. The school disctrict has been the leader in improving the delivery of health care and is a member of the Colorado Business Group on Health. Now another large school district is considering joining this effort this year or next.

To share the savings, we will construct a risk-adjusted global budget using some of HCI3's evidence-informed case rates (ECRs) to promote coordination of care for patients with chronic conditions and reward physicians and hospitals who deliver superior care. Care coordination is particularly important for patients with chronic conditions because savings can result from preventing unnecessary emergency room visits or hospital readmissions and from reducing inappropriate surgery or imaging costs. We should reward those providers who control costs effectively while also improving patient outcomes by delivering appropriate care.

Using ECRs is different from the way most providers get paid today. Under fee-forservice systems, providers get paid for everything they do to a patient; conversely, they don't get paid for what they don't do and for the important time that could be spent in coordinating care. But to produce value for the patient and the payer, we have to reward providers for keeping patients well and coordinating what happens between office visits.

As a result of these efforts, we expect to be able to document value for all stakeholders after the third year of the grant. If all goes well over the next 30 months, we plan to report that the PROMETHEUS payment model will in fact result in better coordination of care, lower costs, and better quality through improved patient outcomes.

Hans G. Wiik, FACHE, MPH, MHA, RPh, is the president and CEO of the integrated Physician Network (iPN), a quality improvement collaborative in Denver (at www.ipn.org). He can be reached at hanswiik@centura.org.