HCI3 is currently working with several implementation partners throughout the country to pilot the PROMETHEUS Payment model.
In addition to the information presented below, please also refer to PROMETHEUS In Time for more recent updates regarding our bundled payment initiatives.
Click here to read about our foundation-funded implementation sites.
Click here to read about our implementation sites that are funded by the organizations directly participating in the pilot.
The following four implementation sites were previously funded by the Robert Wood Johnson Foundation: HealthPartners in Minnesota, Independence Blue Cross – Crozer Keystone Health System in Pennsylvania, Employers' Coalition on Health in Illinois and Priority Health – Spectrum Health in Michigan.
HealthPartners, a non-profit health plan serving Minnesota and certain counties in surrounding states, was a very early adopter of PROMETHEUS and engaged as a pilot site in the summer of 2008 while PROMETHEUS was still under development. Because HealthPartners has a very well resourced internal IT and Quality Management team, they were interested in implementing PROMETHEUS aggressively and independently. HealthPartners took the algorithms from the PROMETHEUS open-source website, and configured the acute myocardial infarction (AMI) ECR themselves, since the PROMETHEUS automated programs and SAS packages were not built at that time. The PROMETHEUS team, however, closely collaborated in the effort with HealthPartners so that the underlying principles and concepts of PROMETHEUS were maintained. Although configuring the PROMETHEUS method in its early stages of development required a fairly intensive effort on their part, HealthPartners succeeded in contracting the AMI ECR in four of their premier networks for operation in plan year 2009. With the improvements PROMETHEUS has made to the ECR software, running PAC analysis has become much easier. HealthPartners' team made a rigorous effort to investigate the outputs and to understand how PROMETHEUS ECRs can enhance their understanding of their high resource patients and to direct needed interventions better.
Independence Blue Cross (IBC), in partnership with Crozer-Keystone Health System is piloting two inpatient procedural ECRs: Hip Replacement and Knee Replacement. IBC initially decided to become engaged with the PROMETHEUS model because it offered a revenue or profit opportunity outside of the traditional unit cost increases. From IBC's perspective, the PROMETHEUS model also provided an opportunity for medical cost containment through continued collaboration of care while leveraging the PROMETHEUS team as an independent third party facilitator. From Crozer-Keystone's standpoint, the PROMETHEUS model offered a chance to get ahead of the payment reform curve, to encourage continued care coordination, and to allow for the system to distinguish itself from among its competitors in the marketplace.
The Employers Coalition on Health (ECOH), in Rockford, IL, was another original Robert Wood Johnson pilot site that attempted to implement PROMETHEUS in order to promote a patient-centered environment and help physicians act in teams – without disrupting current operations. This pilot was originally designed to drive down costs and provide a powerful catalyst for change, and supported supports the coalition's mission to continuously improve the value of health care services to member companies, employees and their families.
For those interested in a detailed analysis of this pilot, please see our recently released case study “The Rockford Prometheus Pilot”, which is available on the HCI3 website. Despite the fact that the Rockford pilot presented many challenges, the site is still viable (but not fully formed) with SwedishAmerican Health System and OSF St Anthony Medical Center participating and providing clinical data, and ECOH employers agreeing to focus on diabetes, coronary artery disease and hypertension. The pilot went live on January, 2010. The MedAssets ECR Engine ran its first alpha version in Rockford where many data defects were identified and worked through. The Rockford pilot was a critical operational learning test bed as it presaged many of the problems that would be observed in other pilot sites with regard to data integrity. Although painful at the time, it helped HCI3 and MedAssets develop workarounds and new methods for anticipating potential data defects and performing essential gap analyses. Consequently, procedures have been tightened up and streamlined. The MedAssets production Engine is now online in Rockford and has been producing quarterly reports since the spring of 2010.
Priority Health is a health plan owned by Spectrum Health, a large health system headquartered in Grand Rapids, MI. One of the original four Robert Wood Johnson-sponsored pilots, Priority / Spectrum began its pilot in the fall of 2009. After having run the PAC analysis over the Priority database, both organizations chose to pursue focusing on CHF, Diabetes, COPD, Asthma, and Colon Resection.
Priority has signed an agreement to install the MedAsset’s Prometheus Engine, a claims tracking and financial accounting system that reconciles the actual cost of care against the predicted cost of care for any given ECR. They now has access to Engine reports through the MedAssets online portal. They are going live with 6 practices as of Jan 1, 2012 (where they have case managers embedded) in an upside model only and will use the MedAssets Engine reports to track the remaining ECRs. In order to be eligible to share in the savings, physicians must come under their PAC budget and total ECR budgets. This financial reward is also tied it to a quality scorecard, where in addition to coming under their budgets, physicians must meet or exceed the prior year's quality score to be eligible for the savings. If all goes well, Priority is considering going live across the board in July 2012.
In alignment with their efforts implementing PROMETHEUS, Priority / Spectrum is working on an ambitious clinical integration/QI/transformation project called THEMIS (no relation to PROMETHEUS). It is a delivery system-wide initiative to improve care processes, streamline workflows, reduce administrative burdens and redundancy, and improve the quality of care patients receive. Although this initiative is much larger in scope, the implementation site will first focus on Diabetes, CHF, Asthma, COPD, and Colon Resection so as to be in line with the areas of focus for the Prometheus pilot. In a forward looking strategy, Priority leadership has spoken to HCI3 about the possibility of using PROMETHEUS ECRs as a means to build themselves into a regional Destination Health center.
Rising health care costs continue to put pressure on state budgets across the nation. Faced with this reality, New York State, which has the highest per capita expenditures on Medicaid and the third highest total health care costs (both public and private) per capita among states, is looking for ways to bolster efforts to contain costs.
As a result, the New York State Health Foundation (NYSHealth) provided a two-year grant to the Health Care Incentives Improvement Institute Inc. in 2009. The objective of the grant is to establish partnerships with both commercial and public insurers across the state to launch two pilot tests for reimbursement using evidence-based case rates and analyze the potential savings this strategy will generate. CDPHP, HealthNow, MVP (leveraging the NYQA database) agreed to share their data to examine the potential for a pilot implementation. A report produced for the NYSHF showed that conservatively the Capital District could achieve a $44.5 million cost reduction if PAC rates for all ECRs were reduced to the minimum national benchmarks. Downstate, Montefiore Medical Center and HealthFirst and Health Plus have also agreed to share their data for analysis. An evaluation of this pilot phase will provide State policymakers with information on where wasteful spending can be eliminated from the health care system and whether this payment strategy will motivate providers to offer high-quality care at a lower cost.
In 2010, NYSHealth funded a study conducted by The Lewin Group entitled "Bending the Health Care Cost Curve in New York State: Options for Saving Money and Improving Care." The study includes a high-level plan for adopting bundled payment methods, featuring PROMETHEUS Payment, and is also a part of NYSHealth's "Best of 2010 Annual Report."
Beginning in the summer of 2009, the Colorado Health Foundation (TCHF) and HCI3 began discussions around funding a new payment reform initiative for the state of Colorado. TCHF is a non-profit organization working to make Colorado the healthiest state in the nation. They invest in the community through grants and initiatives to health-related non-profits. Colorado Business Group on Health is a non-profit coalition representing large purchasers of health care services, who’s mission is to advance the purchaser role to accelerate cost-effective, high quality health care. They will act as a facilitator for the initiative.
Recently, HCI3 was awarded a three year grant to implement the PROMETHEUS Payment model in at least three different pilot sites across the state. HCI3 has also issued a report summarizing the findings from the data analysis, which was completed during the Planning Grant. The details of the grant proposal are as follows.
Because of the ambitious nature of the original proposal, it was decided that the funding should be broken into two grants: 1) a data gathering and analysis phase with the objective of designing two or more Prometheus pilots involving multiple stakeholders, and 2) assuming success in the study grant, a three-year implementation grant to put the Prometheus design deliverables of the study grant into motion. The grant objectives are threefold: 1) Determine the feasibility of payment reform in various Colorado communities by convening stakeholder groups that will analyze payer data and design unique implementation plans. 2) Stimulate the creation of patient-centered accountable, leading to higher quality care while controlling the increase in total cost of care. 3) Obtain buy-in from physicians, hospitals, employers and health plans as a key step to ensure a successful implementation. The study grant mainly revolves around an in-depth ECR PAC analysis, and sharing of the PAC results; HCI3 will be working with a Steering Committee to put Prometheus Payment into motion at the three pilot sites.
Recently, the Center for Improving Value in Health Care (CIVHC) and the Colorado Health Institute (CHI) released a new report that examines strategies to reform the health care payment system, how the new models are being used in Colorado and their potential impact on improving quality and controlling costs. The Report is entitled "New Approaches to Paying for Health Care: Implications for Quality Improvement and Cost Containment in Colorado", and mentions the up-and-coming pilot site in Alamosa, as well as the work being done by the Colorado Business Group on Health to implement six chronic ECRs in the Boulder and Colorado Springs regions.
The following implementation sites are being funded by the organizations directly participating in the pilot: Providence Health Plans and Providence Health and Services in Oregon, Blue Cross and Blue Shield of North Carolina and CaroMont Health in North Carolina, and Horizon Healthcare Innovations in New Jersey. In addition, Community Campaigns for Quality Care has been engaging purchasers in the West to utilize HCI3's ECR Analytics.
Providence Health Plans (PHP) is owned by a large health system, Providence Health and Services (PH&S), and operates out of Portland, Oregon. The plan is 25 years old with 800,000 members in various products such as commercial, ASO, individual, Medicare, Medicaid, worker's compensation and an HMO for Oregon state employees; it is currently doing $1.2 billion in yearly revenue. PH&S operates in 5 states with 27 hospitals, primary and specialty care clinics and serves a population of 7 million people in 30 communities.
PHP is implementing Prometheus only with its proprietary network in Portland and is not using ECRs as a direct means of reimbursement, but as a reporting mechanism in what it refers to as its Global Payment model. As a first step in creating an ACO, the PHP Global Payment model is a way of initiating a virtual PMPM whose main objective is to instill a common bottom line between the plan, hospitals and doctors. Although the 21 ECRs being implemented obviously don't cover the full PMPM, PHS is using ECRs for targeted PAC rate reductions to be coupled with improvements in clinically reported outcomes. PHP has contracted with MedAssets to plug in the Prometheus ECR Engine as a way of automating customized reports to be distributed throughout the organization as a feedback mechanism in it's pursuit of lowering cost trends and improving care outcomes. 2011 will be the first year of operationalization and PHP has even tied executive compensation bonuses to targeted PAC rate reductions; the MedAssets Engine is slated to be in full production by July, 2011.
While the Global Payment PMPM is virtual and will not put the delivery system at risk, it is intended to create savings that will be passed immediately on to PHP customers as premium reductions and enhanced reporting on what the total system is proactively doing to move towards accountable care. PHP has an ambitious program, of which Prometheus is one component, which also include building patient centered medical homes and care packages, i.e., bundled pricing, for orthopedic and cardiac procedures for transparent contracting in the larger medical marketplace.
Community Campaigns for Quality Care (CCQC), a 501c3 public charitable organization, assists government agencies, other purchasers of employee health care, unions and communities to reduce the cost of their health care by improving its quality. In 2010, CCQC began to introduce HCI3 ECR analytics to public and private sector purchasers as a clinically rigorous tool to identify Potentially Avoidable Complications (PACs) among plan beneficiaries and to use this information to promote and reward improved patient results.
CCQC has engaged the following purchasers and coalitions in projects involving HCI3 ECR analytics:
- California Public Employees Retirement System has contracted for an analysis of episode costs, PAC costs and typical care (evidence-based) costs among CalPERS’ 330,000 PPO beneficiaries. Under Dr. R. Adams Dudley’s direction, UCSF will use ECR analytics to identify improvement opportunities and CCQC will recommend interventions that CalPERS can implement to reduce PACs, based on data findings, stakeholder interviews and other research.
- Oregon Health Authority (OHA) contracted with CCQC to analyze Potentially Avoidable Complication rates among the beneficiaries of the Oregon Educators Benefit Board and the Oregon Medical Insurance Pool and to recommend interventions to drive PAC rates down. OHA purchases health care for one in four Oregonians and is at the forefront of lowering and containing costs, improving quality and increasing access to health care.
Blue Cross Blue Shield North Carolina (BCBSNC), in partnership with CaroMont Health is currently piloting one inpatient procedural ECR: Knee Replacement. The pilot officially began in April 2011.
With the changing payment and reimbursement environment, BCBSNC had an interest in promoting new care payment models in order to improve quality and provide cost-effective care for its members. As a result, BCBSNC decided to engage and test the PROMETHEUS model (beginning with Knee Replacement). They saw the model as not only innovative, but also as a means to prepare for the national changes in the payment environment.
CaroMont had recently taken steps to become an accountable care organization (ACO). In doing so, they were seeking to enhance each patient’s experience of care, to improve the health of the population, and to cut costs. After considering several alternatives, they decided to pilot bundled payments for knee replacements and entered into an agreement with BCBSNC.
In March 2012, the pilot team will evaluate the first year results and consider adopting the model for other clinical conditions, and to possibly extend this pilot beyond the first 12 months. In addition, BCBSNC is entertaining offers from other provider organizations who would also like to participate in the pilot and accept bundled payments.
Healthcare Innovations and Collaboration Highlighted in New Jersey
The wholly owned subsidiary of Horizon Healthcare Services, Inc, which was formed to energize collaborative efforts in New Jersey to improve and transform the healthcare delivery system, launched a Major Joint Replacement Episode of Care pilot program in collaboration with five orthopedic practices, representing 25 orthopedic surgeons in New Jersey.
The five partner practices and lead physicians participating in this pilot program are:
Trenton Orthopaedic Group – Mercerville and Pennington, NJ
Michael R. Duch, MD
Seaview Orthopaedic Associates – Ocean, Brick and Freehold, NJ
Arthur K. Mark, MD, FAAOS
Hunterdon Orthopedic Institute – Flemington, NJ
Robert C. More, MD
Reconstructive Orthopedics – Lumberton and Marlton, NJ
Scott D. Schoifet, MD, FACS, FAAOS
Shore Orthopaedic University Associates – Somers Point, Mays Landing, Cape May Court House and Galloway Township, NJ
Stephen J. Zabinski, MD
Through its new collaborative model, Horizon’s subsidiary hopes to improve quality outcomes, increase patient satisfaction with a more streamlined experience, and begin to control the costs of hip and knee replacements. The New Jersey pilot draws upon the knowledge and expertise of leading physicians to develop “best practices” for hip and knee replacements.
Data related to these joint replacements will be run through the Prometheus analytics and analyzed by partnering physicians on the Major Joint Replacement Clinical Advisory Panel. This panel enables the Horizon subsidiary to improve patient care and clinical outcomes and design bundled payments based on Prometheus’ episodic budgets in a collaborative manner. Horizon’s innovations subsidiary is exploring the PROMETHEUS Payment methodology for its Episode of Care pilot because of its sound severity adjustment modeling, ability to identify potentially avoidable complications and focus on quality improvement, and flexibility to meet the pilot’s needs.
Pilot participants will be required to exchange data with the Horizon subsidiary on mutually agreed upon quality metrics. The Horizon subsidiary and the participating practices will regularly review the data to help drive out inefficiencies and reduce potentially avoidable complications like hospital readmissions.
With costs rising at unsustainable rates, it's time to put payment reform into practice – and your organization can play a central role. Let us design a PROMETHEUS pilot for you. Contact us at email@example.com.