STEP 2: Engaged Providers and Payers
Following letters of commitment, pilot sites should begin to engage the providers and
payers that will be part of the pilot. They can do this through an Implementation Kickoff Meeting. This meeting can either be a high level concept review of PROMETHEUS and BTE or it can be more granular and used as a forum to present the results of the initial data analysis. In either case, it is critical to have senior leadership in the room – ideally, representatives from all participating entities in the pilot will be present, including leaders from the health plan(s), employer groups, provider organizations, and hospitals. This meeting can be used to fill in the providers and payers on the findings of the initial data analysis.
LESSON LEARNED: ENGAGED PAYERS AND PROVIDERS
It is essential that both the payer and provider are interested in and motivated to implement PROMETHEUS. For instance, if only the payer is engaged in PROMETHEUS, this presents a problem since the payer and the HCI3 team will have to take time and resources to engage the provider, when there really is little interest there to begin with. At least one of the pilot sites experienced “lulls” throughout the implementation process of 6 months or more with little progress being made, due to low interest alternating on both the payer and provider side. On-going education of both the provider and payer following a successful initial data analysis can foster interest and increase motivation.
Educating the providers and payers is also important. Providers should be informed of the clinical quality measures that will be used as well as have a basic understanding of the PROMETHEUS concept. Payers, too, should be well versed in the overall concept of bundled payment and should acquire a deeper knowledge of the PROMETHEUS Evidence Informed Case Rate (ECR) payment model. Both groups should be educated on the basics of PROMETHEUS and BTE, and why it is urgent for their organizations to improve quality of care services and cost efficiency. The results of the initial data analyses can be presented to both providers and payers in formats that resonate with each party. For example, providers may want to drill down into the details behind Potentially Avoidable Complications (PACs) and examine the top drivers of PACs within their patient populations. They may be interested in targeting patients with high risk factor counts for disease management and care coordination. Payers may want to review both PAC costs and Typical costs to determine sources of variation in episodes. Variation may stem from differences in patient severity, pricing structure, performance, and provider practice patterns.
While the PROMETHEUS Payment model aims to incentivize providers and payers to reduce the dollars spend on PACs, another key aspect of the model ensures that a minimum quality threshold is adhered to. Providers must submit data from their medical records for performance assessment and need to do so via an electronic medical record or registry capable of collecting and reporting clinical data in a format suitable for the implementation, as outlined by the Policy and Procedures documents linked below. Click here to view which EMR vendors are approved by BTE.
LESSON LEARNED: Having a good EMR to collect and report on clinical quality
It is required that any providers participating in PROMETHEUS have a BTE-approved EMR vendor. Providers that have paper-based medical records will not be able to participate, due to the amount of time and resources it would take to pull data on an on-going basis, especially once PROMETHEUS goes live. Having a good EMR system decreases the delay in providing feedback to the organization, which accelerates change.
Upon studying the results of the initial data analysis and learning where improvements can be made in care quality, we want pilot sites to make these improvements happen. Providers involved with the program must make sure they have or will be able to obtain the resources required to improve care upon finding the results of their data analysis. For instance, this would involve having a quality improvement department, infection control teams, disease management programs and case management models. Providers could also implement workflow improvement, process/systems improvement, checklists, population management/outreach, or increase access to their facilities. They could also engage in practice re-engineering such as care coordination, patient education for proactive care, nurse help lines, after hours office timings, and more emphasis on preventative care.
Case Study: SwedishAmerican Health System
SwedishAmerican is a health system located in Rockford, IL that is currently participating in a PROMETHEUS pilot with the Employer’s Coalition on Health. The health system has been actively involved in collecting clinical quality data for performance assessment as part of the pilot. Upon receiving their baseline quality scorecard, SwedishAmerican was able to identify areas for improvement within the domains for which they submitted clinical data: Diabetes, Coronary Artery Disease, and Hypertension. The collection, submission, and reporting of these data allowed SwedishAmerican to confirm areas where they knew they were performing well and also confirm areas in which they saw room for improvement. Right away, the health system identified the need to obtain continuous quality feedback in these domains and not just sit back and wait for an annual report. As such, they are currently considering the process of submitting their quality data on a more frequent basis in order to track performance throughout the year and work towards the implementation of various quality improvement initiatives.
Additionally, SwedishAmerican played an active role in reviewing claims data via the ECR Engine. They identified both the quality data and claims data as critical pieces of information that could help them to improve quality of care and reduce costs. They are currently in the process of an in depth analysis of the episodes of care that are present in their data from 2009-2010. They plan to use the utilization information as a means by which they can target patients for disease management and intensive case management programs. They also plan to select a subset of cases within each report to perform a comparative analysis between the claims data and medical record data.
Case Study: Spectrum Health
Spectrum Health, a delivery system based out of Grand Rapids, MI has partnered with Priority Health to pilot the PROMETHEUS payment model. PROMETHEUS has become part of an overall initiative to move to an integrated delivery system, called THEMIS. Spectrum Health has embarked on an ambitious plan to evaluate and enhance the delivery of care throughout the entire health system. They have partnered with Priority on an impressive case management model that seeks to lessen redundant efforts between the organizations and leverage the experience both bring to the table to reduce gaps in care.
Useful Documents to help educate providers and payers on PROMETHEUS:
PROMETHEUS Payment Model This document outlines the methodology behind PROMETHEUS.
PROMETHEUS Payment: What’s the Score?
This document explains the methods behind the PROMETHEUS Scorecard. It will be useful for educating providers and payers on the basics of PROMETHEUS.
Sustaining the Medical Home: How PROMETHEUS Payment Can Revitalize Primary Care This document will be useful in educating Providers on the benefits of Prometheus.
Sample PROMETHEUS Case Studies for Diabetes, CHF, Bypass Surgery, and Knee Replacement.
Clinician Assessment Guides for Asthma, Cardiac, CHF, COPD, CAD, Diabetes, and Hypertension. These guides are useful for educating Providers on the clinical quality measures for each BTE Care Recognition Program.
Useful Documents that will provide a deeper look into PROMETHEUS:
Locations for Playbooks: Chronic, Inpatient Procedural, Outpatient Procedural, and Acute Medical These Playbooks contain information on the parameters of each ECR, as well as the clinical guidelines that were used to inform the resource use for the base typical portion of the budgets. They also contain the all codes files, which determine what is a PAC, what is Typical, what should be Excluded, etc.
History of PAC Development This document explains how Potentially Avoidable Complications (PACs) were developed.
Evidence-Informed Case Rates: A New Health Care Payment Model This document explains in detail the concepts behind Evidence-Informed Case Rates, or ECRs.
Reliability of PROMETHEUS Measures
Severity Adjustment Fact Sheet
Don’t Severity Adjust PAC Costs
Added Facility Costs due to PACs
Improving Quality in Health care:
PRHI Readmission Reduction Guide: A Manual for Preventing Hospitalizations
National Business Coalition on Health Case Studies for Value Based Purchasing
Other tools:
Policy and Procedures (P&P) documents for BTE Care Recognition Programs: Asthma, Cardiac, Congestive Heart Failure, COPD, Coronary Artery Disease, Diabetes, Hypertension
For each program there is a Policy and Procedures document which outlines all the details of the program as it pertains to data aggregators, including specifications for each of the clinical measures. The P&P will outline the details you’ll need to know to map your data to meet the submission requirements.
File formats for BTE Care Recognition Programs: Asthma, CAD, Cardiac, CHF, COPD, Diabetes, Hypertension
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