The core components of PROMETHEUS Analytics© provide a complete and accurate system from which decisions on incentive structures and new payment models can be made. Each of the components, which have been rigorously tested and validated, encompasses valuable elements that apply to the overall goal of reducing costs and improving quality based on existing claims data analysis.
The overarching clinical logic behind the PROMETHEUS Analytics© is based on allowing a member to have multiple open episodes that may co-exist concurrently and can be related though clinical associations. Services within an episode can be classified as either Typical or Complication, or, entire episodes themselves can also be categorized as Typical or Complication, then associated with other episodes.
Episode construction logic
The episode construction rules for the PROMETHEUS Analytics© is comprised of triggers, modifiable parameters, service assignment rules and clinical associations. Each is an important part of how episodes are assembled and analyzed.
A trigger is the signal or signals that determine when to open an episode and are classified into 4 groups: inpatient facility claim, outpatient facility claim, professional claim and episode.
The modifiable parameters allow flexibility when defining the episode-specific boundaries. These include: episode window, age ranges, coverage gaps and episode minimum and maximum costs.
Service assignments occur after all episodes have been triggered and boundary dates are set. There are four service assignment options: Typical (T), Typical with Complication (TC), Complication (C), and Unassigned (U). The claims containing relevant diagnosis, procedure or pharmacy codes are run through the service assignment rules to classify them as one of the designated options.
Clinical association allows episodes to be connected to one another based on clinical relevance. For any individual patient, conditions and treatments, all of which trigger different ECRs, are often related to one another from a clinical perspective and should be indicated as such. PROMETHEUS Analytics© takes into account these associations and link ECRs together based on the definition of typical or complication.
1) Typical association – Many procedures are done in stages, such as a bilateral knee replacement where two knee replacements are done sequentially. It is essentially the same episode done at two different times and it is important to link them.
2) Complication association – If a patient with coronary artery disease (CAD) suffers a heart attack, which is classified as a complication of CAD, the ECR will trigger an episode for myocardial infarction and, after the episode closes, link it back to the CAD episode already open for that patient.
Provider attribution assigns a patient or patient-episode to one or more providers based on the specific attribution rule used. Rules can be constructed and modified by the user in order to attribute certain episode types to certain providers. Some examples include:
- Any provider that “touches” the episode/patient can “win” the episode
- All providers with greater than 30% of costs “win” the episode
- Single providers with plurality of costs “wins” the episode
When looking to analyze episodes for budgeting or cost and quality purposes, adjusting for patient severity is a critical factor. PROMETHEUS Analytics© accommodates for this when developing expected costs. Factors for severity adjustment include: patient comorbidities, clinical severity markers, patient demographics and historic risk factors.
PROMETHEUS Analytics© creates prospective budgets that take into account a patient’s severity and include provider incentives. For each episode, patient-specific budgets are created based on expected cost of typical care, expected cost of complications, underuse allowance, complications allowance and a margin. The benefit of the prospective budget created by PROMETHEUS Analytics© is that it becomes negotiable up front when the payer contracts with the provider and can be tailored in a number of ways.