Framework

Framework

The Framework of Prometheus Payment

The PROMETHEUS model packages payment around a comprehensive episode of medical care that covers all patient services related to a single illness or condition.

Covered services are based on commonly accepted clinical guidelines or expert opinions that define the best methods for treating a given condition from beginning to end. The prices of all treatments are tallied to generate an Evidence-informed Case Rate™ (ECR). This creates a budget for the entire care episode. ECRs include all covered services bundled across all providers that would typically treat a patient for the given condition (hospital, physicians, laboratory, pharmacy, rehabilitation facility, etc.). The ECR is adjusted for the severity and complexity of each patient’s condition.

To determine the relevant costs of a specific episode, the model separates out two types of risk.

  • Probability Risk: These are risks outside the provider’s control, assumed by the insurer.
  • Technical Risk: These are risks within a provider’s control, and therefore assumed by the provider. These include potentially avoidable complications (PACs) and other variations. PACs are deficiencies in care that cause harm to the patient, and might have been prevented with more effective treatment. An example is when a patient with diabetes needs an amputation because of uncontrolled blood sugar. We have found that up to 40 cents of each dollar spent on chronic conditions, and up to 20 cents of each dollar spent on acute hospitalizations and procedures, are because of PACs.