Implementations

Implementations

PROMETHEUS in Time: Current Status of Implementations and Analytic Activities Around the Nation

Since its inception in 2007, PROMETHEUS Payment has made significant strides as an operational payment model. A good synopsis of the progress made is recounted in a recently released HCI3 paper, “That Was Then, This Is Now: The Progression of PROMETHEUS Payment.” This paper details the maturation of a small, philanthropically funded non-profit moving episode of care payment into a national market embedded in 70 years of fee-for-service infrastructure and cultural inertia. Among none of the founding members of PROMETHEUS was there ever an expectation that it was possible to dramatically impact such a vast ship of state overnight. We did believe, however, that it was possible to demonstrate proof of operational concept in a handful of pilot site implementations. For some observers, this may seem to be a modest series of accomplishments. But for anybody working in the field trying to improve even small pieces of the broken American healthcare behemoth, it was certainly most challenging, and absent the participation of Medicare or Medicaid, would continue to be so for some time to come. What follows is a brief structural update, by region, of PROMETHEUS implementations, analytical activities, RWJF AF4Q Technical Assistance, and ECR Engine installations. It should be noted, however, that where real progress has been made, we are limited in what we can say because of organizational sensitivities around such topics as contracting and cost data outcomes. No doubt, as program confidence builds, comfort in public statements will emerge in due time.

Current Implementations

The Pennsylvania Employees Benefit Trust Fund (PEBTF) administers health care benefits to approximately 77,000 eligible Commonwealth of Pennsylvania employees and their dependents and 63,000 retirees and their dependents, as well as additional employer groups. PEBTF has teamed with the Orthopedic Institute of Pennsylvania (OIP) and Pinnacle Health to implement both hip and knee replacement surgery bundles. These bundles include a look back period of 30 days prior to the surgery and 90 days following the procedure. The bundle includes all relevant services to the joint replacement including the inpatient admission, imaging studies, home health, skilled nursing facility stays, physical therapy, and any complications such as emergency room visits or readmissions.

Each patient in the bundle program receives a customized budget for their total cost of care based on the patient’s historic risk factors. Risk factors are identified using the patient’s medical history to accommodate any comorbidities or existing diagnoses. Once the patient’s course of treatment is complete, an analysis is performed to compare the budgeted costs to actual costs. Providers will be eligible for incentives if the cost of care comes in at an aggregate total that is less than the anticipated costs based on the budgets. Providers will also be required to meet quality measures to receive any incentive payments.

In an effort to help providers deliver cost-effective and high quality care, each participating partner in the bundle was given an in-depth review of their historical costs and quality scores. As such, potential savings are achieved through a decrease in potentially avoidable complications (PACs) or reduction in the utilization of high-cost services such as skilled-nursing facilities.

The 1-year pilot program will be completed on December 31, 2015. It will be followed by case study that will be published here in 2016 that will evaluate the implementation focusing on the process, lessons learned, and pre and post implementation outcomes.  If the pilot is successful, PEBTF would like to have it inform future contracts with the provider groups, with a shared savings component built in. Working with the Orthopedic Institute of Pennsylvania (OIP) and Pinnacle Health to implement both hip and knee replacement surgery bundles. The Year 1 pilot ends December 31 2015.

The Community Health Choice (CHC) in Houston Texas is a nonprofit insurer covering 300,000 lives, two-thirds of them in Medicaid, and maintains a specialty with Children’s Health Insurance Program (CHIP) perinatal patients. CHC manages more than 25,000 births each year.

CHC is working with two major health systems and obstetric practices (University of Texas Medical Branch (UTMB) and the University of Texas Health Science Center (UT Health) to implement maternity care bundles. The maternity care bundle includes the pregnancy, delivery with a post-discharge period of 60 days, and neonate care for the first 30 days of life. The implementation includes a quality scorecard and patient outcomes survey covering key quality metrics for prenatal and post partum care outcomes that will be used to determine the cost sharing amounts in the second year of implementation. The participating physicians helped choose the quality metrics and will select their own methods of adjusting clinical care to meet the financial and quality goals.

The budgets for the bundle are based on a blended historic cesarean section and vaginal delivery rate. As such, potential savings are achieved through lowering the unwarranted cesarean section rate. Additionally, savings are achieved through a decrease in the potentially avoidable complication rate during the pregnancy and the delivery. The year 1 implementation ends March 2016 with an upside only reconciliation. The intention is to move to both upside and downside in year 2.

CHC was interested in pursuing bundled payments as a new way to reduce medical costs while at the same time improving the quality of care for its pregnant patients.. A case study will be published here in 2016 that will evaluate year 1 of the implementation focusing on the process, lessons learned, and pre and post implementation outcomes. If the pilot is successful, the insurer would like to have it inform future contracts with the provider groups, with a shared savings component built in.

Previous Implementations

The Northeast Region

PROMETHEUS activities in the Northeast have been primarily located in the state of New York funded by the New York State Health Foundation (NYSHealth) which provided a two-year grant to HCI3 in 2009 to establish partnerships in two pilot sites with both commercial and public insurers across the state using evidence-based case rates (ECRs). The Capital District Physicians Health Plan, HealthNow, MVP Health Care (leveraging the New York Quality Alliance database) agreed to share their data to examine the potential for a pilot implementation. The resulting study showed that the Capital District could achieve at least 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 also agreed to share their data for analysis. An evaluation of this pilot phase could 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.

Additionally, HCI3 completed PAC analysis and presented the results to HealthFirst in early November, 2011. HealthFirst was interested in understanding how PROMTHEUS ECR drill-downs can be used to identify and quantify differences across providers in the cost of treating certain conditions. Differences across providers point to potential target areas for improving care delivery and lowering costs. Rather than use PROMETHEUS to determine episode budgets for bundled payment, HealthFirst used the model to report back to its provider groups on variation in costs and the incidence of PACs in an effort to assist its providers in improving health care delivery and outcomes. This is a common first phase implementation step in many pilots as plans and providers see value in establishing new feedback loops as a prerequisite to payment change. The analysis demonstrated that the high prevalence of diabetes combined with a relatively high potentially avoidable complications (PAC) percentage provided the greatest opportunity for savings and care improvement. Consistent with a recently published paper, this analyses showed that there was as much as a 70% difference in the costs of treating diabetes across various HealthFirst providers, even after adjusting for differences in severity, and that these differences were primarily due to differences in the costs of PACs.

In November 2011, HCI3 presented results of data analysis to HealthNow, focusing on one inpatient procedure (CABG) and one outpatient procedure (Angioplasty (PCI)), and comparing some of the major health systems in the Buffalo area. This highlights opportunities for improvement in care delivery and targets areas for reduction in potentially avoidable complications (PACs).

Under a Technical Assistance contract with the National Program Office managing RWJF’s AF4Q effort, HCI3 has been working with several AF4Q sites to perform cost / trend analysis. One of these sites is Maine. In addition to their work on Bridges to Excellence (BTE) quality measurement, Maine is exploring using the PROMETHEUS model to evaluate episode of care using their All Payer Claims Database (APCD) for Medicare, Medicaid and the commercial population.

The Mid-Atlantic Region

The Crozer-Keystone Health System (CKHS, located in southeastern PA) and Independence Blue Cross (IBC, a large Blue plan operating primarily in southeastern PA) have been working with HCI3 to assemble a total hip / total knee (TKR) ECR arrangement. The CKHS / IBC dyad is a perfect example of where some observers may conclude that progress has been slow and modest. But from our point of view, the time taken has been very valuable. Both organizations, while being cautious, have been extremely cooperative in vetting PROMETHEUS and making good suggestions for improvement (all of which have been incorporated into the most recent modifications of the PROMETHEUS TKR episode).

The target population for the TKR contract is IBC’s commercial and Medicare beneficiaries. Both parties made two important modifications to the PROMETHEUS TKR ECR in that they changed the episode post-discharge tail to 90 days from 180 days (analysis showed that nearly all TKR episode costs could be efficiently captured in that time frame), and they added a DRG filter to exclude bilateral replacement cases. Both modifications create a much tighter bundle.

On September 6th, 2011, the two organizations began a non-paying shadow-pricing period based on a case rate with 100% PAC amount and a 50-50 gainshare target. In the PROMETHEUS standard transitional model, it is common for payers and providers to contemplate an ECR “observation” period before placing actual dollars at stake. The observation period gives both parties a chance to better understand episode of care pricing dynamics and to learn how to manage ECR Engine outputs (although IBC is not currently hooked up to an automated episode claims Engine, but rather using the ECR analytic program for reporting and reconciliation).

Under the arrangement, CKHS flags potential TKR patients and relays the patient IDs to IBC. Using outputs from the PROMETHEUS software, IBC manually creates unique, patient-specific budgets and sends them back to CKHS to be shared with orthopedic surgeons. IBC will also creatie interim reports on accumulated TKR costs against predicted budgets on a monthly basis. As part of this process, HCI3 has been working with CKHS and MedTrak, a data collection software firm, to review potential quality data metrics for TKR. Importantly, CKHS filed a letter of intent to participate in the CMMI Bundled Payment pilot.

Horizon Healthcare Innovations, a subsidiary of Horizon BCBS of New Jersey, also worked with HCI3 on joint replacement (total hip and total knee) bundles for their commercial and Medicare populations (with a diagnosis of osteoarthritis). Horizon has launched its efforts in collaboration with 5 area orthopedic practices. The pilot unfolded in three phases.

Phase 1 began in January 2011. It entailed formation of a Clinical Advisory Panel (CAP) with a physician lead from each pilot practice participating. The CAP provided regular input into the pilot design including identification of clinical best practices and efficiency opportunities. They also developed and agreed on clinical metrics and reporting requirements (e.g. never events and DVT/PE prophylaxis) for inclusion in the pilot. Phase 1 also established a Research Data Exchange process in which the practices shared administrative and clinical data for eligible patients with Horizon. The CAP agreed in this phase to employ the PROMETHEUS methodology for retrospective claims analysis and severity adjusting budgets.

Phase 2 began in July of 2011 and is working to validate the outcomes-based payment model. Patients continue to be flagged for inclusion in the pilot. The Research Data Exchange is now being operated through a clinical data portal (rather than the initial manual data collection). As IBC is doing, budgets are created manually using the PROMETHEUS analytics package and shared with the physicians. They are then reconciled on a quarterly basis. The budgets are constructed according to the constructs agreed upon by the CAP in Phase 1. They are based on each practice’s historical data, so that improvements can be measured in terms of each practice’s unique baseline. It is a shared savings model (upside only — if practices exceed budgets, they will not be at risk); both quality and cost targets must be met or exceeded for shared savings to be distributed—a consistent PROMETHEUS payment principle. Horizon is currently considering bringing in additional orthopedic practices as well as expanding the range of ECRs they are piloting. It is the intention that Phase 3 will ultimately create a true bundled payment with risk sharing.

The Pennsylvania Employees Benefit Trust Fund (PEBTF) administers health care benefits to eligible Commonwealth of Pennsylvania employees, retirees and their dependents, and since 2010 has deployed the BTE Excellence in Chronic Care program for diabetes, coronary artery disease, hypertension, congestive heart failure, asthma and chronic obstructive pulmonary disease. All participating practices were required to submit Year 1 quality data (calendar year 2010) in Q1 2011 (for the programs for which they had enough eligible patients). These data were scored and patient-mix-weighted so that scorecards could be created. PEBTF bases participating provider rewards on PROMETHEUS ECR analytics specifically aimed at PAC rate reductions, which are split into fixed and variable rewards. Fixed rewards were paid at end of Q2 2011. So far, four practices have received rewards, and between those four, 10 clinicians received 25 different BTE care recognitions. Additionally, HCI3 has been running PEBTF data to look at year-over-year trends in episode costs and determine areas of opportunity for bundled payment pilots, with preliminary interest being in hips and knees. The current resulting PEBTF pilot is described above under Current Pilot Implementations.

The Midwest Region

Priority Health is a health plan owned by Spectrum Health, a large health system headquartered in Grand Rapids, MI. One of the original four RWJF-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 focus on CHF, Diabetes, COPD, Asthma, and Colon Resection. Priority connected to the MedAssets Bundling Engine (which included the PROMETHEUS ECR definitions) and as a result had access to Engine reports through the MedAssets online portal. They went live with 6 practices as of Jan 1, 2012 (in which they have embedded case managers) in an upside model only. In alignment with their efforts implementing PROMETHEUS, Priority / Spectrum worked on an ambitious clinical integration/QI/transformation project called THEMIS. 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.

Of interest, Spectrum Health has submitted an LOI for the CMMI bundled payment pilots. Priority is supporting Spectrum along with 3 other health systems in Michigan who have also submitted LOIs. Priority’s goal is to set up parallel pilots with the other systems (that mirror what they intend to do with CMS) within their commercial and Medicare Advantage populations.

The Employers Coalition on Health (ECOH), in Rockford, IL, was another original RWJF pilot site. For those interested in a detailed analysis of this pilot, please see our case study “Rockford-CaseStudy”. Despite the many challenges encountered during the Rockford implementation, the pilot progressed 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 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 painstaking, it helped HCI3 and MedAssets develop workarounds and new methods for anticipating potential data defects and performing essential gap analyses. Consequently, procedures have been significantly streamlined.

Cox HealthPlans is another provider-owned health plan (CoxHealth) operating in Springfield, MO. Cox completed its PAC analysis on 24 months of claims data and presented the results this year to the CoxHealth Joint Operating Committee (the JOC is the operating system at CoxHealth representing the hospital, primary care, and specialty care divisions). Cox is plugging into the MedAssets ECR Engine to support the implementation of 4 chronic episodes: diabetes, asthma, hypertension, and congestive heart failure. The PROMETHEUS ECRs will be placed into production via a pilot with the health system employee health plan (12,000 members) using a narrow network of CoxHealth physicians. The health plan is concurrently working on an innovative operating system for the commercial market designed to create engagement at the member level. Moreover, Cox HealthPlans submitted a Letter of Intent for CMMI’s bundled payment pilot with plans to function as a convener for CoxHealth providers; the research protocol was submitted using DRGs mapped to 8 PROMETHEUS ECRs (pulled from the HCI3 website). Cox will have the Medicare data shipped directly to MedAssets for PAC analysis and discounted price estimation. Cox HealthPlans and Cox Health are entertaining plans to form a jointly held LLC to manage risk under the CMMI pilot.

HealthPartners is 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.

In late 2009, the Governor of MN and his staff announced a series of bold initiatives focused on instituting value-based payment in the state. One of those initiatives was to define and then implement “care baskets” that would cover a number of chronic and procedural episodes. As a result, HealthPartners wisely decided to focus on the statewide initiative rather than continuing an independent effort.

The Midwest region was also an active user of HCI3 technical assistance in the Cincinnati AF4Q site, focusing on BTE diabetes and cardiac measures. The AF4Q leadership assembled local stakeholders to examine community-wide metrics, asking HCI3 to perform a first round of PAC analysis for them, which included aggregated claims data from United, Humana and Anthem. At that juncture, it was not possible to obtain cost data, so HCI3 focused the analyses on utilization metrics such as PACs per 1,000, Emergency Department visits per 1,000, Facility Admissions per 1,000, and Average Lengths of Stay. HCI3 also looked at PCMH vs. Non-PCMH results. As of this writing, HCI3 is waiting for a refreshed round of data from the 3 plans noted above as well as HealthSpan and Aetna with an eye towards performing the same kind of frequency analysis and writing up a more comprehensive report for the community. It is hoped that stakeholders will see the need to complement frequency analysis with cost data.

In addition, HCI3 is supporting the Wisconsin AF4Q team in the implementation of two bundled payment projects. The first is focused on total knee replacements and the second on diabetes care. Local plans, including Anthem BCBS are actively participating in defining bundled payment contracts with willing providers.

The Southeast Region

Blue Cross Blue Shield of North Carolina (BCBSNC) has been working with HCI3 for several years through its BTE provider measurement and reward programs, and in 2011 kicked it up a notch by accessing the entire suite of tools and programs, including PROMETHEUS. In order to get ahead of the payment reform curve, BCBSNC decided to initially focus on procedural ECRs. The plan (which is the most dominant payer in North Carolina) performed extensive analysis on these types of episodes, eventually landing on TKR. BCBSNC considered this ECR to be a good first step in bundled payment. Although BCBSNC is currently exploring pilots with several health systems/hospitals in North Carolina, they began their first official implementation in April 2011 with the CaroMont Health System located in Gastonia, NC. In what has to be a PROMETHEUS pilot site record, BCBSNC began their contract negotiations with CaroMont in January 2011, with a 90-day timeline of moving to implementation – and succeeded! The contracting process included:

  • Engagement of all providers
  • Analysis of specific data
  • Data sharing
  • Development of quality metrics with participating providers
  • Rate development and negotiation
  • Addendum to provider agreements

CaroMont implemented the PROMETHEUS model with BCBSNC for four reasons. First, BCBSNC and CaroMont both believed that payment redesign and delivery system redesign go hand-in-hand (keeping the Triple Aim in mind). Second, orthopedic surgeons and anesthesiologists are independent community physicians, and an episode of care payment model encouraged the hospital and physicians to better collaborate on a clinical basis. (As a matter of fact, community physicians actually led the care redesign process.) Third, CaroMont perceived the PROMETHEUS model as a critical step in becoming an ACO. Fourth, and finally, the project served as a good faith demonstration to show how both CaroMont and BCBSNC are responding to recent health reform legislation passed by the state of North Carolina and community concerns about pressing economic challenges.

The Western Region

In March of 2011, The Colorado Health Foundation (TCHF) announced that it would underwrite a three-year grant to support HCI3 and the Colorado Business Group on Health (CBGH) to implement a multi-stakeholder collaborative around PROMETHEUS chronic ECRs. The three-year grant followed closely on the heels of an earlier TCHF grant for HCI3 and CBGH to perform PAC analysis for interested plans operating in Colorado, including Medicaid. The purpose of the first grant was to familiarize payers and providers with the PROMETHEUS concept and to test whether they would be willing to move forward towards implementation. Having past that test, the Foundation funded a three-site implementation grant: North Denver, Colorado Springs and Alamosa.

Although the feasibility study took sixty days longer than anticipated, data from five commercial health plans plus Medicaid were analyzed and providers in several locations submitted proposals for piloting PROMETHEUS. Since beginning the Colorado pilots, HCI3 and CBGH together put in place several critical components for piloting Prometheus . These include:

  • Employer Commitments and Approach. Employers have executed letters of intent, based on draft calculations of their ROI derived from the feasibility analysis, to pilot and participate initiatives in both Colorado Springs and Boulder/Longmont. They have agreed to pool data to achieve statistical significance, commit to common scorecard measures and targets as well as employ common Incentives across their communities and plan for benefit design changes supportive of patient compliance/engagement.
  • Payer Claims Feedback Strategy Developed and Underway. Two principle steps have been taken to assure the availability of PAC drill-down data on an on-going basis. First, CBGH has established a claims repository and is currently working with employers to require that TPAs submit data on their behalf. Second, five of the six commercial carriers and TPAs have agreed to participate in an operational assessment to assure the smooth flow of data. So that they can hook up to a Bundled Payment Engine.
  • Purchaser/Provider Dyads Established. In all three communities, purchaser/provider dyads have been established and regularly convene in accord with adopted workplans. In all three communities, these dyads represent between 75 and 85% of the practicing primary care physicians. Their first priorities have been to assure physician understanding and acceptance of the model. ECRs have been selected and, as data become available, the dyads will begin establishing targets for PAC reductions. In the interim, they are beginning a dialogue with regard to gain-sharing models.
  • Bundled Payment Engine Installation. Because of lessons learned in other sites, HCI3 knew that data defects compromising speedy Engine installations would be a big problem. Accordingly, a portion of the grant was dedicated to a readiness gap analysis for the 6 participating plans / TPAs. As of now, Rocky Mountain Health Plans, Colorado Choice Health Plans, MedNet and Ameriben are undergoing this analysis.. HCI3 has demonstrated the reporting capabilities of PAC drill-downs to implementation site providers with very positive results. Consequently, provider enthusiasm is high. This is especially true for provider groups that have been working to achieve accountability. They have never received feedback from payers using cost and clinical data that would help them in their re-engineering efforts and so the prospect that plans and TPAs will be pushing this information out to them actually feel like collaboration.
  • Colorado/County Medical Society Support and Involvement. At both the County and State level, medical society representatives have actively participated in these pilots.

While undesirable, delays in Colorado are neither significant nor completely unexpected. Unlike other PROMETHEUS implementations, all three of these implementations are being undertaken on a community-wide basis. By this we mean that, in two of the communities, multiple, sometime competing purchasers along with multiple, sometimes competing providers are collaborating in driving change. As such, the progress has very arguably been remarkable – in part facilitated by the lessons of the earlier pilots in other parts of the country.

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 they 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 tied executive compensation bonuses to targeted PAC rate reductions.

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 used ECR analytics to identify improvement opportunities and recommended 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.

Conclusion

With the announcement of CMMI’s Bundled Payment for Care Improvement pilot and the more recent Comprehensive Care for Joint Replacement Model, it would seem that episode payment, first foreseen by Dr. Jerry Solon over 40 years ago, has finally become a reality. Despite the fact that the idea has been waiting in the wings for nearly a half century, to many the concept is bold and new, and for most administrators scattered throughout the healthcare system, completely counterintuitive.

Much has been learned and many new toolkits have been added that never existed before. Health analytics partners have come on board and licensed the Prometheus analytic software and methodology and are poised to assist the market. Technology vendors like TriZetto have stepped up to fill the automated operational void – we expect more, with further innovations. New start-ups backed by venture capital have emerged. Entities are making use of the HCI3 Discover Your Opportunity reporting capability to evaluate the potential.

In the 9 years since RWJF and the Commonwealth Fund first gave HCI3 a chance to get started, and given the current state of healthcare reform, it would appear that with all we have learned since then, PROMETHEUS arrived just in time.