Transcript Document
1 Confidential | Copyright © 2014 TriZetto Corporation Options to Enhance Payment Bundling with New Prometheus Release Cathy Avery - Product Design 2 Confidential | Copyright © 2014 TriZetto Corporation Health Care Incentives Improvement Institute (HCI3) • Not for profit with independent BOD made up of employers, health plans, providers, health care services experts • Emanates from the combination of Bridges To Excellence, Inc. and PROMETHEUS Payment, Inc. • Funded by RWJF, CO Health Foundation, NY State Health Foundation • Implementing BTE, PROMETHEUS and other payment programs throughout the country 3 Confidential | Copyright © 2014 TriZetto Corporation What is Prometheus Payment? A payment model offered by HCI3 with the following intentions 4 Confidential | Compensate fairly and reward excellence in care Provide incentives for better outcomes Encourage teamwork and responsibility for patient care A framework to improve the current inefficient payment system Copyright © 2014 TriZetto Corporation What is the value of this partnership? The NetworX Payment Bundling Content Package for PROMETHEUS extends the functionality of NetworX Payment Bundling, allowing clients to apply PROMETHEUS logic to claims during adjudication. Using this content package with the TriZetto software, clients can implement PROMETHEUS payment models much more quickly and with far less configuration work and complexity. 5 Confidential | Copyright © 2014 TriZetto Corporation PBA Implementation of Prometheus Supports chronic, acute, and procedural episodes Allows episode editing to meet local needs Delivers the expertise of both TriZetto and HCI3 Supports both prospective and retrospective payment models Includes maintenance such as periodic updates of configuration from HCI3 delivered in the TriZetto software Includes Potentially Avoidable Complications (PAC) logic as well as the ability to alter payment differentially for typical and PAC claims Supports payment around budgets, in both prospective and retrospective models Integrates with both TriZetto and non-TriZetto core systems 6 Confidential | Copyright © 2014 TriZetto Corporation Available in PBA 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 7 Confidential Acute Myocardial Infarction (AMI) Asthma (ASTHMA) Cesarean Section (CSECT) Chron Obstruct Pulmonary Disease (COPD) Colon Resection (COLON) Colonoscopy (COLOS) Congestive Heart Failure (CHF) Coronary Angioplasty (PCI) Coronary Artery Disease (CAD) Coronary Artery Bypass Graft (CXCABG) Diabetes (DIAB) Gall Bladder Surgery (GBSURG) Gastro-Esophageal Reflux Disease (GERD) Hip Replacement (HIPRPL) Hypertension (HTN) Hysterectomy (HYST) Knee Arthroscopy (KNARTH) Knee Replacement (KNRPL) Low and High Risk Pregnancy (PREGN) Pneumonia (PNE) Stroke (STR) Upper GI Endoscopy (EGD) Vaginal Delivery (VAGDEL) | Copyright © 2014 TriZetto Corporation Prometheus Concepts 8 Confidential | Copyright © 2014 TriZetto Corporation Types of Episodes 9 Confidential Acute Medical – Acute MI, Stroke, URI Chronic – Diabetes, Asthma, CAD Procedural – Knee Replacement, Colonoscopy System Related Failures – Coma, Infections, Pancreatitis | Copyright © 2014 TriZetto Corporation Trigger Events Rules that define when a patient bundle should be created The receipt of one or more claims Containing specific elements Within designated time frames 10 Confidential | Copyright © 2014 TriZetto Corporation Service Assignment Rules Rules that define if a claim / line should be attached to a patient bundle Triggered the bundle Contains a related diagnosis and/or procedure Is a complication of the condition 11 Confidential | Copyright © 2014 TriZetto Corporation Categories of Data Diagnoses and Procedures can comprise Triggers Related Conditions/Services Complications 12 Confidential | Copyright © 2014 TriZetto Corporation Configuration Concepts & Considerations 13 Confidential | Copyright © 2014 TriZetto Corporation Data Configuration The data provided in the Prometheus episodes is configured in PBA in the following ways Generic Qualifier Groups TriZetto Built Nested Qualifier Groups • Generic Qualifier Groups (QG) that include the unique Trigger, Related and Complication Diagnosis and Procedure information for each Episode. • Include clinical data provided by HCI3 and cannot be changed by the client. • These QGs are prefixed by “PROM_” followed by the PROMETHEUS acronym for the Episode. • TriZetto supplied QGs that, along with some foundational QGs, combine the generic PROMETHEUS information into nested QGs to facilitate the creation of the rules in the Episode Definitions. • This data, all prefixed with “(TZ)” and “(TZ) PROM_” can be modified by the client. • “(TZ) Episode”, category used on pricing actions in the PROMETHEUS Episode Definitions Pricing Service Category • “(TZ) Complication”, code used to capture complications in the PROMETHEUS Episode Definitions Supplemental Data Code 14 Confidential | Copyright © 2014 TriZetto Corporation Episode Definition Templates TriZetto provides template Episode Definitions for each of the 23 PROMETHEUS Episodes • Each definition contains appropriate Creation and Line/Claim Inclusion Rules. Rules • Each rule uses one pre-defined QG as the rule qualifier. Qualifiers • All Content/Inclusion rules are set to “Apply Episode Pricing”. Pricing Action Complication Processing Order 15 Confidential | • Content rules have been established distinctly for Lines/Claims that indicate a complication of the condition. • Given the construction of the QGs and their associated Actions, rules have been established in an order consistent with the ‘last term to qualify’ philosophy. Copyright © 2014 TriZetto Corporation Contract Considerations It is the client’s responsibility to evaluate Episode Definitions against provider contracts • Review the supplied QGs and Episode Definitions. Review • Create additional Service Categories and/or Supplemental Data Codes as required. • Create additional QGs as required. Supplement Modify 16 Confidential | • Modify the Pricing Rules and Actions to support the contracts in place, taking care to order the rules to achieve the correct pricing, bundling and data capture results at the line and/or claim level. Copyright © 2014 TriZetto Corporation Accessing Prometheus Data 17 Confidential | Copyright © 2014 TriZetto Corporation Download Prometheus Data Files Licensed clients can download the PROMETHEUS data files from the CX NetworX downloads page. 18 Confidential | Copyright © 2014 TriZetto Corporation Importing Data Once downloaded, import the desired episodes into NxPBA 19 Confidential | Copyright © 2014 TriZetto Corporation Prometheus Episodes in NxPBA 20 Confidential | Copyright © 2014 TriZetto Corporation Qualifier Groups – Supplied Values (HCI3) 21 Confidential | Copyright © 2014 TriZetto Corporation Qualifier Groups – Nested Groups (TZ) 22 Confidential | Copyright © 2014 TriZetto Corporation Qualifier Groups – Nested Group Details 23 Confidential | Copyright © 2014 TriZetto Corporation Episode Definition – Hip Replacement 24 Confidential | Copyright © 2014 TriZetto Corporation Episode Creation 25 Confidential | Copyright © 2014 TriZetto Corporation Roadmap 26 Confidential | Copyright © 2014 TriZetto Corporation To Come… Formal certification with HCI3 for current episodes supported Introduction of additional Prometheus episodes Implementation of initial version of Prometheus episode definitions including ICD-10 27 Confidential | Copyright © 2014 TriZetto Corporation Workshop Survey We would like to extend you an opportunity to provide candid feedback. During the workshop you should have received an e-mail notification for you to take an on-line survey. If you could take a few minutes to complete at this time , we would greatly value your feedback. For your convenience, the survey will be available throughout the remainder of the conference should you not be able to complete immediately. 28 Confidential | Copyright © 2014 TriZetto Corporation Thank You! 29 Confidential | Copyright © 2014 TriZetto Corporation