Transcript Document
Overview PROMETHEUS ® Payment Model Pilot Project 2012
What we’ll cover today:
1.
Description of PROMETHEUS Payment Pilot (PPP) 2.
How PROMETHEUS payment model works 3.
How Spectrum Health is structurally approaching PPP 4.
Lessons learned 5.
Comparison to CMS Bundled Payment
Who We Are - Spectrum Health
• Integrated Healthcare System – West Michigan − 9 owned hospitals, 14 in network, 8 in a Quality network − Spectrum Health Medical Group • 400+ physicians and growing − Health Plan • 600,000+ members − Continuing Care Division • Over 600 beds − Ambulatory services • 140 service sites • $4.7 Billion – Annual Revenue − 60,000 acute care admissions − 8,300 births − 172,000 ED visits − 148,000 Urgent Care visits − 630 helicopter transports
PROMETHEUS:
P rovider payment R eform for O utcomes M argins E vidence T ransparency H assle reduction E xcellence U nderstandability and S ustainability
• Prometheus was a rebel who did not accept things as determined by the power of Zeus. Prometheus chose to aid mankind whom Zeus would have had live in the cold and dark. Our version of Prometheus carries with it the hope of bringing some measure of payment reform, for a better health care world for patients, providers, plans and purchasers .
Bridges to Excellence
• Not-for-profit organization. Francois DeBrantes- President • Recipient of Robert Wood Johnson grant • 4 pilot projects – Prometheus • Original Pilots • Philadelphia - Crozer Keystone Health System • Rockford, IL - Employer Coalition • Minnesota - Health Partners • Grand Rapids - Spectrum Health www.bridgestoexcellence.org
What is PROMETHEUS?
• PROMETHEUS Payment®, Inc. (PPI) • Not for profit created to steward development and implementation of bundled payments • PPI design team drawn from: • Bridges to Excellence • American Hospital Association • Harvard University • Blue Cross Blue Shield Association • MA Health Data Consortium www.prometheuspayment.org
Combined Forces
Bridges to Excellence
Healthcare Incentives Improvement Institute
PROMETHEUS
Today’s non-integrated care and payment system
Providers bill and are paid separately; if patient has complication, providers are paid again Payers
No reward for higher quality
Poor quality Hospital Physician Ancillary RX Episode of care Payment High quality Hospital Physician Ancillary RX Episode of care
PROMETHEUS model
Reformed payment Improved quality Better outcomes reduced cost at
Bundling changes the conversation on payment • Bundled payments provide incentives to delivery networks to: – Integrate – Improve quality – Improve patient outcomes – Lower costs
Triple Aim
Why bundle?
• …because today’s payment methods do not produce superior results at affordable costs • Nor do they provide economic incentives to improve quality or create incentives for integration or collaboration • Goal: Create a different payment system to change the cost curve Bundled payment/Bundled care
What is a bundled payment?
Physician
Facility
Ancillary /RX • • • • Pays an episode with evidence-informed case rates (ECR®) Includes payment for a percent of “potentially avoidable complications (PAC)” Providers are rated for efficiency and quality using a “scorecard” ECR®s cover chronic and acute care
Savings shared but system cost reduced
$10 $9 $8 $3 $2 $1 $0 $7 $6 $5 $4
Difference is non-payment for portion of PACs
Current payment for episode Bundled payment for episode Bonus Other Physician Hospital
Claims processing and payment does not change
Hospitals Physicians Claims $$ Rx Other Priority Health Paid Claims ECR Actual to Budget ECR Budget Tracker
How the payment model works
1.
ECR Price Budget • Base set by guidelines and empirical data analysis (ideal care model) Adjust for local patterns and pricing • Margin – E.G. 10% • Allowable PAC Rate • #1 PAC cost: admissions to acute care hospital (at least for chronic conditions) 2.
Physician Quality Scoring • Agreed upon quality measures • Clinical measures Poor quality measures Superior quality measures • Process measures • Weighted average score
How the payment model works
3.
Hospital Quality Scoring • Leapfrog, CMS Hospital Compare • Outcomes, process, volume, patient safety, patient experience • Weighted average score 4.
Hospital and Physician Quality Scores • Blended • 50 is threshold, 90 full payout (scale of 100) 5.
Result: Paid claims + Quality Payout = Bundled Payment • Actually a form of pay for performance • Negotiated quality payout from difference between ECR budget and actual claims paid (“who gets to keep the difference?”)
Types of ECRs
Type of ECR Chronic Medical Acute Medical Inpatient Procedural Outpatient Procedural Trigger Outpatient Professional Inpatient Facility Inpatient Facility Outpatient Facility/ Professional Time Window One year from trigger 3-day look-back; 30-day look-forward 30-day look-back; 180-day look-forward 30-day look-back; 180-day look-forward Examples Diabetes, CHF, COPD, Asthma, CAD, HTN AMI Hip/Knee Replacement, Bariatric Surgery Colonoscopy, Knee arthroscopy We have 20 ECRs in total that represent about 35% 40% of all costs in a commercially insured population.
An ECR is budgeted for each patient
Total ECR price = Type of services x Frequency x Price per service Based on 50% of current defect rate Currently based at 10% of typical Arrived at through step-wise multi variable regression model Adjusts ECR for local patterns Informed by guidelines and empirical data analysis $1,100 -- $12,300 $260 -- $2,430 $2,600 -- $24,300* CHF ECR Range** $3,960 -- $39,030 * $1,100 was added to the base set of claims-based/observed services to create a right-sized evidence-informed set of services.
** The upper range can be greater than the amount stated depending on the severity of the patient
14 20
PAC Rate Comparisons
Example of “relational” Quality Scoring
• Practice Jones gets a 70.91
• Practice Jones refers all patients to Hospital A • Hospital A’s score is 76.75
• Practice Jones’ total Prometheus Scorecard Quality Score is: – 70.91*0.7 + 76.75*.3 = 72.66
• Since 72.66 is within range of 50-90, partial quality payment is made .
Decisions in Preparation for PROMETHEUS payment
1.
2.
3.
4.
5.
PAC reduction target Margin Quality metrics and thresholds Distribution of awards Distribution of remaining ECR funds
What do we get out of it?
1.
Gain intellectual insight regarding bundled payment, mostly within the SH system 2.
National recognition (Rand, Harvard School of Public Health, HFMA) 3.
Support/In-kind services from BTE/Prometheus 4.
Drives integration within SH and community
PROMETHEUS Structure at SH
• Steering Committee- representation from PH, SHHG, SHMG. Includes six physicians • Executive Committee- subset of Steering Committee, much like executive committee of a board.
• Four sub-committees – Administrative and Finance – Clinical Delivery System – Informatics and Infrastructure – Communications
The THEMIS Project (Structure)
• Team-based Healthcare Energizes Management of Illness and Sickness • Creating a Seamless Experience for Patients & Families by Integrating Care Delivery
THEMIS
Goddess of good counsel, piety, and hospitality….
….and, in Greek mythology, the mother of PROMETHEUS
THEMIS
THEMIS Vision
By 2015, the care we provide will be distinctively patient-centered and integrated across our continuum
Goal of the THEMIS structure
To organize and align the operational work of Spectrum Health entities around coordinating access and care across the continuum Note: The THEMIS structure is designed to address issues beyond “just” PPP. These groups are focused on improving throughput, coordination of care, improving quality, various related issues beyond PPP.
Executive Summary
Objectives of the THEMIS structure:
• To coordinate the design & implementation of distinctively patient-centered and integrated care • To implement patient-centered and integrated care for specific patient groups, using explicit prioritization criteria to select each year’s target populations and projects • To leverage and manage the System’s assets more robustly and strategically to achieve our distinctly patient-centered and integrated care
Proposed Structure
Seven THEMIS Focus Teams 1.
Primary Care & Ambulatory Specialties Focus Team 2.
3.
Acute and Post-acute Services Focus Team Children’s Health Focus Team 4.
Community Medicine Focus Team 5.
System support team: Coordinated Access 6.
System support team: Training & Care Management Decision Support Systems 7.
System support team: Tele-health
Lessons Learned (Learning)
1.
Clinical Reengineering • Absolutely necessary, but still a fragmented mindset.
• Physician reaction and pushback Control PAC detail 2.
Managing the ripple effect • Priority Health approximately 20% of revenues • Windfall creation for other payors • Where/When is tipping point?
• Aligning other payors • Managing capacity
Comparison to CMS Bundle
1.
2.
PROMETHEUS • Condition based episode of care • Primary Care based − Goal: Avoid hospitalization • One model applies to all conditions − P4P on steroids CMS • Condition based episode of care • Hospital based − DRG specific • Four Models − P4P and/or condition specific capitation
Questions?
www.prometheuspayment.org
www.bridgestoexcellence.org
www.hci3.org