Reducing the Waste Line
By Rebecca Jones
PROMETHEUS Tackles Avoidable Health Costs
Main Photograph by Howard Sokol; Hospital Image Provided by Centura Health
EDITOR'S NOTE: The Colorado Health Foundation provided a $250,000 grant to Bridges To Excellence Inc. to support a PROMETHEUS pilot program in Colorado. Bridges To Excellence has developed the PROMETHEUS payment model to engage communities in Mesa, El Paso and Teller counties as well as the Denver metro area. The grant covers staffing, data analysis, travel and other costs associated with the project. PROMETHEUS stands for Provider Payment Reform for Outcomes, Margins, Evidence Transparency, Hassle Reduction, Excellence, Understandability and Sustainability.
Of the $2.5 trillion the nation spent on health care last year, a lot went to treatments or procedures that did little or no good or may even have harmed patients.
"On chronic outpatient episodes, like diabetes or heart failure, we often see avoidable complication rates over 50 percent. So for every dollar spent, 50 cents is going for poor care or to pay for hospitalizations that never should have occurred," says Doug Emery, a Utah-based health policy expert with the Health Care Incentives Improvement Institute. "In some places, it's 80 cents on the dollar. This shows in stark and actionable terms what everybody's always known, but not known what to do about."
The institute has developed a payment model it hopes will have positive effects. Called the PROMETHEUS Payment program, the model departs from existing fee-for-service plans, which don't encourage health professionals to practice preventive care since the sicker a patient gets, the more services that patient must purchase.
Under the PROMETHEUS model, health professionals would be paid a set amount for each "episode of care" involving a patient. The fewer avoidable complications that occur throughout a patient's treatment, the greater the profit for health professionals. The plan encourages integrated care and collaboration – thus maximizing everyone's profit while minimizing the patient's need for costly services.
The Centura Health system, which includes 12 hospitals, seven senior living communities and Centura Health at Home, is committed to PROMETHEUS.
"We're very supportive, and once we figure out what those [episode payments] are for this state, we want to be part of the pilot, actually trying this type of payment out with our physicians and hospitals for the delivery of care," says Pam Nicholson, senior vice president of strategic integration.
Figuring out payments is tricky, however. It involves analyzing thousands of insurance claims to determine what was avoidable and what wasn't.
That's what's happening in Colorado right now. Emery is working with the Colorado Business Group on Health to compile two years' worth of claims data for a number of health care plans around the state. Before year's end, Emery hopes to have statewide average care costs for a number of medical conditions along with the likelihood of complications resulting from those conditions. The result would be evidence-informed case rates.
"Then we'll work with health plans and providers to design a system that will allow us to pilot a payment plan in two to four communities," Emery says.
Collecting the needed information isn't hard – but it's time-consuming.
"The IT departments of health plans are always getting a lot of requests for data and information, so it's hard to get prioritization when you have a lot of other projects in the queue," says Donna Marshall, executive director of the Colorado Business Group on Health.
Nicholson believes PROMETHEUS will be good for Centura Health and its patients.
"We just feel that this so aligns with where we're headed," she says. "People don't want to be in a hospital. We want to have the right access points for them to get the care they need when they need it, and the current [payment] incentives don't lend to that model very well. But models like PROMETHEUS align with us perfectly."