Engaging Providers and Payers

    • February 27, 2011

Steps to Encourage Willing and Enthusiastic Participants

Without the buy-in of the CEO and other C-suite executives, there is little chance of success. But that essential top-down commitment is not enough. You need to engage providers and payers around this initiative as well. There must be clear efforts to organize teams and committees on both sides, and they cannot stop at merely getting everyone around the table for a meeting. There must be a strong bias toward action.

To build momentum, PROMETHEUS Payment recommends a formal kickoff meeting to present the initial data analysis, review the high-level concepts behind the model and foster a strong sense of urgency for improving quality and cost efficiency. Building clinical collaboration and a strong consensus behind the pilot will significantly improve your chances of success.

This meeting can be a high-level concept review of PROMETHEUS or it can be more granular and used as a forum to present the results of the initial data analysis. In either case, senior leaders and other representatives from all participating health plans, employer groups, provider organizations and hospitals should be in the room. You may also need to provide more detailed education for providers and payers around key concepts like ECRs, PACs and scorecards.

Providers must have a good understanding of the PROMETHEUS model and the clinical quality measures used. Payers should clearly understand the bundled payment concept and ECR model. Overall, both groups should understand why it is urgent for their organizations to undertake this initiative and work together to make it a success. Initial data results should be presented to both providers and payers in formats that resonate with each group, preferably with real examples from the initial data analysis.

Caution Point

For the pilot to succeed, payers and providers must make it an internal priority. To encourage this, some pilot site payers tie compensation directly to the success of the PROMETHEUS implementation. Some providers also tie their clinical re-engineering efforts to the pilot, focusing first on the targeted ECRs, then expanding their efforts to other areas of the practice. Generally speaking, integrating the pilot into the larger goals and aspirations of each participating organization can help make it a priority for all participants.

Explaining Scorecards and Bonuses to Providers

Clinicians will be expected to submit clinical data to an independent third party for scoring. With this data, a quality “scorecard” will be created. This is a performance assessment tool that provides continuous quality feedback to providers and serves as a measurement tool upon which any potential rewards or bonus opportunities will be contingent.

The scorecards will measure provider performance through a mix of quality care metrics, such as meeting clinical guidelines, achieving positive patient outcomes, avoiding complications and improving patient satisfaction. See a sample scorecard. This model puts accountability for care where it belongs—in the hands of providers. And they are only held accountable for variables they can control. As previously discussed, providers will continue to get paid under their current negotiated fee schedules, with a substantial PAC allowance included in each budget.

If complications occur, this allowance is used to offset costs of corrective treatment. If providers manage patients well and minimize PACs, they keep that allowance as a bonus. As a result, those who create the most value will earn the highest compensation under PROMETHEUS. Most physicians today—particularly specialists—are facing reduced fee schedules. PROMETHEUS can relieve this pressure by tying bonus opportunities to PAC reductions and compensating physicians for the quality of care they collectively deliver, not the number of tests or procedures they perform. For these reasons, providers may also want to drill down into the details behind PACs and examine the top drivers of PACs within their patient populations.

Explaining Technical Requirements to Providers and Payers

Generally, providers should have robust clinical information systems that provide “acceptable” EMRs. However, if the pilot focuses on a discrete ECR (such as diabetes), providers can organize a part of their practices to manage those patients without a significant investment in infrastructure or technology. What constitutes “acceptable” records? The simple answer is that provider’s system should be recognized by the Bridges to Excellence (BTE) Physician Office Systems program.

BTE, like PROMETHEUS, is part of HCI3. This BTE Physician Office Systems program is designed to recognize practices that use information systems to enhance the quality of patient care. To obtain recognition, practices must demonstrate that they have implemented systematic office processes to reduce errors and increase quality. For example, this requires maintaining patient registries to identify and follow up with at-risk patients. Another criterion is using electronic systems to maintain patient records, enter orders for prescriptions and lab tests and provide patient reminders.

Ideally, a practice's electronic systems should interconnect with other systems, use nationally accepted medical code sets and be able to integrate data such as lab results and medical histories from other organizations' systems. Providers must also make sure they have (or can obtain) the resources to improve care based on the scorecard results.

For instance, this could involve a quality improvement department, infection control team, disease management program, or case management models. Improvements could be accomplished through enhanced processes and systems, patient care checklists, better population management and outreach and other means.

As for payers, they must have a certain level of cleanliness and accuracy in their data for the pilot to succeed, and high quality claims data at the member level is essential. (This was explained in detail in Getting Started With Your Own Pilot: Conducting Initial Data Analysis.) See data specifications. Remember, it is not necessary to contact HCI3 to launch your pilot implementation, although the PROMETHEUS team always available to provide advice and support.

Caution Point

When engaging providers and payers, it’s important to convey a sense of excitement about the benefits PROMETHEUS can bring, such as reducing money wasted on PACs, delivering more collaborative care and providing better patient experiences. And using real data always helps. In the words of one participant, “It makes a difference when you can use data to demonstrate that wasteful spending and deficiencies of care are real and in our costs. It was evidence that made national theories locally relevant … we had an immediate opportunity for PAC reduction and cost savings.”