Defining the Scope

    • February 27, 2011

Based on your initial data analysis, if you decide that proceeding with PROMETHEUS Payment makes sense for your organization, you can decide which ECRs to focus your pilot on.

Four Questions to Answer Before Choosing Your ECRs

The selection of ECRs is entirely up to the pilot site partners. The answers to these key questions will help you make an informed decision.

  1. Does the ECR represent a potential cost savings opportunity?
  2. Is this condition/procedure the best place to focus quality improvement efforts?
  3. Are quality improvement efforts already occurring around this condition or procedure – and, if so, how can those efforts be leveraged?
  4. Is this ECR consistent with our mission (such as becoming a destination center for a certain procedure, or becoming known for providing excellent chronic care management)?

Depending on your answers to these questions, the choice of ECRs for you to select should be clear.

Choose Your Care Recognition Programs

In addition to choosing your ECRs, you will need to select one or more of the Care Recognition Programs offered by BTE. The BTE Care Recognition Programs are designed to correspond with the various ECRs, and provide a mechanism to evaluate provider performance based on the clinical data they submit. (These programs underlie the provider scorecards discussed in the previous section.) The BTE Care Recognition Programs include the following:

  • Asthma Care
  • Cardiac Care
  • Cardiology Practice Recognition
  • Congestive Heart Failure Care
  • COPD Care
  • Coronary Artery Disease Care
  • Depression Care
  • Diabetes Care
  • Spine Care
  • Hypertension Care
  • Medical Home

The specifications of each BTE Care Recognition Program should be carefully reviewed with the pilot site before the programs are selected. These specifications can be found in the Policies and Procedures manuals. (As discussed in Engaging Providers and Payers, BTE also offers a Physician Office Systems recognition program, which lays out the criteria provider EMR systems must satisfy.)

BTE Recognition programs measure the quality of care delivered in physician practices, with a special emphasis on managing patients with chronic conditions, who are most at risk of incurring PACs. The programs are based on nationally recognized measures by organizations such as National Committee for Quality Assurance (NCQA) and the American Board of Internal Medicine. They are designed to reward providers who meet certain performance measures, based on care provided to a sample of individual patients and documented in the medical records of those patients. Clinicians and practices get a complete report on their measures from the clinical data submitted, with benchmarks on performance and peer comparisons.

Creating an ECR Amendment and Building Consensus

Once the scope of the pilot is agreed upon, agreements must be made regarding which ECRs and measures will be implemented, and which providers, provider specialties and health systems to engage. These should all be spelled out in what is called an “ECR Amendment”—an addendum to current provider contracts that sets forth the terms and conditions by which the pilot partners agree to proceed.

The contract must specify the ECRs chosen for the pilot, the risk-sharing arrangement, the size of the PAC allowance built into the prospective budgets and the criteria upon which financial rewards are based (such as PAC reductions or minimum quality thresholds). In most sites, incentives are offered to providers and health systems in the form of bonuses.

These are typically paid at the end of the year to those clinicians who come under their ECR PAC budgets by delivering quality care to patients. To use one very simple example: let’s say you decide on a PAC allowance of 100 percent for a CHF ECR, with a PAC reduction rate goal of 6 percent. If the participating providers reduce PACs in a given CHF episode by 6 percent, they are collectively eligible to receive that entire PAC allowance as bonus payments, with the distributed amounts based on each provider’s level of participation in that episode.

Caution Points Provider incentives must be proportional to the effort required to earn them. If they are too low, it will diminish your chance of success. Incentives also work best if they are designed to increase over time, so doctors who continually improve their practices are rewarded in kind. The better they get, the more incentives they deserve—and the more patients should be encouraged to utilize them. Quality is a constant process, and the incentives must reflect that.