After laying the groundwork for the PROMETHEUS Payment pilot in your organization – and developing a strong consensus to support it—you are now ready to launch your pilot site and begin work.
Physicians Will Submit Their Clinical Data
To get the pilot underway, clinicians will submit clinical data to a third party, such as a data intermediary or one of PROMETHEUS’ partner Performance Assessment Organizations (PAO) for scoring. Depending on the areas you wish to focus on, you may have several options available for submission. Providers must submit data from their medical records for performance assessment via an EMR or registry capable of collecting and reporting clinical data in a format suitable for the implementation, as outlined by the Policy and Procedures documents.
There are multiple paths available to clinicians, depending on the specific ECR. For example, clinicians or practices may submit data on outcome and process measures to NCQA for assessment. Those connected to an approved data aggregator (e.g., EMR vendor, Patient Registry vendor, Health Information Exchange) may have their data submitted on their behalf to an independent PAO for an automated evaluation. Clinicians or practices may also submit their data directly to IPRO through its Clinical Data Portal.
Health Plans Plug Into the ECR Engine
Health Plans will plug into the PROMETHEUS ECR Engine, a claims tracking/financial accounting system. It combines all data elements into one system, allowing payers and providers to price, reimburse and track ECR-related claims.
The engine-specific processing is separated into Filter, Navigator and Accumulator modules:
- The Filter determines if a claim is part of an ECR.
- The Navigator steers claims to the appropriate decision categories, such as Exclude, Conclude, Terminate, PAC, or Typical.
- The Accumulator places claims into separate Typical and PAC buckets and calculates the dollars associated with each bucket to perform the reconciliation process for the financial analysis.
Upon the conclusion of running an ECR for your data, each ECR will produce an output report. This will tally actual costs and compare them to predicted costs for payment purposes.
Payers and providers will not have to modify their existing claims systems to accommodate implementation of the model. The Engine will work in the background tracking the ECRs and keeping payers and providers informed. Through ongoing data analysis, you can compare your performance to established industry baselines and make continuous quality and cost efficiency improvements.
Payments are Distributed
Payments are based on the negotiated contracts between providers and payers as well as a basket of quality measures embedded in the PROMETHEUS Payment scorecard.
During the pilot, providers and payers will bill and reimburse claims as they currently do via the fee-for-service system. Historical claims data allows for the accumulation of risk factors to build and provide severity-adjustment information to construct ECR budgets on a per patient basis.
PROMETHEUS prospectively budgets but does not prospectively pay episodes. In other words, the ECR budget is compared to the actual spending for that particular ECR. If all providers who manage the patient are able to do so within the ECR budget, they are potentially eligible for a bonus at the end of the year. The portion of the bonus depends on two factors: their quality score and their level of involvement in the episode.