PROMETHEUS Payment is a new compensation approach, based on medical episodes of care, now being piloted at three pilot sites across the country.

Funded by RWJF, the current pilot implementations are designed to test the validity of the PROMETHEUS model. Each pilot is unique, and based on the specific needs of each participating organization and its multiple stakeholders.

Pilots now underway:

  • Independence Blue Cross, in partnership with Crozer Keystone Health System in Pennsylvania, focuses on hip replacement and knee replacement.
  • The Employers' Coalition on Health in Rockford, Illinois, focuses on diabetes, hypertension and coronary artery disease. Altogether, this site will involve 140 employers and three area health systems, and cover more than 50,000 lives.
  • Priority Health–Spectrum Health in Michigan focuses on diabetes, congestive heart failure, asthma, chronic obstructive pulmonary disease and colon resection. This organization includes a medical center, regional community hospitals, a dedicated children’s hospital, a multispecialty medical group and a nationally recognized health plan. In this multi-stakeholder setting, the pilot site has the potential to cover more than 500,000 lives.

In addition, the New York State Health Foundation is working to establish partnerships with commercial and public insurers to launch two pilot tests and the Colorado Health Foundation is currently working to define the scope of a pilot implementation as well.

These are well-known organizations that together represent millions of covered lives. The pilots now underway have provided a substantial knowledge base of best practices, essential action steps and potential barriers to implementation. This toolkit summarizes the key lessons from the pilots and provides a step-by step guide to conducting your own.

What PROMETHEUS is: a promising path to effective payment reform

The PROMETHEUS model packages payment around a comprehensive episode of medical care that covers all patient services related to a single illness or condition. It is designed to bring economic incentives in line with the medical profession’s desire to improve patient health and create an environment where doing the right things for patients helps providers and insurers do well financially.

The designers believe it addresses the full range of issues necessary to create a payment system that is fairer and more accountable than the current fee-for-service system, without introducing new administrative burdens or changing the way patients access care. They believe it enables employers and health plan to increase efficiency and pay for the quality, not quantity, of care. And they believe it encourages physicians, hospitals and health systems to work in teams to share information, take collective responsibility for a patient’s health and improve treatment value and outcomes.

What PROMETHEUS is not: proven over time in a wide range of settings

While early feedback and data are promising, a full and robust set of results has yet to be recorded and analyzed. To be sure, PROMETHEUS is no magic bullet. It is one of a number of innovative payment models designed to help transform today’s fragmented and inefficient health care system. It will not be the best solution for every organization, but it may be a good one for yours, based on the following criteria.

Who should explore PROMETHEUS—and who shouldn’t?

A pilot site requires the active participation of at least one payer and at least one provider organization. Since a key goal is to encourage physicians and hospitals to work together, and overcome the organizational barriers of siloed fee-for-service medicine, ideal pilot sites include multiple provider organizations and other multi-stakeholder organizations (including health plans, employer groups, provider organizations and hospitals).

Organizations should be motivated to explore the possibilities of new compensation models and ready to work through the kind of organizational change required. In other words, a site must have willing payers and providers, the enthusiastic involvement and support of the CEO and other high-level executives, and a sense of urgency within all participating organizations. As a practical matter, pilot sites should also have access to high quality claims data at the member level. Ideally, EMR systems will already be in place. While not absolutely necessary, EMR systems are certainly helpful in implementing a data-driven model like PROMETHEUS, as is a well resourced IT and Quality Management team.

An organization with most or all of these attributes will be a good candidate for a successful PROMETHEUS pilot. In the next section we will review the fundamentals of how PROMETHEUS Payment works and the steps involved in piloting the model.

Caution Points

  • A pilot site must have adequate patient sample sizes for each area that is to be analyzed and implemented; 30 patients is the minimum for the analytics to be conclusive. But to actually create budgets, HCI3 prefers a much larger number of patients. For this reason, medium-to-large size health plans are typically the best candidates.
  • For a pilot implementation to succeed, there must be a strong sense of urgency to think proactively, overcome obstacles and avoid “analysis paralysis.” The effort must be a high priority of all participating organizations. This includes a willingness to devote time and resources to the implementation, whether that means allocating funds, reassigning existing staff, or hiring new data analysts or other professionals.