1. Theory, Results and Implementation
Implications for Patient Safety
August 19th, 2008
Francois de Brantes
National Coordinator

2. About PROMETHEUS Payment
Not for profit with independent BOD made up of employers, plans, providers, health care services experts
Funded in 2006 by CMWF to develop and model Evidence-informed Case Rates
Funded in 2007 by RWJF to develop implementation plan
Funded in 2008 by RWJF to support pilot implementations

3. Core Concepts of Prometheus
The price of an episode of medical care is specific to any patient-provider-payer triad
The price has to include all the services recommended by evidence or expert opinion
Episodes can be priced for chronic care, procedural care, or acute care
There is no need for legal or financial integration of providers, just clinical integration
The current rate of “defects” has to be cut by half

4. Risk bifurcation in the PROMETHEUS model
Global Cap
Total Cost of Care
“Coarse” Episodes
Reliable Care
Costs of all Diabetes Episodes
Costs of all Typical Episodes
Costs of all Potentially Avoidable Complications
Costs of all Base Services
Costs of all Severity Adjusters
ECRs
Insurer – Probability risk
Provider – Technical risk
Consumer – Probability risk

5. An Evidence-informed Case Rate… for each patient-provider-payer combination
Total ECR price = Type of services * Frequency * Price per service
Based on 50% of current defect rate
Allowance for Potentially Avoidable Complications
Margin
Currently based at 10%
Severity-adjustment caused by known patient health status
Arrived at through step-wise multi-variable regression model
Adjusts ECR for local patterns
“Normal” variation reflecting practice patterns
Informed by guidelines and empirical data analysis
Core services that are recommended by best practice or evidence
The ECR explicitly removes excess cost of care caused by errors and creates a strong incentive to eliminate defects and improve quality. 5

6. PACs, HACs, and Never Events
Potentially Avoidable Complications also include Never Events and Hospital-Acquired Conditions
Our most recent data suggest that HACs represent 30% of the PACs in hip or knee replacements
A PAC is essentially anything that harms the patient
We’re not looking for zero defects, we’re looking to halve the current rate of defects and create a powerful incentive to go beyond that
Industrial process re-engineering suggests that getting beyond Six Sigma often requires an expense that exceeds any known benefit
The stricter the rule, the more likely games will be played

7. Results of AMI Model – Patient A
$61,500
$61,500
Scorecard Incentive

8. Results of Diabetes Model – Patient B
$6,500
$6,500
Scorecard Incentive

9. Total margin relative to Potentially Avoidable Complication Rate