June 29, 2010
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Funding for this project from the Robert
Wood Johnson Foundation is gratefully
acknowledged
Amita Rastogi, Elizabeth Siteman and the
whole Prometheus Payment analytic team
(including MassPRO) made numerous
contributions to the work presented here (but
should not be blamed for my subsequent
errors)
Base case rate
•Evidence-based services
•Other routine care for
condition
•Risk adjusted
Warranty for
f
complications
Pay for
performance
•All
All potentially avoidable
complications (PACs)
•Warranty set at 50% of
baseline
•Quality,
Quality, patient satisfaction
3
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Robert Wood Johnson Foundation funded a
series of pilots of Prometheus Payment
Private payers-providers
payers providers in MN
MN, PA
PA, IL
IL, MI
Evaluation of pilots’ implementation of
Prometheus led by Susan Ridgeley of RAND
Coordinated effort to work with pilot baseline
data to understand opportunities
opportunities, risks
risks, likely
impact of adopting ECR-based payment
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Examine distribution of ECRs,
ECRs typical and PAC
costs by condition
Examine association between ECR typical,
typical
PAC costs and quality
Model distribution of net payment changes
for providers based on Prometheus Payment
applied with different assumptions (e
(e.g.,
g
stop-loss)
selection
Examine implications of self
self-selection,
behavioral responses of providers
$30,000,000 $25,000,000 $20,000,000 PAC
$15,000,000 $10,000,000 $5,000,000 $0 CHF
COPD
DM
Asthma
HTN
CAD
AMI
Stroke Pneumonia
Hip
Knee
CABG
Colon
Bari
PAC
$45,000 $40,000 Typical
$35,000 $30,000 $25,000 $20,000 $15,000 $10,000 $5
000
$5,000 $0 CHF
COPD
DM
Asthma
HTN
CAD
AMI
StrokePneumonia Hip
Knee
CABG
Colon
Bari
$7,000,000
PAC Pharmacy
$6,000,000
PAC
Professional
$5,000,000
$4 000 000
$4,000,000
$3,000,000
$2,000,000
$1,000,000
$0
CHF
COPD
Diabetes
Asthma
HTN
CAD
10000
8000
6000
Typical
4000
PAC
2000
0
Mean
Median
95th
Percentile
2500
2000
1500
Typical
1000
PAC
500
0
HbA1c testing - yes
HbA1c testing -no
2500
2000
1500
Typical
1000
PAC
500
0
LDL Screeening Yes
LDL Screening No
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Simulate self-selection and provider
behavioral change under alternative risk
sharing parameters
Model payer savings
Examine risk pooling opportunities
Model contract-level impacts with multiple
ECRs