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Launch Implementation


The next step is the actual launch of the implementation. After the Evidence-Informed Case Rates (ECRs) and BTE Care Recognition Programs have been chosen, health plans and providers agree to an “ECR Amendment”, which is an addendum to their current provider contracts and sets forth the terms and conditions by which the pilot partners agreed to proceed. For example, the agreement may outline the scope of the ECRs chosen for the pilot, the risk sharing arrangement, the size of the Potentially Avoidable Complication (PAC) Allowance that will be built in to the PROMETHEUS prospective budgets, the criteria upon which financial rewards are contingent (e.g. PAC reductions, a minimum quality threshold), etc. See the link below for a sample Provider-Payer Contract Amendment, as well as an example of the key decision points that are discussed and included in the amendment.


LESSON LEARNED: Begin planning out contracts at the start of the implementation process

It is recommended that once the decision is made to participate in PROMETHEUS, plans and providers should begin thinking through what “going live” looks like, especially from a contracting perspective. Because member contracts may require altering, this is a process that plans and providers should get started on immediately since it has potential to be very time-consuming.


Case Studies: ECOH; Priority Health and Spectrum Health

In the Rockford pilot site, ECOH decided on a PAC Allowance of 100% for each of the 3 pilot ECRs. This means that the ECR will have a PAC Allowance equal to 100% of the total PAC dollars accumulated in the prior year. ECOH has set a PAC reduction rate goal of 6%. If health systems are able to reduce PACs by 6% per ECR, they are eligible to share in the savings with ECOH 50-50.

For example, if the total bonus opportunity is $100,000 – ECOH would keep $50,000 and the health system would be eligible for $50,000. The provider portion of the $50,000 is contingent upon the quality score, the quality scores are calculated using the Bridges To Excellence Care Recognition Programs. If a provider scores 80%, they get $40,000. There will likely be a remainder and so ECOH has chosen to refund that remainder to the employer members or roll it over into the next year.

Similarly, Priority Health and Spectrum Health have agreed to set the PAC Allowance to 100%. The first “live” year of their pilot will consist of measurement and reporting and so there will be no upside or downside. Priority and Spectrum are also instituting a quality scorecard that is currently in draft form, but the goal of the scorecard is to provide valuable and timely quality feedback reports to the providers to track their performance and identify areas for potential improvement.


Once scope of implementation is defined, and the BTE Recognition Programs and ECRs have been chosen, the site can begin to expand the necessary team members involved in the project, from both the clinical, administrative, IT/Development, and quality management points of view.

Participating clinicians and health plans are both responsible for submitting data during the course of the implementation. Clinicians must agree to submit clinical data to an independent third party for performance assessment to determine their scores in the selected BTE Care Recognition Programs. An essential component of the PROMETHEUS Payment model is the incorporation of a comprehensive quality scorecard. The quality scorecard is a performance assessment tool that provides continuous quality feedback to providers and also serves as a measurement tool upon which any potential rewards or bonus opportunities are contingent. The Scorecard is an essential element of what makes the PROMETHEUS Payment model different from other payment systems as well as different from typical pay-for-performance models, even though it uses many of the same measures that pay-for-performance programs use today. It is the mechanism by which efficiency and effectiveness are synthesized, which results in better health for patients, bonuses for providers, and decreased outlays for payers. Please see the link below for an example Scorecard.


LESSON LEARNED: Assign necessary staff members to Prometheus

It is essential to have a team of staff members allotted to the implementation of PROMETHEUS. Our pilot sites have learned from experience that a team of people is needed to facilitate and administer the implementation amongst other corporate priorities. This is especially necessary for the work involving pulling claims data and submitting quality data. Pilot sites have found it useful to hire a data analyst specializing in SAS programming, or to devote one of their current data analysts to the implementation. It is also important to have a clear project management team within the pilot site on both the payer and provider side, with each management team including a project leader/champion.


Health plans that choose to participate in a pilot implementation must agree to plug into the ECR Engine and submit claims data. The health plans’ submission of claims data to the ECR Engine is crucial to a PROMETHEUS implementation. The Engine is a combination of claims tracking and financial accounting system. Payers and providers will not have to modify their existing claims systems to accommodate the implementation of the model. Instead, the Engine will work through the tracking of the ECRs in the background and inform payers and providers. Instead of using our Engine, pilot sites do have the option to create their own.

HCI3 has contracted with health care IT vendors to build the ECR Engine. These IT vendors are being tasked with creating the Engine that interfaces with pilot site plans to receive claims data on an on-going basis and assigns each claim as either Typical, PAC, or Exclude based on the rules of the underlying metadata. The metadata defines the parameters of each ECR and determines whether the information on each claim is relevant to the ECR. To learn more on the ECR Engine, please see the links to the documents below.


Prospective Budgeting & Retrospective Reconciliation:

Prior to embarking on an implementation, it is important to understand that Prometheus ECRs are not paid on prospectively. Instead, providers and payers bill and reimburse claims as they do currently 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 prospective pay episodes. The ECR budget is compared to the actual spend for that particular ECR. If each of the providers who co-manage the patient are able to do so within the ECR budget are potentially eligible for a bonus at the end of the year. The portion of the bonus the providers are eligible to share in directly depends on (1) their quality score and (2) their involvement in the episode (e.g. office visits).


Samples to help in drafting Agreements:

Key decision points This document gives examples of the items that must be discussed and included in the Provider-Payer Contract ECR Amemdmemt.

Provider-Payer Contract Amendment: Principles and Template

*Coming Soon: Paper on Prospective Budgeting and Retrospective Reconciliation

Educational information about the Engine:

ECR Engine Overview

ECR Manual for SAS v3.5.2
This document outlines the methodology that has been used to create the ECRs, the automated SAS programs and the risk-adjustment payment models. In addition, it includes step by step instructions on how to format your data and run the Prometheus ECR automated programs to calculate ECR budgets using healthcare claims data and SAS software.

Information about data analytics and scoring:

Scorecard Example



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