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Outpatient Procedural ECRs

An Evidence informed case rate (ECR®) is a risk-adjusted budget for an entire care episode which includes all covered services across all providers that would typically treat a patient for that condition.

PROMETHEUS Payment currently has six outpatient procedural ECRs for the following procedures: colonoscopy, gall bladder, knee arthroscopy, PCI (angioplasty), pregnancy and delivery, and hysterectomy.  The outpatient procedural ECR time spans are dependent on the procedure.  Any outpatient procedural ECR with inpatient or outpatient facility claims has a 30 day look back and a 90 look forward.  Any outpatient procedural ECR without inpatient facility claims has a 7 day look back and a 30 day look forward period.  Pregnancy and delivery has a 9 month look back and a 2 month look forward.

Outpatient procedural ECRs are designed to promote coordination of care by having the entire range of services associated with the episode being derived from one bundled payment, with a reward incentive built in for physicians who deliver superior care.

ECRs are patient specific, in that the patient's characteristics are analyzed and a payment amount is calculated based on factors such as the patient's age, risk factors, and co-morbidities. 

Outpatient facility, professional and pharmacy claims are analyzed to determine a patient's conditions and risk factors.  These claims are then sorted into two types: typical claims and claims associated with Potentially Avoidable Complications (PACs). PACs are any events that negatively impact the patient and are potentially controllable by all of the clinicians who manage and co-manage the patient. Each ECR has an allowance to cover the cost for any PACs that occur. If PACs are reduced or eliminated, the leftover allowance is distributed amongst all providers for the patient as a bonus.

Version 3.5 Outpatient Procedural ECR freeware is available here for clinicians and practices who are interested in learning the number of eligible patients they have for any of the given outpatient procedures, the breakdown of claims associated with the procedure into typical services and PAC-related services, and their PAC rates.

The Outpatient Procedural ECR playbooks are available below to provide detailed information regarding the outputs of the test dataset and how the ECRs are constructed.

Outpatient Procedural ECR Playbooks:

1. PCI
2. Pregnancy and Delivery
3. Knee Arthroscopy
4. Gall Bladder
5. Hysterectomy
6. Colonoscopy