The PROMETHEUS Model: Lighting the Fire of Clinical Integration

As the debate about clinical integration has evolved, the standard definition has been refined to describe the process of physicians working systematically to improve their processes across the medical field of providing effective, quality care. The PROMETHEUS Payment model is showing potential in addressing one of the more problematic challenges to widespread health reform.

While the ultimate goal of patient care is a cause espoused by physicians and health care administrators, the barriers along the way — in particular the financial burdens — have proven cumbersome. Standardization coupled with measurement, communication between health care providers and leadership development in all medical professionals can attend to the logistical and even the regulatory hurdles.

However, how to pay for improved quality care and decreased overall costs remains unchanged by various propose payment models. Rather than expanding upon the unit-of-service payment, PROMETHEUS Payment operates on an episode-of-care system.

Shifting Payment’s Focus

Currently in ongoing pilot studies at four United States sites, the model involves bundling the medical services a patient receives from all providers for one illness or condition. Each comprehensive episode from acute and chronic illnesses to inpatient procedures is assigned an evidence-informed case rate (ECR) that serves as the budget for the patient’s total medical services, regardless of where or by whom those services are provided.

The Motivation Behind the Model

PROMETHEUS Payment is intended to foster collaboration between the different players in a patient’s care team, which is incentivized by a system of bonuses based on a comprehensive quality scorecard and the measured reduction of potentially avoidable complications (PACs). The scorecard assesses the clinical and patient satisfaction outcomes, as well as each provider’s individual contribution to both.

Built into the ECR, in addition to the reimbursements for services, is an amount to be paid as a bonus based on the final scores. However, rather than grounding a physician’s portion simply on his or her performance, 30% of his or her score is tied to the performance of the other providers who treated the patient. Each provider then becomes responsible for ensuring the entire care team follows the appropriate clinical guidelines and affords the patient the best, most effective service.

In relation to PACs, the PROMETHEUS Payment team discovered in an evaluation of national data that complications account for 40 cents of every dollar the health care industry spends on chronic conditions on top of 15 to 20 cents of every acute hospitalization and procedure dollar. A PAC allowance is also factored into the ECR to cover complications should they arise, but if they do not present in a patient’s case, the allowance is distributed as bonuses to providers on the care team.

Thus far, PROMETHEUS Payment pilot studies have demonstrated cost savings despite the two-fold allowances built into each ECR.

MD News November 2011