White Paper AGA: An Episode-of-Care Framework for the Management of Obesity-Moving Toward High Value, High Quality Care: A Report From the American Gastroenterological Association Institute Obesity Episode of Care and Bundle Initiative Work Group.

The American Gastroenterological Association acknowledges the need for gastroenterologists to participate in and provide value-based care for both cognitive and procedural conditions. Episodes of care are designed to engage specialists in the movement toward fee for value, while facilitating improved outcomes and patient experience and a reduction in unnecessary services and overall costs. The episode of care model puts the patient at the center of all activity related to their particular diagnosis, procedure, or health care event, rather than on a physician's specific services. It encourages and incents communication, collaboration, and coordination across the full continuum of care and creates accountability for the patient's entire experience and outcome. This paper outlines a collaborative approach involving multiple stakeholders for gastrointestinal practices to assess their ability to participate in and implement an episode of care for obesity and understand the essentials of coding and billing for these services.

Prometheus payment model: application to hip and knee replacement surgery.

The Prometheus Payment Model offers a potential solution to the failings of the current fee-for-service system and various forms of capitation. At the core of the Prometheus model are evidence-informed case rates (ECRs), which include a bundle of typical services that are informed by evidence and/or expert opinion as well as empirical data analysis, payment based on the severity of patients, and allowances for potentially avoidable complications (PACs) and other provider-specific variations in payer costs. We outline the methods and findings of the hip and knee arthroplasty ECRs with an emphasis on PACs. Of the 2076 commercially insured patients undergoing hip arthroplasty in our study, PAC costs totaled $7.8 million (14% of total costs; n = 699 index PAC stays). Similarly, PAC costs were $12.7 million (14% of total costs; n = 897 index PAC stays) for 3403 patients undergoing knee arthroplasty. By holding the providers clinically and financially responsible for PACs, and by segmenting and quantifying the type of PACs generated during and after the procedure, the Prometheus model creates an opportunity for providers to focus on the reduction of PACs, including readmissions, making the data actionable and turn the waste related to PAC costs into potential savings.

Evidence-informed case rates: paying for safer, more reliable care.

There is widespread dissatisfaction with the current modes of paying for health care. Created by Prometheus Payment, evidence-informed case rates (ECRs) are designed to create fair payments for all providers delivering care to a patient for a particular condition. ECRs would combine global fees with an allowance for complications and performance incentives.The authors model ECRs for two scenarios, acute myocardial infarction and diabetes. Their analysis shows that, under fee-for-service payments, a high proportion of the costs of care go toward potentially avoidable complications--some 30 percent of payments for acute myocardial infarctions and 60 percent of payment for diabetes care. They conclude that ECRs would hold the delivery system accountable for the technical risk it imputes on the total costs of care--for medical errors and potentially avoidable complications. Further, ECRs would create incentives for providers to deliver care that is safer, more reliable, and consistent with evidence-based guidelines.

Episode of care analysis reveals sources of variations in costs.

OBJECTIVES: To understand and reveal the underlying sources of inter- and intraplan variation in a selected number of chronic and procedural episodes. STUDY DESIGN: Analysis of allowed claims from 9 regional health plans covering commercially insured populations in different areas of the United States. METHODS: Use of the PROMETHEUS Evidence-Informed Case Rates analytics to 1) calculate total plan costs and cost of specific episodes, 2) create price and severity adjustments, and 3) determine coefficients of variation. RESULTS: The interplan coefficients of variation for total per member per year costs and per episode costs vary from 0.1 to 0.55, while the intraplan coefficients of variation vary from 0.4 to 5.5. In both analyses, the coefficients of variation for potentially avoidable complications (PACs) were higher than the coefficients of variation for typical costs. CONCLUSIONS: There is significant variation in episode costs within a plan, and PACs have significantly more variation than typical costs. Plans and accountable care organizations would benefit from understanding the source of variation of their episode costs in order to improve overall cost of care.

New York state ear, nose, and throat specialists' views on pre-sinus lift referral.

BACKGROUND: Dental implant surgery in the posterior maxilla often involves the maxillary sinuses. Sinus surgery for dental implants is highly successful, but the preoperative risk is difficult to assess because a routine preoperative evaluation does not include an intranasal examination by an otolaryngologist. The purpose of the present study is to obtain the opinions of ear, nose, and throat (ENT) specialists located within New York state in an effort to establish a referral protocol before performing a maxillary sinus elevation. This study assesses the need to consult an ENT specialist for evaluation and treatment recommendations in the pretreatment workup. METHODS: A questionnaire and a stamped, return envelope with an identification number was mailed to 302 physicians who maintained a current ENT-specialty practice or practiced that specialty in a hospital or clinic setting in New York state. The requirement criteria included a valid address and specialty designation. Up to two follow-up phone calls were made, and another questionnaire was mailed 30 days after the initial mailing. The questionnaire included eight computerized tomography (CT)?scan images that represented different sinus configurations. Answers to the five questions were statistically evaluated and analyzed. A total of 63 recipients returned the questionnaire and were included in the study. RESULTS: A majority of 58.7% (95% confidence interval: 46.9% to 71.1%) of respondents recommended that a maxillary sinus CT scan should be routinely prescribed before a sinus-lift surgery. Patient symptoms that ENT specialists suggested indicated referral included nose complications/problems (40.1%) and sinus issues (23.6%). Of the eight CT-scan images, referral suggestions were >50% for the following: an occluded sinus with septum, inflammation at the base of the sinus only, a sinus with a generalized thickened membrane, an oroantral fistula, a thickened sinus membrane in association with teeth that had endodontic and/or periodontic involvement, and a nearly completely occluded sinus that was missing palatal bone. For patients with seasonal allergies, ENT specialists suggested delaying surgery (20.6%) or controlling symptoms before surgery (41.3%). Concerns included a past history of a sinus surgery (87.3%), chronic sinusitis (85.7%), presence of ostium stenosis (68.3%), nasal or sinus obstruction (82.5%), and oroantral fistulation (74.6%). CONCLUSIONS: Within the limits of the study, an attempt is made to develop a preoperative protocol, and 63 responses from ENT specialists suggested that the majority (58.7%) would recommend a maxillary CT scan before a sinus-lift surgery. Their greatest concerns were a prior sinus surgery, severe sinus inflammation, nasal/sinus obstruction, and oroantral fistulation.

Reducing potentially avoidable complications in patients with chronic diseases: the Prometheus Payment approach.

UNLABELLED: OBJECTIVE (OR STUDY QUESTION): To determine whether a new payment model can reduce current incidence of potentially avoidable complications (PACs) in patients with a chronic illness. DATA SOURCES/STUDY SETTING: A claims database of 3.5 million commercially insured members under age 65. STUDY DESIGN: We analyzed the database using the Prometheus Payment model's analytical software for six chronic conditions to quantify total costs, proportion spent on PACs, and their variability across the United States. We conducted a literature review to determine the feasibility of reducing PACs. We estimated the financial impact on a prototypical practice if that practice received payments based on the Prometheus Payment model. PRINCIPAL FINDINGS: We find that (1) PACs consume an average of 28.6 percent of costs for the six chronic conditions studied and vary significantly; (2) reducing PACs to the second decile level would save U.S.$116.7 million in this population; (3) current literature suggests that practices in certain settings could decrease PACs; and (4) using the Prometheus model could create a large potential incentive for a prototypical practice to reduce PACs. CONCLUSIONS: By extrapolating these findings we conclude that costs might be reduced through payment reform efforts. A full extrapolation of these results, while speculative, suggests that total costs associated to the six chronic conditions studied could decrease by 3.8 percent.