According to legend, Prometheus (the Greek Titan) brought fire and enlightenment to mankind. Unfortunately, PROMETHEUS (the payment system) has has not shed any positive light on the concept of payment reform.
The fee-for-service payment system, the norm in the United States for decades, has recently come under fire as one of the driving forces behind the expensive and uncoordinated health care delivered in this country. Utilizing a retrospective philosophy, the fee-for-service system does not incentivize health care providers to focus on outcomes; instead it encourages increased volume.
Alternatives to the fee-for-service system have arisen in the past, notably capitation payments under health maintenance organizations, but these prospective systems have not yet supplanted fee-for-service.
The latest iteration of prospective payment systems is bundled payment; one experimental variant of this is the the Provider Payment Reform for Outcomes, Margins, Evidence, Transparency, Hassle reduction, Excellence, Understandability, and Sustainability (PROMETHEUS) Bundled payment experiment.
Researchers undertook a case study approach to investigate the implementation of PROMETHEUS at three pilot sites in Pennsylvania, Michigan, and Illinois. PROMETHEUS was designed as a payment system that would pay for all care under a defined episode. By bundling what typically are multiple charges from hospital services, imaging, professional services (i.e. doctors), and sometime rehabilitative services, the bundled payment concept encourages these various components of the health care system to coordinate and streamline care in order to reap financial benefits. The payment rates for each bundle are termed “evidence-informed case rates.” Bundles range in nature from chronic care such as diabetes, to acute conditions such as heart attacks, and to procedures such as joint replacement. Case rates are modified by “potentially avoidable complications,” a term used to encompass technical risks assumed by the health care providers due to poor systems, planning, or training. The potentially avoidable complications modification functions as a “warranty” by providers on the quality of care delivered within that bundle.
Three years into the pilot programs, neither of the three institutions had established any contracts or begun to make bundled payments. Interviews with stakeholders revealed several themes explaining the poor implementation of PROMETHEUS.
Pilot sites had extreme difficulty defining bundles in terms of their current services and processes. The bundling concepts were easier to implement for procedures compared to chronic medical conditions because procedures tended to have more defined pathways and involved fewer clinicians. Once defined as within a bundle, it was difficult for providers to determine if a specific service should be considered typical care or a potentially avoidable complication.
Payers have been unable to agree on how to allocate “shared savings” while providers have been unwilling to accept a “withholding” strategy. Additionally, providers have not yet determined how to fairly allocate payments received amongst themselves. Physicians, while supportive of the concept of PROMETHEUS, do not buy-in when the rubber hits the road.
The pilot sites also found that PROMETHEUS adds to an already complex and burdensome system of billing for providers. Instead of replacing the old system, bundled payments add one more contractual payment scheme to the fee-for-service structures retained by other insurers.
Lastly, some pilot sites simply viewed PROMETHEUS’ methodology skeptically. In one case, the assumption that potentially avoidable complications could be reduced by a specific amount was deemed purely arbitrary and not evidence-based.
The concept of bundled payments as envisioned by the creators of the PROMETHEUS system has a long way to go before its ready for prime-time. Physician buy-in appears low, implementation has been slow, and many are skeptical that prospective payments can be made in a way that are fair to both payers and providers. Even if that parity can be achieved, fairness between providers – hospitals, doctors, and the like – will likely remain elusive. As evidenced by the recent clamor against modifications to the Medicare fee-for-service rates, the success of PROMETHEUS – and the concept of bundled payment – remains doubtful.
Cedric Dark, MD, MPH