Potentially Avoidable Complications What Ob-gyns Need to Know Welcome to the training. Today we will discuss potentially avoidable complications.

Learning Objectives After participating in this training, participants will be able to Define potentially avoidable complications Describe the PROMETHEUS payment model Infer various ways to reduce the number of potentially avoidable complications within their practice Before we begin, let’s review the learning objectives. After completing this training, participants will be able to define potentially avoidable complications, describe the PROMETHEUS payment model, and infer various ways to reduce the number of potentially avoidable complications within their practice.

What Are Potentially Avoidable Complications? Problems experienced by a patient during treatment that could potentially have been avoided if care had been delivered in a different way Created to determine the amount of unexplainable variation in total costs of care that could be reasonably attributed to complications under the control of providers Potentially avoidable complications, referred to as PACs throughout this presentation, are problems experienced by a patient that could potentially have been avoided if care had been delivered in a different way. PACs were created to help tease out the proportion of unexplainable variations of cost that could be attributed to providers.

Why Do PACs Matter? Health Care Incentives Improvement Institute (HCI3) analyzed 3.5+ million commercial claims for patients under 65 Found that PACs account for up to 30 cents of every US Health dollar in across 6 common chronic conditions1 Asthma Coronary artery disease Congestive heart failure Chronic obstructive pulmonary disease Diabetes Hypertension PACs are important because, according to the Health Care Incentives Improvement Institute, they account for up to 30 cents of every dollar in US health spending across six common chronic conditions, including asthma, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, diabetes and hypertension.

Why PACs Matter, continued Insurers want to eradicate PACs to improve health care quality and reduce overall costs “Low-hanging fruit” – costly mistakes that can be corrected Requires behavior change among providers The rate of PACs can be a performance measure in P4P systems as well as a method of implementing a payment model with penalties for such complications PROMETHEUS payment model is one promising tool PACs also matter because their eradication is seen by insurance companies as one way to improve health care quality and reduce costs. Many PACs are considered “low-hanging fruit” or costly mistakes that can be corrected with a simple change in practice or intervention. Though seen as “low-hanging,” eliminating PACs requires behavior change among providers, which can take a considerable amount of time. The rate of PACs is being used widely across the health care system as a performance measure in value-based payment and other alternative payment models. PROMETHEUS is one promising tool for reducing PACs that is being widely adopted.

What Is PROMETHEUS? A bundled payment model designed to split responsibility for technical and probability risk between clinicians and insurers. Technical risk Controllable by the clinician Responsive to the clinician’s clinical skills and the systems of care he/she Probability risk Based on the likelihood that a random event will occur to a patient as a result of their genes, health status, etc. Any external event outside the control of the clinician PROMETHEUS is a bundled payment model designed to split responsibility between clinicians and insurers. The model differentiates between technical risk, or that which is controllable by clinicians, and probability risk, which is based on the likelihood that a random event will occur that is outside the control of a clinician.

PROMETHEUS, continued Currently the only payment model with an analytic platform that includes PACs Based on 4 basic concepts Fair compensation for physicians, hospitals and health systems Direct and powerful incentives to deliver better care and outcomes Team-based care, information sharing, and collective responsibility for patient health Transforming the health care system to one that is more integrated and accountable Model was first piloted at 3 sites beginning in the mid-2000s Now serves as a model for payment reform initiatives around the country PROMETHEUS is the only payment model with an analytic platform that includes PACs. It launched in the mid-2000s, and centers on 4 basic concepts: Fair compensation for physicians, hospitals and health systems Direct and powerful incentives to deliver better care and outcomes Team-based care, information sharing, and collective responsibility for patient health Transforming the health care system to one that is more integrated and accountable

PROMETHEUS, continued Began with 21 episodes and corresponding evidence-informed case rates (ECRs) ECRs are the payment rates for each episode of care ECRs are severity-adjusted to the patient and include all covered services related to the care of the condition ECRs are built to differentiate between typical services and those associated with PACs The current version has 97+ distinct episodes Some are related Some can be grouped by disease When PROMETHEUS first became available, the model contained 21 episodes of care with corresponding evidence-informed case rates (or ECRs). ECRs are essentially the payment rates for each individual episode of care. These payment rates are severity adjusted and are built to differentiate between typical medical services and those associated with PACs. The current version of PROMETHEUS has expanded to include over 97 episodes.

PROMETHEUS, continued PROMETHEUS has 2 categories of PACs Those related to the index condition or stay, e.g., loss of libido after total hysterectomy Those related to patient safety failures, e.g., post-operative wound infection after cesarean section All PACs are identified through trigger diagnostic codes ICD-10 diagnosis codes ICD-10 PAC codes ICD-10 procedure codes CPT/HCPCS procedure codes Drug groups Within the PROMETHEUS model, there are two kind of PACs: those related to the index condition, for example, loss of libido after total hysterectomy, and those related to patient safety failures, for example, post-operative wound infection after cesarean section. Each episode within the PROMETHUS payment model relies on diagnostic coding to identify the PACs.

PROMETHEUS, continued In 2011, the National Quality Forum endorsed 4 PAC measures as comprehensive outcome measures:2 Proportion of patients with a chronic condition that have a PAC during a calendar year Proportion of acute myocardial infarction patients that have a PAC (during the index stay or in the 30-day post-discharge period) Proportion of stroke patients that have a PAC (during the index stay or in the 30-day post-discharge period) Proportion of pneumonia patients that have a PAC (during the index stay or in the 30-day post-discharge period) In 2011, the National Quality Forum (or NQF) endorsed four PAC measures as comprehensive outcome measures. This is a significant achievement, as many NQF-endorsed measures and standards serve as a foundation for initiatives to enhance health care value and improve patient health outcomes.

PROMETHEUS, continued The NQF-endorsed measures can now be implemented by various entities Doctors and other health care providers Hospitals and other health care facilities Employers Health plans, public agencies, and others across the country Implementers have access to comparable data Identify gaps in measurement Better understand cost and quality issues The four NQF-endorsed measures can now be implemented across the country. Clinicians, hospitals, and other health care facilities reporting on these measures will have access to comparable data through NQF that can be used to better understand their individual health care cost and quality issues.

Why PACs Matter for Ob-gyns Providing care with high numbers of PACs lowers health care quality and increases health care spending In the PROMETHEUS model, higher cost episodes are those that include larger numbers of PACs So why does this matter for ob-gyns? Evidence suggests that providing care with high numbers of PACs lowers health care quality and increases health care spending. Indeed, in the PROMETHEUS model, as you can see from the graph on the right, higher cost episodes are those that include larger numbers of PACs.

Why PACs Matter for Ob-gyns, continued The PROMETHEUS bundled payment model includes numerous episodes for ob-gyns Cesarean section, vaginal delivery, gynecological cancers, hysterectomy, newborn care, pregnancy, preventive care, and urinary tract infection All PROMETHEUS episodes are open source, meaning they can be used widely in payment and delivery system reform efforts See ob-gyn episode definitions at prometheusanalytics.net/deeper-dive/definitions- readable Within each episode, there is risk of facing PACs The PROMETHEUS payment model includes multiple episodes for ob-gyns, including cesarean section, vaginal delivery, gynecological cancers, hysterectomy, newborn care, pregnancy, preventive care, and urinary tract infection. To access these open source episodes, visit the PROMETHEUS website and click “Deeper Dive.”

Why PACs Matter for Ob-gyns, continued Reducing PACs requires behavior change among providers, but will result in higher quality health care and reduced costs Failure to reduce PACs could result in penalties from third-party payers, including Medicare, Medicaid, and private insurers PAC reduction models, like PROMETHEUS, can help move the health care system to one that rewards value over volume While reducing the number of potentially avoidable complications in any ob-gyn practice will require behavior change among physicians, doing so has the potential to reap considerable savings and improve care quality and patient outcomes. Conversely, as the US health care system as a whole moves away from volume-based reimbursement, failure to reduce PACs could result in penalties from third party payers, both public and private. PAC reduction models, like PROMETHEUS, can help ob-gyns and the health care system as a whole complete the transition to a system that rewards value.

Contact ACOG For more information, visit www.ACOG.org/Practice- Management Send inquiries to PracticeManagement@acog.org For more information, visit www.ACOG.org/Practice-Management. Send inquiries regarding Potentially Avoidable Complications to practicemanagement@acog.org.

Resources 1 de Brantes, Francois, Rosenthal, Meredith A., and Painter, Michael. (2009) “Building a Bridge from Fragmentation to Accountability — The Prometheus Payment Model.” New England Journal of Medicine 361:1033-1036. http://www.nejm.org/doi/abs/10.1056/NEJMp0906121 2 National Quality Forum Quality Positioning System. www.qualityforum.org/QPS