Episode of Care definitions are procedure, diagnosis and pharmacy codes grouped together to outline the entire range of treatment for more than 90 conditions. These include all covered services across all providers that would typically treat a patient for a single illness or condition (hospital, physicians, laboratory, pharmacy, rehabilitation facility, etc.) The PROMETHEUS episode definitions that can be used for multiple purposes, including bundled payment and ACO payment programs, reference-pricing initiatives, and for cost and quality analysis of providers.
There is a need for scientifically designed and validated episode of care definitions that have a multi-purpose use. Because the definitions are made available, implementations of payment reform programs and cost and quality analysis initiatives have a comprehensive starting point from which to build.
There are three key features that distinguish our episodes from others:
1. Potentially Avoidable Complications (PACs) -- as illustrated in the figure below showing the episode prices for cataract surgery in a commercially insured population, the higher cost episodes are almost always due to higher PAC costs.
2. Core Services -- condition episodes, and in particular chronic conditions, include markers for services that are recommended by medical specialty societies as being important for the management of a condition. When an episode of care doesn't include any evidence that core services were delivered, that can be construed as an underuse of needed services. The figure below shows the underuse of needed services for the management of coronary artery disease, by provider.
3. Potentially Avoidable Services -- many episodes include services that are flagged as potentially avoidable, having been identified by the Choosing Wisely campaign as not recommended for the management of that condition. The figure below shows services that may not be recommended for the management of patients with coronary artery disease, by provider.
These features, taken together, provide insights for payers, physicians, hospitals and health systems that are unique among health care analytics software and can help reduce costs of care while improving the quality of care delivered to patients.