Thursday, August 20, 2009

MORE on Prometheus....

I've posted about this before, but here is an article from the NEJM, which is a bit more substantive.

Prometheus....NO, not the god who was forever condemned to watch his liver being eaten every day, but a healthcare payment system that was first implemented in Rockford, Ill.


Prometheus in Practice

A 63-year-old white man with chest pain and a history of unstable angina is admitted to a teaching hospital. The patient has hypertension and diabetes. An electrocardiogram reveals ST-segment elevation in the lateral leads. The man is taken to the cardiac catheterization laboratory, where coronary angiography reveals severe triple-vessel disease as well as 60% stenosis of the left main coronary artery. A left ventriculogram shows mitral regurgitation (grade 2 to 3) with papillary muscle dysfunction. The patient is then taken urgently to the operating room, where he receives two venousgrafts and a left-internal-thoracic-artery graft. In addition, a mitral-valve reconstruction procedure is performed to correct the mitral regurgitation. The surgery is a success, and the patient returns to the intensive care unit in stable condition. However, his blood sugar is out of control, and he requires an insulin drip. His stay in the intensive care unit is prolonged by 2 days, and he must stay another day in the step-down unit. He is discharged 8 days after surgery in stable condition. One week after discharge, he is readmitted for a wound infection in his leg from the vein harvest site. He requires wound d├ębridement and a course of antibiotics.

Under fee-for-service payment, the hospital would receive $47,500 for the bypass surgery, and the surgeon would receive $15,000 for performing the procedure. The extended hospital stay that was necessitated by the uncontrolled diabetes would result in an additional $12,000 for the hospital and $2,000 for the physician, and the readmission costs would total $25,000, for a grand total of $101,500.

Under Prometheus, the case-payment rate for this patient would include a severity-adjusted budget for typical costs of $61,000 for the hospital and $13,000 for the physician. The severity-adjusted allowance for PACs would be $15,300, for a total budget of $89,300. Had the readmission been prevented, the hospital and physician would effectively have earned a bonus of $12,800 ($101,500 – $25,000 = $76,500, which is $12,800 less than the Prometheus budget).

BTW, Doctors HATE this concept. But they pretty much hate anyone telling them what to do.....


jjmd said...

Get your facts right!

Fee for doing the CABG is around 4200 at the MAX.
It is very easy to crticize the MDs when you have never been in their shoes

Michael Halasy, MS, PA-C said...

Umm, that was cut and pasted from the NEJM article. I did not state myself what the fees are, as I have never worked in cardiac surgery.

There are some physicians btw that support this concept too. Not many, but some.