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.

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.

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.

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.

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.

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.