Two patients in the same clinic. Same problem. Same symptoms. Different doctors beget different treatment plans. Two different charges. Why?
Employers and payors want to know. That fact is that while many healthcare providers boast a lot about quality, few measure their performance either on clinical outcomes and customer satisfaction.
As part of a comprehensive quality management program, Prizm helps quality-minded healthcare companies, hospitals and physician groups reduce treatment variation through written clinical protocols and pathways that standardize the way each physician in a practice triage treats patients. It's true that the benefit of a pathway is in quality. But there is a bigger financial benefit as well. By developing consistent treatment guidelines, Prizm can create case rate packages that cover a month-long episode of care at an attractive, predictable price for managed care.
Prizm, for example, has successfully contracted with health insurance plans using Prizm's case rate methodologies. Instead of getting reimbursed on a CPT-code basis, Prizm clients can be reimbursed on an ICD-9 code basis. The approach is desirable to managed care, because it addresses the quantity of units consumed. For instance, even austere discounts merely reduce the price for a physician office visit or a PT visit. However, such discounts do not control the number of times that CPT code is billed.
Case rate packages are a win-win situation for the quality-oriented provider and managed care payor. In this way, the provider is rewarded for its efficiency rather than punished for it. That's because the best providers will reduce the number of units provided to the best case scenario.
Prizm's proprietary protocols enable a spine center to sort back pain patients into price-predictable categories—without X-rays, MRI or physician exam. Prizm invested over $50,000 on statistical analyses that evaluated means and standard deviations for spine ICD-9s. A spine center can price for an episode of care for physician visits, diagnostics and therapy. Prizm has contracted successfully with a variety of carriers. Without such tools, a spine center would be economically punished for providing conservative care, because it will have fewer CPTs to bill.
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Wouldn’t it be convenient if someone created a listing of spine centers of excellence across the United States that all emphasize non-surgical treatment options before surgery?
Finally, there is a place.