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In January 2022, CIVHC release an update to the Shop for Care tool. The tool empowers users to shop for the most affordable and highest quality care by comparing cost and quality information for over 100 procedures at over 53 named facilities across Colorado using data in the Colorado All Payer Claims Database (CO APCD). Now Coloradans are able to compare prices for more procedures than ever before, and they can make informed decisions in selecting their care by comparing prices for procedures and imaging services such as knee, hip or shoulder replacement, C-section delivery, mammography, and more.

The prices for imaging services in the tool reflect facility payments only, and do not include additional fees like what a radiologist might charge to read your results. However, non-imaging procedure prices in the tool represent the full “episode of care” to give consumers a comprehensive picture of what they can expect to pay before, during and after a procedure. But just what is an “episode of care?”

What Is an Episode of Care?

An episode of care takes the costs of all the services that are typically associated with a specific event or condition, like a knee replacement, and totals the price between consultation, surgery fees, and follow-up care. So, rather than showing separate costs you and your insurer will pay for care associated with your service, episodes of care account for the entirety of what you are likely to pay.

Let’s use a knee replacement as an example. Here are some services and fees that are likely going to occur around your procedure:

1. Pre-op Services:
o Orthopedic Surgeon evaluation costs
o MRI to inspect your knee
o Surgeon evaluating the results of your MRI
o Other visit with your doctor before surgery to make sure you’re ready, including lab tests if you have other chronic conditions they are concerned about
2. Procedure Services:
o Hospital or other facility fee (including operating room, device costs, etc.)
o Surgeon fee
o Anesthesiologist fee
o Medications you receive during the procedure
o Pain medications and anti-inflammatories you receive to take home with you
3. Post-op Services:
o Doctor’s office visit to see how your knee is healing
o Physical therapy visits
o Medications you need after surgery that you didn’t get in the hospital or outpatient center
o Any additional lab tests or services you need during recovery

This graphic gives a more technical break down of how episodes of care are calculated in the CO APCD:

CIVHC uses the PROMETHEUS episode methodology to calculate episodes of care. Claims in the CO APCD are evaluated to find one of nearly 100 potential “trigger codes” that indicates a procedure that has episode-related costs has occurred at a facility or hospital. Then claims are evaluated to see if expected care before during and after is available in the CO APCD to build the complete episode and calculate the total cost. If not all of the “typical” episode-related claims are in the database, that particular instance of the procedure is kicked out of the analysis so that other procedures with the full episode can provide an apples to apples comparison. To learn more about what is included in a PROMETHEUS calculation, please visit the Shop for Care Methodology and FAQs.

How Can Consumers Use Episodes of Care?

When choosing where you will have a medical procedure performed, estimation of costs and the best quality are probably the most important considerations when comparing options. CIVHC chose to report prices based on episodes of care because it most successfully provides all-in costs across all services you might receive. Evaluating the patient experience and overall hospital ranking quality information in the tool along with the prices makes both the cost and the quality comparisons possible.

How Can Providers Use Episodes of Care Data?

Some providers and payers are entering into payment arrangements that pay for value over volume. These payments are called “Alternative Payment Models” because they are different that the traditional fee-for-service model that pays for each service individually. One type of APM is a bundled payment which pays a hospital or provider one payment for all of the care that occurs around a procedure. By paying one price, regardless of what happens, facilities are incentivized to coordinate pre and post care with high value providers, and make sure that things like surgical site infections or other negative outcomes are minimized.

By evaluating episode data from claims, payers and providers can determine what an appropriate bundled payment arrangement might be, and can use the specific data for each segment of the episode, for example, physical therapy costs, to determine where they might have opportunities for cost savings.

A great example of the usefulness of bundled payments to providers working to lower costs is the Colorado Public Employees’ Retirement Association (PERA), which has addressed variation in price for knee and hip replacements through their PERACare Select bundled payment program. CO PERA worked with several hospitals to negotiate a bundled rate, and through the program, patients are incentivized to use these high value facilities which has saved both the patients and the company money while improving outcomes. You can learn more about the program in our Change Agent Chat with PERA.