What’s At Stake with the CMS New 2023 Hospital New Orthopedic PRO Performance Measure

CMS released earlier this year its fiscal year (FY) 2023 Medicare Hospital Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital Prospective Payment System (LTCH PPS) final rule. Reimbursement raised by $26 billion for qualified patients and aligns new care provisions with financial incentives (the full text is available here).

Among the most significant updates is the release of 10 new quality measures — including two that apply directly to orthopedic procedures:

• Hospital-Level Risk-Standardized Complication Rate Following Elective Primary Total Hip Arthroplasty/Total Knee Arthroplasty measure (beginning with the FY 2024 payment determination)
• Patient-Reported Outcomes (PRO) following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) Performance Measure (THA/TKA PRO-PM).

Starting October 3rd, providers may begin to collect data for CMS’ first round of voluntary reporting. We, at PatientIQ, strongly recommend getting started right away so there is ample time to test and fine-tune new workflows before reporting is required. Hospitals that fail to meet any of the IPPS reporting requirements will receive a deduction from their annual payment update in FY2028.

The PRO-PM Measure: What’s Involved

The overall goal of the hospital-level THA/TKA PRO-PM is to measure the extent which patients’ self-assessment of their pain and functional status improves before and after their elective THA/TKA procedure. The measure cohort includes patients enrolled in Medicare fee-for-service (FFS), ages 65 years or older who underwent an elective, primary THA and/or TKA.  

The PRO-PM measure is significant because it’s the first time the patient’s outcomes — their direct, subjective feedback — will directly impact provider outcomes. Success will hinge on a healthcare provider’s ability to effectively share data and collaborate with patients. Here are some things to consider:

The Data Sources:

• Patient-reported outcome (PRO) and risk variable data (to identify the measure outcome and some risk variables)
• Administrative claims data (to identify the measure cohort and risk variables)
• Medicare enrollment and beneficiary data (to identify the measure cohort)

Dates to Note:

• Hospitals need to collect PROs before and after an elective, primary THA/TKA procedure
• Preoperative PRO data: collected 90 to 0 days before the procedure
• Postoperative PRO data: collected 300 to 425 days after the procedure

What's Included:

• The measure accounts for patient risk factors obtained from a patient’s 12-month administrative claims history as well as preoperative patient- or provider-reported risk variables.
  

How is non-response accounted for?

• Since responding to PRO data is voluntary, we understand the importance of accounting for non-response. Therefore, the measure uses a statistical approach called inverse probability weighting (IPW) to consider patient characteristics of all eligible THA/TKA patients to address potential non-response bias.

Next Steps for Orthopedic Providers

Now is the time to dig into the law and make sure you are clear on what this means for your practice.

It’s also time to begin the voluntary reporting process: The pre-operative data collection period begins on Monday, October 3, 2022, and runs through June 30, 2023, for THA/TKA procedures occurring between January 1, 2023, and June 30, 2023. Participating in the voluntary process which will ensure your hospital has ample time to:

• Identify collection processes that don’t disrupt clinical workflows,
• Test PRO data submission to CMS, and
• Receive confidential feedback reports with information on PRO data response rates and results

The introduction of the new PRO-PM measure offers an opportunity for healthcare providers to assess patient experience, improve care and demonstrate quality. Contact PatientIQ if you need further guidance from a trusted partner that can oversee the PRO survey process and ensure your PRO-PM measures are ready to submit during the initial voluntary period.