orm_april-2024 - 23

OR Business
The increasing importance of patient-reported outcomes
Mandatory reporting of patient-reported outcome (PROs) data in
VBC is essential for hospitals to keep their practices up to date and
is an important determinant of the level of reimbursement providers
receive.
Starting in 2025, subsection (d) hospitals (acute care facilities
paid under the Inpatient Prospective Payment System) are required
to submit data on quality measures (including PROs) to the Centers
for Medicare & Medicaid Services each year as part of the Hospital
Inpatient Quality Reporting (IQR) program. This data will be an important
factor in determining quality of care, and by extension will influence
the reimbursement amounts for providers. Hospitals that fail to
meet the reporting requirements will face penalties in the form of a
one-fourth reduction in their Annual Payment Update under the IPPS.
An example of additional data reporting requirements that have
most important quality measure that
is assessed before and after surgery,
both immediately and long-term, " he
explains. " Surgeons are provided data
about the Improvement in quality of
life of their intervention. Participating
surgeons, like me, get feedback about
how well out interventions worked, and
how our patients do compared to other
surgeons. "
ACHQC and HOUSES both reflect a
focus on a broader definition of care
quality-one that is more in line with
the tenants of VBC, and with what frontline
surgeons already know is most important
to patients. " The improvement
in a patient's quality of life after an
intervention is ultimately the most important
variable that the patient cares
about, " Dr Reinhorn says. " Patients
want to know when they can get back
to work, daily activities, recreation, and
exercise. "
Evaluating value
Under VBC's expanded model of what
constitutes quality care, reimbursement
rates depend heavily on the quality of a
provider's data reporting, says Bronwyn
Spira, founder and CEO of digital care
management platform Force Therapeutics.
If data reveal a higher-than-average
number of adverse events driving
www.ormanager.com
already been implemented is the Comprehensive Care for Joint
Replacement Model. In place since 2016, this VBC model focuses
on three major elements including PROs for total hip and knee arthroplasty
(THA/TKA) patients. In 2023, providers were required to
submit at least 80% of PRO data for THA/TKA preoperative and postoperative
procedures. In 2024, the percentage will increase to 85%
for postoperative and 90% for preoperative care.
For example, a recent ruling by CMS on capturing PROs in total
joint and total hip shows that hospitals not reporting a complete data
set for 50% of all eligible patients can receive a penalty in the form
of a 25% reduction in Annual Payment Update (usually 2-4%) for all
the hospital's Medicare Part A FFS claims, including non-orthopedic
claims. The penalty also includes disqualification of a hospital from
participation in all Medicare value-based purchasing programs.
up costs, the provider
could be penalized.
Under-reporting certain
metrics also can
jeopardize reimbursement.
For example, a
recent ruling by CMS
on capturing patientreported
outcomes
Bronwyn
Spira
(PROs) in total joint and total hip shows
that hospitals not reporting a complete
data set for 50% of all eligible patients
can receive a penalty (sidebar, The increasing
importance of patient-reported
outcomes).
Bad data reporting can have consequences
beyond lower reimbursements,
Spira says. As the transition to VBC
accelerates, private payers (insurance
companies) will use data to create better
policies, pinpoint cost-effective treatment
approaches, prevent fraud, and
deter against overbilling and unethical
practices. For example, a provider might
not be recommended, or even avoided,
due to a tendency to create high costs
for the payer.
On the other hand, providers may
be rewarded if data show above-average
results. " Effective data additionally
enables providers to construct a better
argument for improved reimbursement, "
says Eziah Syed, CEO at Mend,
a life sciences company
in New York City. " For
instance, The Joint
Commission evaluates
practices based on their
data quality, and these
evaluations impact a
practice's capability to
secure increased reimbursement. "
As an example, he cites a success
story involving the company's Upgraid
program, which combines nutrition and
pharmaceutical products with pre- and
a post-surgery digital health coaching
platform. From September to November
last year, data collected on this system
from a practice in Oklahoma showed
a higher-than-average number of PROs
after elective primary total hip or total
knee arthroplasty (THA/TKA).
Eziah Syed
After hospitals submit preoperative
and postoperative PRO data to CMS,
CMS uses that data to create a final
risk-standardized improvement rate
(RSIR). For example, if a hospital receives
60% RSIR, it indicates that 60%
of the patients reported a significant
improvement in THA/TKA procedure.
In this case Upgraid followed all of The
Joint Commission's criteria, so it the
group received a higher rating. " These
ratings can then serve as a negotiating
proof point with payers, " Syed says.
OR Manager | April 2024
23
https://www.aaos.org/quality/research-resources/patient-reported-outcome-measures/ http://www.ormanager.com

orm_april-2024

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