Successful use of patient reported outcomes in bundled patient contracts

It is a new era in total hip and knee joint replacement (TJR). On April 1, Centers for Medicare & Medicaid Services (CMS) is launching its first mandatory bundled-payment initiative.

For the first time CMS will link payment to quality and patient satisfaction measures in addition to cost. This aggressive approach is expected to improve patient outcomes and control costs. Private insurers are expected to follow.

With this first mandatory initiative, CMS has focused on one of its most expensive and common procedures: There are more than 1,000,000 TJR surgeries each year. In 2004, aggregate charges (the "national bill") for primary TJR surgeries was $50.5 billion (knees > hips). By 2030, demand for TJR is projected to grow by 174% (hips) and 673% (knees), with the fastest growth among patients under 65 years of age.

Under the new Comprehensive Care for Joint Replacement (CJR) program, providers will be on the hook to track quality and prove value in patient care and will be accountable for the cost of episodes of TJR from the time of surgery through 90 days after discharge. CMS will tie each hospital's incentive or penalty to a composite quality score based on three measures: complications within 90 days, the Hospital Consumer Assessment of Healthcare Providers and Systems survey (HCAHPS), and a patient-reported outcome measure (PRO). The composite quality score will take into account significant performance improvement in perioperative complications and patient reported outcomes measures which together could amount to some 60% of the total quality score.

While many of the 789 hospitals participating in the new CJR program are running to figure out how to clinically and operationally manage the TJR episode, surgeons who have been participating in Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement (FORCE-TJR) have already been using a TJR episode management system based on validated patient-reported outcome measures (PROs) to successfully optimize patient care and report quality metrics.

Here are five lessons learned from the more than 250 surgeons and 25,000 TJR patients who have used FORCE-TJR over the past four years for successful TJR episode management:

1. PROs provide actionable data to help guide clinical decision-making.
PROs measure the function and pain that a patient experiences before and after surgery. Validated national benchmarks for patient-reported pain and disability pre-TJR now exist and can be a valuable aid for patients and their surgeons. Comparing a patient's self-reported measures of pre-surgery pain and disability to national norms can help in shared decision-making if TJR is appropriate for the patient and if the timing of TJR is optimal. With this information, surgeons are able to answer: (1) How do my patients' pre-operative risk profiles compare to other surgeons? (2) How does the timing of patient surgery as described by pain and functional limitations compare to national practice?

2. Identifying key risk factors before, during and after TJR can go a long way toward managing the entire 90-day episode of care and successfully participating in value-based contract gainsharing.
PROs and clinical risk factors are critical to identifying patients who are at high risk to have post-op pain and poor outcomes. Once identified, those patients can be managed to reduce post-op complications, emergency room use or hospital readmissions. Surgeons also found PROs useful for informing post-discharge location (home, SNF) and rehabilitation needs. Of particular significance, FORCE-TJR has risk-adjusted, US national benchmarks for peri-operative adverse events, patient-reported outcomes, and early implant failure in both CMS patients, and the 45% of TJR patients who are under 65 years of age. FORCE-TJR worked with CMS to improve their risk-adjustment methods for the CJR program. CMS now recommends submitting additional risk factors such as: BMI, smoking history, pre-op pain and function, and severity of arthritis pain in non-operative hips, knees, and low back. We found that these risk factors are important for more accurate and fairer risk-adjustment when reporting readmission rates and PROs in hospitals caring for more complicated patients or patients with more comorbidities. Such risk adjustment can make the critical difference in whether hospitals and surgeons reach the threshold for participation in the gainsharing opportunities embedded in the CJR program.

3. Incomplete data submission can lead to loss of income and poor provider rankings.
In order to thrive under the new CJR value based reimbursement program, additional reporting and tracking is necessary. Many systems that collect PROs are hospital centric, but the hospital stay is a brief part of the process and hospitals have been less successful in collecting post-discharge outcomes. In order to maximize PRO collection and adverse event surveillance, FORCE-TJR surgeons use a web-based system that follows the patient across the continuum of the episode to different settings. When FORCE-TJR surgeons tracked patients after discharge from the hospital for 30 days (readmissions) and 90 days (for adverse events), we learned that surgeons and hospitals did not have complete event data. On average, one in four patients who experienced a readmission were cared for at a different hospital from where the TJR was performed. While CMS has the total cost and utilization data across time- both at the TJR facility and elsewhere- within the 90 day period, the hospital and surgeon usually do not have these data. Based on this national data, the TJR hospital is at risk for under-estimating readmission costs by 25% which could have significant impact on a provider's bottom line under the CJR value-based contract.

4. Making PRO data collection easy for both patient and surgeon's office is key to success.
With a PRO capture rate of 96% pre-TJR and 85% post-TJR, FORCE-TJR has an unprecedented data completion rate. We've found the key is understanding that it takes more than IT for successful data collection. Engaging and supporting staff with a pro-active tracking system that provides prompts for missing PRO data helps assure capture of complete episode data. Patient enrollment in the surgeon's office, where patients are educated about the need for complete data both before and after TJR makes a big difference. The timing and location of PRO collection postoperatively are especially important to ensure valid outcome assessment. Reaching patients in their homes after surgery is significant because substantial variation exists in the timing of orthopedic office visits following TJR; also, most patients do not return to the original hospital, making hospital collection of PROs unlikely. Data for patients with the most successful outcomes may not be captured with office-based PROs, as patients with optimal pain relief and functional gain are more likely to miss a postoperative office visit than are patients with persistent pain or limitations.

5. Post-TJR PRO measures can be a valuable patient satisfaction and engagement tool.
Was the TJR a success? Only the patient really knows. For most patients, TJR is an elective procedure to improve their quality of life by relieving pain and improving function. After TJR, pain relief and functional gain can be quantified through PROs. Patients can compare post-op scores against national norms and also track them over time to see how much progress they've made since earlier visits. Physicians use post-TJR PROs to tailor follow-up care to support recovery and maximize pain relief and functional return. Patients who report pain relief and improved function are most likely to report improved quality of life, engagement in work and daily activities, and satisfaction with their surgery. For the first time, PROs provide a validated quality measurement that allows third party payers to compare quality between different practices and hospitals based on mean scores for all patients treated by those providers.

Value-based payments, with an emphasis on measuring and reporting quality and improvement in care, are part of CMS' effort to tie 90% of payments to incentive programs by 2018. As the healthcare industry emphasizes patient-centered care and patient engagement, PROs are expected to play an increasing role in assessing performance and determining the effectiveness of different treatments.

About FORCE-TJR (Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement) - FORCE-TJR is a comprehensive arthroplasty value management system that helps orthopedic surgeons and hospitals successfully optimize patient care and report quality metrics. FORCE-TJR provides surgeons and hospitals real-time, individual perioperative patient risk assessments, including patient reported outcome (PRO) data, that allows for risk-based patient management to minimize adverse events and assure best outcomes. Aggregate data provide comprehensive, practice feedback to improve and manage patient care, meet payer reporting requirements, compare performance to peer surgeons/ institutions, and secure quality incentive payments. FORCE-TJR data and methods were established under a $12 million grant from the Agency for Healthcare Research & Quality. With a PRO completion rate of 85%, FORCE-TJR has the only risk-adjusted, US national benchmarks for adverse events, PROs, and early implant failure in both CMS patients, and the 45% of TJR patients who are under 65 years of age.

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