The Centers for Medicare & Medicaid Services (CMS) already mandated the total hip/knee arthroplasty patient-reported outcome-performance measure (THA/TKA PRO-PM) as a pay-for-reporting measure in quality reporting programs starting in mid 2024. Now, CMS is requiring this same measure as a pay-for-performance quality measure for lower extremity joint replacements (LEJR) episodes in the Transforming Episode Accountability Model (TEAM), a new mandatory episode-based payment model beginning in 2026.
The crux of the THA/TKA PRO-PM is the requirement to collect and report a set of patient-reported outcome measures (PROMs) and additional data elements at both pre-op and 1Y intervals for a specific percentage of eligible patients. These data elements include the HOOS Jr.. KOOS Jr., PROMIS Global, and VR-12 PROMs, as well as risk variables and matching variables.
In quality reporting programs, inpatient and outpatient settings have to collect and report “matched” data–meaning at both pre-op and 1Y post-op for each patient–from at least 50% of eligible patients, while the requirement for ASCs is 45%. Processing of this data includes a substantial clinical benefit (SCB) threshold, which is an increase of 22 points on HOOS Jr. and 20 points on KOOS Jr.; CMS utilizes this and the other data elements to produce a facility-level risk-standardized improvement rate (RSIR).
If these settings do not collect and report the minimum required amount of data, the totality of their Medicare reimbursement–not just for total hip and knee replacements–would be at risk of reduction. Industry benchmarks show that most hospitals do not currently collect this level of data.
Under TEAM, on the other hand, CMS will use this same measure to conduct care quality adjustments to reimbursements, meaning participant performance on this quality measure will impact the payment reconciliation process, directly affecting whether participants gain financial incentives or owe repayments to CMS.
Digital care excellence can enable substantial patient engagement and PROMs compliance exceeding CMS mandatory requirements. An analysis of hip and knee patient data from 6 of our most well-established hospital partners, comprising large hospital systems or academic medical centers across several states, demonstrated that these hospital systems far exceeded the quality reporting requirement even before it became mandatory. Moreover, a vast majority of patients met both the minimal clinically important difference (MCID) in their functional scores and the SCB threshold discussed above.
With 21,982 THA and TKA patients aged 65 years or older included in the study, the results of our analysis are shown below:
- Opt-in Rate: 91%
- KOOS Jr. Matched 1Y Compliance: 71%
- HOOS Jr. Matched 1Y Compliance: 69.7%
- TKA VR-12/PROMIS Global Pre-op Compliance: 87%
- THA VR-12/PROMIS Global Pre-op Compliance: 86%
- KOOS Jr. ≥ MCID: 67.6%
- KOOS Jr. ≥ SCB: 56.5%
- HOOS Jr. ≥ MCID: 78.6%
- HOOS Jr. ≥ SCB: 70.7%
The organizations included in this analysis are already on track to meet both quality reporting and TEAM requirements without any additional effort or resource utilization, avoiding potentially substantial financial penalties and benefiting from the savings they incur through the delivery of high-quality hybrid care. Achieving this level of compliance is only possible through robust patient engagement strategies and capabilities across the whole episode of care.
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