CMS Mandates THA/TKA PROs in ASC and HOPD Quality Reporting

In its CY2024 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center (ASC) Payment System final rule, the Centers for Medicare & Medicaid Services (CMS) has finalized, among other updates, its proposal to adopt mandatory reporting of the patient-reported outcome-based performance measure (PRO-PM) following total hip and knee arthroplasty (TKA/THA) in both the Hospital Outpatient Quality Reporting (OQR) and ASC Quality Reporting (ASCQR) Programs.

This aligns with CMS inpatient rulemaking finalized in late 2022, which introduced the THA/TKA PRO-PM into the Hospital Inpatient Quality Reporting (IQR) Program through a phased approach, with two voluntary reporting periods in 2023 and 2024, followed by the first mandatory collection period starting April 2, 2024 and the first reporting deadline on September 30, 2025 (learn more about the IQR PRO-PM updates here).

Why is this being implemented?

CMS is implementing this measure—which was developed through a voluntary PRO data collection program in the Comprehensive Care for Joint Reconstruction (CJR) model—to gather insights on how to to address disparities in outcomes and clinical practice across the US, namely readmission and complication rates, by encouraging an emphasis on care coordination throughout the entire episode of care for THA and TKA.

Because the primary motivations for THA and TKA procedures are to lower pain and improve joint function, CMS contends that PROs represent an important measure of outcomes.

How will this be measured?

Substantial clinical improvement will be assessed based on the difference in patient score on joint-specific PRO instruments between preop PRO assessment and postop PRO assessment; more specifically, the outcome measure depends on the proportion of patients who meet or exceed a threshold of 22 points on Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement (HOOS, JR) for THA and 20 points on Knee injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS, JR) for TKA.

CMS will utilize PROs (further detailed below), as well as claims data, Medicare enrollment and beneficiary data, and US Census Bureau survey data for measure calculation, to conduct data aggregation, matching, risk adjustment analyses, and to account for non-response bias. This will result in a hospital-level risk-standardized improvement rate (RSIR), representing a quality of care metric that accounts for patient mix, patient-level risk, and non-response bias.

What data do I have to submit?

Providers will be able to submit data themselves or via a vendor or registry through the existing CMS infrastructure for quality reporting programs. Below is a list of all assessment variables that will be required for data submissions:

Source: CY2024 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center (ASC) Payment System final rule.

Which patients do I have to collect data from?

THA/TKA patients must meet the following criteria to be eligible for PRO collection:

• 65 years or older undergoing elective primary THA or TKA, excluding revisions, fractures, and staged procedures
• Enrolled in Medicare FFS Part A and B for 12 months prior to the date of the procedure and enrolled in Medicare Part A and B during the procedure
• Discharged alive (patients that leave hospitals against medical advice are excluded)

When will this be required?

This measure will be implemented for both HOPDs and ASCs through a phased approach, with three voluntary reporting periods followed by the first period of mandatory reporting; the specific timelines for performance periods, data collection windows, and submission deadlines are shown in the table below:

Source: Tables 136, 137, 142, and 144 from the CY2024 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center (ASC) Payment System final rule.

Why should I participate in voluntary reporting?

• Ensure PRO collection flows with clinical workflows efficiently:
  • For facilities not already collecting PROs, beginning to do so requires careful consideration of how such a process may impact internal workflows and what time and cost burdens a hospital may have to adapt to.
  • For facilities not submitting data directly, the voluntary reporting periods provide time to partner with a vendor or establish a submission process through a registry.
• Test and refine data submissions to the OQR and ASCQR before mandatory reporting begins.
• Receive confidential feedback reports including details on response rates and results, as well as RSIRs, which would provide insight on how your facility is performing relative to other participants in voluntary reporting:
  • This information can be helpful for facilities wanting to ensure all processes for effective clinical practice are established prior to mandatory reporting.

Are there penalties for not participating?

Facilities that do not report the minimum requirements of mandatory reporting will see a negative impact–specifically a 2% reduction–on their annual payment update (APU) for CY2031. That said, there are no penalties for facilities that choose to not participate in voluntary reporting cycles.

To be clear, both the OQR and ASCQR programs are exclusively pay-for-reporting programs, and any payments arising from these programs are not affected by patient outcomes, but rather only by a lack of reporting compliance. Therefore, facilities that do not meet the minimum mandatory requirement of submitting timely complete data on at least 50% and 45% (for HOPDs and ASCs, respectively) of their eligible patients will be penalized in 2031, regardless of the quality of patient outcomes.

Will results be reported publicly?

During voluntary reporting, CMS will make public the list of hospitals that chose to participate and/or the proportion of complete pre-op or post-op data they submitted.

Following mandatory reporting, hospitals will receive feedback reports before results are made available publicly, after which results and response rates will be posted on the Department of Health and Human Services’ Care Compare tool.

Learn how Force Therapeutics can support your CMS quality reporting programs. Contact us today.

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