CMS Issues New THA/TKA PRO-PM in the FY 2023 Hospital IPPS

Introduction to CMS’s 2023 Hospital IPPS Final Rule

On August 1st, CMS announced the final ruling of the Hospital Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital Prospective Payment System (LTCH PPS) for fiscal year (FY) 2023. This is big news- the program boosts reimbursement for hospitals by $2.6 billion, which equates to a 4.3% increase. There are also 10 new measures being adopted under the Hospital Inpatient Quality Reporting (IQR) Program. Two (2) of the 10 measures relate directly to Orthopedics so many of our clients and friends will experience considerable impact. One of the measures will evaluate Hospital-Level Risk-Standardized Complication Rate (RSCR) Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) Measure. This blog will specifically unpack the second of the two (2) measures that will require reporting on patient-reported outcomes- the Hospital-Level, Risk Standardized Patient-Reported Outcomes Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) Performance Measure (THA/TKA PRO-PM).

What is the backstory/history of the Hospital IPPS Program and the THA/TKA PRO-PM?

CMS pays acute care hospitals for inpatient stays under a payment program called the Inpatient Prospective Payment System (IPPS). It is updated by CMS annually. Within the IPPS is the Hospital Inpatient Quality Reporting (IQR) Program that allows CMS to collect data from hospitals that are paid under the program. The IQR program was originally mandated in Section 501(b) of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 and continues to be updated. It is a pay-for-reporting quality program with the goal of “driving quality improvement through measurement and transparency by publicly displaying data to help consumers make more informed decisions about their health care. It is also intended to encourage hospitals and clinicians to improve the quality and cost of inpatient care provided to all patients.” 

The THA/TKA PRO-PM is a new measure for FY 2023 under the Hospital IQR Program that will impact those in Orthopedics. Elective primary THA and TKA are very common procedures for those suffering from degenerative joint disease or osteoarthritis. The procedures can alleviate pain, improve function and improve quality of life; however, patients’ outcomes can vary. The THA/TKA PRO-PM is designed to collect large-scale PRO data to better understand hospital-level variation in outcomes from those procedures. This measure is modeled after the voluntary PRO data collection option within the Comprehensive Care for Joint Replacement (CJR) model and aligns with the Meaningful Measures Framework. CMS stated they believe that “measuring patient-reported outcomes is an important aspect of patient-centered healthcare” and “that the patient voice should be prioritized across healthcare systems and providers”.

What data points are collected, when do they need to be collected, and how is data submitted? 

The THA/TKA PRO-PM uses four (4) data sources for the calculation of the measure: PRO data; claims data; Medicare enrollment and beneficiary data; and U.S. Census Bureau survey data. The combination of PRO data and risk variable data will be collected pre-operatively between 90 and zero days prior to the THA/TKA procedure. The PRO data will be collected using either HOOS JR (for THA patients) or KOOS JR (for TKA patients) and either PROMIS Global (mental health subscale items) or VR-12 (mental health subscale items). The Single-Item Health Literacy Screening (SILS2) questionnaire will be collected as well.

PRO data will also be collected post-operatively by hospitals between 300 and 425 days following the THA/TKA procedure. Hospitals will again collect PRO data from HOOS JR (THA patients) and KOOS JR (TKA patients).

The measure will assess hospital-level risk-standardized improvement rate in PROs between the pre-operative and post-operative time periods. CMS defines patient improvement using pre-defined thresholds of 22 points on the HOOS JR and 20 points on the KOOS JR.

Hospitals can either choose to submit their data to CMS for measure calculation directly or utilize an external entity, such as a vendor or registry, to submit data on their behalf. CMS’s goal of offering multiple options for submission is to give hospitals flexibility in selecting a collection option that works best for their workflow. The Hospital Quality Reporting (HQR) system will leverage the existing CMS infrastructure currently utilized for other quality measures like HCAHPS. Files can easily be shared in multiple formats, including .csv and .xml. Detailed instructions and information regarding data submission for the THA/TKA PRO–PM is available through the CMS website, QualityNet.

Who is impacted by the THA/TKA PRO-PM?

Hospitals that perform elective primary THA/TKA procedures will be impacted by this measure. The measure will include patients who are:

• Enrolled in Medicare fee-for-service (FFS) Part A and Part B for the 12 months prior to the date of the index admission and enrolled in Part A during the index admission;
• Aged 65 or older; and
• Discharged alive from a non-Federal short-term acute care hospital. The measure includes only elective primary THA/TKA procedures (patients with fractures and revisions are not included).

While the rule applies to inpatient settings only right now, CMS is aware of the ongoing shift of procedures like THA and TKA towards outpatient settings, especially Hospital-Based Outpatient Departments (HOPDs) and Ambulatory Surgery Centers (ASCs). They hope to expand similar measures to these settings in the future.

When does reporting start?

There are two voluntary reporting periods for the measure followed by mandatory reporting. Below is the timeline:

• The first voluntary reporting period will begin with pre-operative PRO data on procedures performed January 1, 2023 through June 30, 2023.
  • Pre-operative data collected from October 3, 2022 through June 30, 2023 and post-operative data on those same patients collected from October 28, 2023 through August 28, 2024. See Figure 1 below.
  • CMS will then provide confidential feedback to participants in 2025.
• The second voluntary reporting period will begin with pre-operative PRO data on procedures performed July 1, 2023 through June 30, 2024.
  • Pre-operative PRO data collected from April 2, 2023 through June 30, 2024 and post-operative data on those same patients collected from April 26, 2024 through August 29, 2025. 
  • CMS will then provide confidential feedback to participants in 2026.
• Mandatory reporting will begin with procedures performed July 1, 2024 through June 30, 2025. See Figure 2 below.
  • Pre-operative PRO data collected from April 2, 2024 through June 30, 2025 and post-operative data on those same patients collected from April 27, 2025 through August 29, 2026.

Figure 1: Voluntary Reporting Period

Figure 2: Mandatory Reporting Period

Hospitals that submit data during the voluntary reporting period will receive confidential feedback reports from CMS detailing the results of that submission period. Participating hospitals can then use this feedback to benchmark themselves against other participating hospitals, and measure improvement of functional health outcomes. It is also a great time for hospitals to gain experience with collecting and reporting and work out any issues that arise. There is no penalty for not participating during the voluntary reporting period. There is also no monetary incentive for submission during this time as the Hospital IQR Program cannot provide incentive payments. Data submitted during the mandatory period of the THA/TKA PRO–PM will be used in part to determine FY 2028 payment determination.

How was the THA/TKA PRO-PM modeled after the voluntary PRO reporting in CJR? 

The Comprehensive Care for Joint Replacement (CJR) model is a bundled payment model that financially rewards hospitals, physicians, and post-acute care providers for coordinating care and reducing costs for episodes of care. It also incentives the collection and submission of THA/TKA PROs but does not require it. The new THA/TKA PRO-PM was developed using the PRO tools and risk variable data submitted by CJR participant hospitals. CMS also took feedback and lessons learned from the participants when developing the measure including the decision to allow hospitals to collect and submit fewer data points, allow for flexibility in data collection options, allow for a longer pre-operative data collection window, and allow for a lower reporting threshold.

What are people saying, good and bad, regarding the THA/TKA PRO-PM?

Below is a summary of the comments that supported the measure. They stated that PRO data-

• Will provide patients with valuable information on the quality of joint care provided by hospitals 
• Is an effective measure of the success of a procedure
• Will incentivize collaboration between providers in order to improve patient outcomes
• Is a helpful way to get insight into quality improvement opportunities
• Is essential for value-based payment models

On the other hand, below is a summary of the comments that did not support the measure. They expressed concern about-

• The volume of newly proposed quality measures for the Hospital IQR Program overall
• The fact that it could be burdensome to hospitals for financial and labor-related reasons 
• Patients getting survey fatigue
• The proposed voluntary and mandatory reporting timelines
• The fact that outpatient settings are not included

Please note that the above is not exhaustive of the comments CMS received.

What happens if you choose not to submit, or you do not have data to submit?

Hospitals that fail to meet any of the IPPS reporting requirements will receive a deduction from their annual payment update FY 2028. The deduction amount has changed over time but the American Recovery and Reinvestment Act of 2009 and the Affordable Care Act of 2010 modified the deduction to be one-quarter of the applicable annual payment rate.

What is the benefit of starting to collect/submit PROs right away?

It’s all about getting ahead of the curve on mandatory reporting. While the mandatory period for the THA/TKA PRO–PM will not begin until 2024, it’s never too early to start capitalizing on the value of PROs. CMS has established two (2) voluntary reporting periods in order to allow for hospitals to prepare adequately – identifying the right process to fit into your clinical workflow is an important first step to a successful PRO program. If your organization is interested in participating in the first voluntary reporting period, please reach out to the CODE Team to get started on your PRO collection program. Or, you can download the free PRO Vendor Checklist to help your team learn what you should ask when selecting a PRO vendor, and what to expect from them.

References

Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2023 Rates; Quality Programs and Medicare Promoting Interoperability Program Requirements for Eligible Hospitals and Critical Access Hospitals; Costs Incurred for Qualified and Non-qualified Deferred Compensation Plans; and Changes to Hospital and Critical Access Hospital Conditions of Participation– https://public-inspection.federalregister.gov/2022-16472.pdf

Acute Inpatient PPS– https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS

FY 2023 Hospital Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital Prospective Payment System (LTCH PPS) Final Rule- https://www.cms.gov/newsroom/fact-sheets/fy-2023-hospital-inpatient-prospective-payment-system-ipps-and-long-term-care-hospital-prospective

Hospital Inpatient Quality Reporting Program- https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/HospitalRHQDAPU