Understanding the New THA/TKA PRO-PM Measure: A Guide for ASCs and HOPDs

Tired of penalties and missed opportunities to boost your hospital's revenue?

The Centers for Medicare & Medicaid Services (CMS) is implementing a new program to monitor patient outcomes following total hip arthroplasty (THA) and total knee arthroplasty (TKA) procedures. This program, known as the THA/TKA Patient-Reported Outcome-Based Performance Measure (PRO-PM), focuses on outpatient settings and leverages patient-reported data to evaluate pain reduction and functional improvement after surgery.

Why is this happening?

The growing number of THA and TKA procedures shifting to outpatient facilities necessitates a robust system for tracking patient progress. PRO-PM aims to ensure high-quality care by directly incorporating patient experiences into quality measurement. This data will be crucial for:

Improved Decision-Making: By understanding patient outcomes, providers can refine surgical techniques and optimize post-surgical care plans.
Shared Decision-Making: Patient-reported data empowers patients to actively participate in discussions about their surgical options and expected recovery.
Quality Improvement: Analyzing PRO data allows healthcare facilities to identify areas for improvement and implement targeted interventions to enhance patient satisfaction.

Who is Impacted?

This program applies to all HOPDs (Hospital Outpatient Departments) and ASCs (Ambulatory Surgical Centers) performing elective primary THA and TKA procedures. There are some exceptions, including Critical Access Hospitals (CAHs) (though voluntary participation is encouraged) and facilities outside the US.

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:

Data Type	90-0 days Pre Operative Data	300-425 days Post-Operative Data
PROMs	HOOS JR (for THA) KOOS, JR (for TKA)	HOOS JR (for THA) KOOS, JR (for TKA)
Patient-Or-Provider-Reported Risk Variables	PROMIS Global or VR-12 mental health subscale items	N/A
	Single-Item Health Literacy Screening questionnaire
	BMI or Weight(kg)/Height(cm)
	Chronic (>= 90 day) Narcotics Use
	Total Painful Joint Count: Patient Required Pain in Non-operative Lower Extremity Joint
	Quantified Spinal Pain: Patient Reported Back Pain, Oswestry Index Question
Matching Variables	Medicare Provider Number	Medicare Provider Number
	Medicare Health Insurance Claim (HIC) Number/ Medicare Beneficiary Identifier (MBI)	Medicare Health Insurance Claim (HIC) Number/ Medicare Beneficiary Identifier (MBI)
	Date of Birth	Date of Birth
	Date of Procedure	Date of Procedure
	Procedure Type	Procedure Type
	Date of Admission	Date of Admission
PROM-related Variables	Date of PRO Data Collection	Date of PRO Data Collection
	Mode of Collection	Mode of Collection
	Person Completing the Survey	Person Completing the Survey
	Generic PROM Version	N/A

What Patients are Included?

The measure focuses on patients who meet the following criteria:

Underwent an elective primary THA/TKA procedure in an HOPD or ASC setting
Enrolled in Medicare FFS Part A and B for at least 12 months before and during the procedure
Aged 65 years or older

Patients undergoing procedures for fractures, revisions, or discontinued surgeries are excluded.

Reporting Cycle	Performance Period	Per-operative data collection window	Pre-operative data submission deadline	Post-operative data collection window	Post-operative data submission deadline
Voluntary Reporting - 1	Jan 1, 2025 - Dec 31, 2025	Oct 3, 2024 - Dec 31, 2025	May 15, 2026	Oct 28, 2025 - Feb 28, 2027	May 15, 2027
Voluntary Reporting - 2	Jan 1, 2026 - Dec 31, 2026	Oct 3, 2025 - Dec 31, 2026	May 15, 2027	Oct 28, 2026 - Feb 28, 2028	May 15, 2028
Voluntary Reporting - 3	Jan 1, 2027 - Dec 31, 2027	Oct 3, 2026 - Dec 31, 2027	May 15, 2028	Oct 28, 2027 - Feb 28, 2029	May 15, 2029
Voluntary Reporting - 3	Jan 1, 2028 - Dec 31, 2028	Oct 3, 2027 - Dec 31, 2028	May 15, 2029	Oct 28, 2028 - March 1, 2030	May 15, 2030

How Does it Work?

Hospitals use a combination of data to measure performance, including:

Patient-reported information (PRO data): Surveys about pain, function, and mental health before and after surgery.
Insurance claims data: Shows what medical services patients received.
Medicare information: Confirms patient eligibility (age, insurance).
General health data: Used for national comparisons.

Hospitals submit this information electronically for all eligible patients:

Age 65+ with Medicare
Getting a hip or knee replacement surgery (THA/TKA)

What are the Success Criteria?

To avoid potential payment reductions, facilities must meet the following submission rates during mandatory reporting:

Hospitals: 50% of eligible procedures
ASCs: 45% of eligible procedures

Timeline and Benefits of Early Participation

Voluntary reporting periods are available from 2025 to 2027, allowing facilities to adapt their processes.
Mandatory reporting commences in 2028.
Early participation benefits include:
- Establishing a smooth data collection system
- Gaining insights into facility performance compared to others (voluntary reports are confidential)

What is the financial penalty for not reporting a complete data set for 50% of all eligible patients?

CMS will reduce 25% of the Annual Payment Update (usually 2-4%) for ALL the hospital's Medicare Fee - for - Service Part A claims, including non-orthopaedic claims. Additionally the hospital Will be disqualifide from partcipation in all Medicare value-based purchasing programs.

How will hospitals be scored?

CMS will publicly report the percentage of patients who achieve a substantial clinical benifit (SCB)

Substantial Clinical Benefit Threehold
HOOS, JR - 22 points	KOOS, JR - 20 points

CMS will factor in all the risk variable data you submitted as well as your claims data, to create you final risk standardized improvement rate" (RSIR). If, for example, you achieve a 60% RSIR, that means that, in general, 60% of your patients reported a substantial improvement after their THA/TKA procedure.

Consequences for Non-Participation

Hospitals and centers failing to submit sufficient data will face a reduction in their annual payment update from Medicare. Public reporting of results will also begin after mandatory reporting starts.

Conclusion

The new THA/TKA PRO-PM program presents both challenges and opportunities for ASCs and HOPDs. While ensuring high-quality patient care is paramount, navigating the complexities of data collection and reporting can be daunting. BestOutcomes can be your perfect partner in navigating the THA/TKA PRO-PM landscape. Our comprehensive solutions will help you:

Effortlessly collect and manage patient-reported outcome data (PRO) through user-friendly surveys and reporting tools.
Ensure data accuracy and completeness, minimizing the risk of submission errors and potential payment reductions.
Gain valuable insights into patient outcomes to refine surgical techniques, optimize care plans, and improve patient satisfaction.
Stay ahead of the curve with ongoing support and guidance throughout the PRO-PM implementation process.

By implementing BestOutcomes, you can not only ensure compliance with the THA/TKA PRO-PM program but also leverage valuable patient data to enhance quality of care, strengthen patient engagement, and ultimately improve your facility's revenue cycle.