In this episode, Maria Miranda, Director of Emerging Payment Models at BESLER, discusses the different types of patient reported outcome data and how they are being used as part of bundled payment models.
Michael Passanante: Hi, this is Mike Passanante. Welcome back to the Hospital Finance Podcast. Today, I’m joined by Maria Miranda who is the Director of Emerging Payment Models here at BESLER Consulting. And Maria has joined us to help us understand more about quality reporting as it relates to the CJR program.
Maria Miranda: Thank you, Mike.
Mike: So Maria, quickly, what are PRO’s and how are they captured?
Maria: I think the first thing I’d like to do is distinguish between PRO’s, PROM’s and PROPM’s.
So, PRO stands for Patient Reported Outcome. The FDA defines PRO’s as follows:
Any report of the status of a patient or person’s health condition, health behavior or experience with healthcare that comes directly from the patient without interpretation of the patient’s response by a clinician or anyone else.
A PROM is Patient Reported Outcome Measures. And these are basically the tools that are used to assess the patient reported health status.
So, for CJR, a number of tools are utilized. There are different types of PROM’s that can be utilized for CJR.
One type is the HRQL measure, Health-Related Quality of Life measure. And that includes the Veterans Rand 12 Item Health Survey (otherwise referred to as the VR-12), which includes physical and mental health and the PROMIS Global which includes physical, mental and social health.
The CDC defines Health Related Qualify of Life as “an individual’s or group’s perceived physical or mental health over time.” There are also joint replacement specific measures such as the HOOS and HOOS, JR. for hips and the KOOS and KOOS, JR. for knees.
So, the PROPM is basically a PRO-based performance measure. And this is based on PRO data that is aggregated for the provider.
So, in putting these all together, I’ll give you an example for CJR, Mike. Basically, an example of a PRO or a Patient Reported Outcome would be knee pain.
An example of a PROM might be question #4 on the KOOS, JR. Survey. That question asks the patient what level of pain he/she is experiencing when they go up or down the stairs.
The PROPM might be the percentage of patients that answer “severe” on that question #4, but then, upon follow-up , answer “moderate” on the same question.
These are measures that are useful in assessing short-term and long-term results for care decisions.
Mike: Can you tell us what kind of information is collected for CJR.
Maria: So, the HOOS, JR. Hip Survey includes questions related to pain, function of daily living. And the KOOS, JR. Survey has those same questions, but also includes a question on stiffness.
The HOOS and KOOS Surveys which are the original surveys are more comprehensive and take much longer to complete. They’re meant to be used for short- and long-term periods to monitor the effectiveness of treatment.
So, for example, the KOOS Survey, the original KOOS Survey for knees would include five different scales—pain, other symptoms, function in sports and recreation, function in daily living, and knee-related quality of life.
Mike: I know quality plays a role in the CJR program. And we’ve discussed a few of these measures before such as HCAHPS for patient satisfaction and risk standardized complication rates. Can you tell us why patient reported outcomes are different?
Maria: Sure! Specific to CJR, CJR hospitals are required to submit HCAHPS and complication rates. They’re not required to submit PROs. So it’s voluntary. However, if they decide to submit it, they automatically get two points as part of their Total Composite Quality Score.
So, they’re really not obligated to do it. But what you need to think about is once CMS starts gathering this information, at some point, they’ll probably turn around and make it mandatory.
Mike: So, how do these Patient Reported Outcomes impact a CJR-participating hospital’s reconciliation?
Maria: So, as I’ve mentioned before, you get two points for just submitting the quality information for PRO’s. The Quality Composite Score ranges from 0 to 20 and has four different categories based on your score range that determines your discount when it comes to target pricing. The higher your category, the lower the discount which means your target price is a little higher and you’ve got a little more wiggle room.
So, as an example, if Hospital A is at the 50th percentile and has achieved 7 points for the complication rate and 5.6 points on the HCAHPS, they’d have a total quality score of 12.6 out of 20. And that places them in the good category. They would see a discount of 2% on reconciliation.
If that same facility submitted voluntary PRO information, they’d get the additional two points, bringing them to 14.6 points of 20. And that places them in the excellent category, and it reduces their discount to 1.5%.
So, it really does add up. Every little bit adds up on reconciliation.
Mike: Are there specific requirements for PRO reporting in the CJR program?
Maria: Sure! There are requirements for the type of PROM that you utilize and their timing requirements. A participating CJR hospital desiring to submit data must do so on at least 50% of their episodes or at least 50 patients per performance period. Then they’ll automatically receive the two points.
But that minimum creeps up. Just like with everything else in the CJR program, every performance year has different requirements. So, by the end of the program, that minimum creeps up to 80% or 200 patients.
The hospital has basically three different options for reporting on hips and knees under CJR. Option A, they can either use that Veterans Rand 12 (the VR-12) or the PROMIS Global pre-op and post-op plus post-op data for the revised list of risk variables noted in table 28 of the final rule. So, it’s a combination. You’ve got the VR-12 or PROMIS, plus you’ve got to do those variables in the final rule.
The VR-12 has 12 questions (as the name suggests) and the PROMIS has 10 questions. And then, there are eight items that are requested on that table 28. So, that’s option A.
Option B, they can just use the HOOS, JR. or KOOS, JR. pre-op and post-op. These forms have six and seven questions respectively.
And they’re called HOOS, JR. and KOOS, JR. because they’re just shorter forms of the original HOOS and KOOS. But they’re specific. Those forms are specific to hip and knee replacements. And that’s why they’re shorter. You can use those as opposed to having to go through all the other methods.
Option C is doing the original HOOS or KOOS. The pain sub-scale which has 10 and 9 questions respectively, in conjunction with the HOOS and KOOS function of daily living sub-scale pre-op and post-op. That section has 17 questions. So, this option has a total of up to 27 questions. The entire survey itself has 42 questions, but you only need to do the pain scale and the functions of So, as you can see, it would appear that option B is the easiest because HOOS, JR. and KOOS, JR., they only have up to seven questions. It’s much easier. But every hospital has different reasons for going with one of these.
So, for pre-op, the data is collected 90-0 days prior to the procedure. And for post-op data, it’s collected 270-365 days after the procedure.
And there are also timeframes for collecting the data that’s going to vary based on the performance period. So you’re too late right now to collect data for the first performance period, so you should be collecting data now for the second performance period.
There’s a table that CMS does publish. It was updated back in August.
Mike: What if a hospital is not already collecting data? Does it make sense for them to start now?
Maria: Well, again, there are timeframes. So, if they haven’t already started for the first performance year, it’s too late. But if they are within the timeframe to collect data for a specific performance year, they should absolutely consider it.
Depending on the tool that they’ve decided to use, whether they go with the HOOS (original) or the HOOS, JR. or the VR-12, they really just need to determine how much time and effort it’s going to take to implement that. They’d have to put a process in place for collecting the data and submitting the data. And make sure that they track the minimum number of responses in order to get credit for it.
They also want to look at their data internally to see if collecting this additional PRO information is going to have an impact on their reconciliation.
So, as an example, if the provider is already in that top category of “excellent”, which is between 13 and 20, if they’re like at 19 or 20, collecting that extra two points is not going to move the needle. It’s not really going to do anything for the reconciliation. But if they’re at the lower level, within striking distance of that next category, then that would make a difference for them.
And just as with anything in CJR, even if you’re in a good position now, your score will continue to change. And CMS might make changes as well to the requirements by either shifting the ranges around or making it more difficult for you to get into a higher category.
So, it probably just makes sense to see if you’ve got the resources internally. Decide which of the PROM’s you’d like to use and start collecting the data.
Mike: Are there any other benefits to collecting this information?
Maria: Sure, absolutely. So, PRO data can be very useful to providers in trying to assess the impact of care. Additionally, the use of the tools in capturing data gives providers an opportunity to engage the patient in their own care which can have a positive impact on their overall patient satisfaction. And that can have a direct or indirect impact on HCAHPS. And we know HCAHPS also impact your total quality score.
The data can be used for training purposes or to adjust your care redesign efforts in the future.
There are also registries out there that can capture this data for you. So if you don’t have the resources internally, there are registries there, even national registries out there, that you can join and you can capture this data. And in doing so, you’re also able to compare yourself to other peers and see how you’re doing.
PRO data collection may continue to be critical as more procedures become targets for value-based payment models as well either by CMS or even by health plans. So it probably pays to get used to utilizing the tools as the industry continues to hold providers accountable for positive outcomes and patient satisfaction.
Mike: Maria, thanks for helping us understand more about PRO’s.
Maria: Great! Thank you.