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All Eyes on Hips and Knees

by Patricia Franklin, Professor and Director, Clinical and Outcomes Research, Department of Orthopedics and Physical Rehabilitation, University of Massachusetts Medical School

April 1, 2016 begins a new era in total hip and knee joint replacement (TJR), with significant implications across the healthcare spectrum.  On that date Centers for Medicare & Medicaid Services (CMS) is launching its first mandatory bundled-payment initiative and for the first time linking payment to quality and patient satisfaction measures, in addition to cost measures. Private insurers are expected to follow. 

With its first mandatory initiative, CMS has focused on one of its most expensive and common procedures:

  • There are more than 1,000,000 Total Hip and Knee Replacement surgeries each year
  • Between 1997 and 2004, aggregate charges (the ‘national bill’) for primary TJR surgeries increased dramatically: from $8.9 billion to $50.5 billion (knees > hips).
  • By 2030 the demand for total hip and knee replacement is projected to grow by 174% and 673%, respectively
  • Fastest TJR growth among patients < 65 years of age

The challenge is on to prove value in healthcare.  In orthopedics, surgeons participating in the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement (FORCE-TJR), are using a TJR episode management system based on validated patient-reported outcomes (PROs) to successfully optimize patient care, report quality metrics and prove value.  Under the new CMS orthopedic bundled payment program, PROs may make the critical difference in avoiding penalties, receiving incentive payments and prospering in a value-based healthcare world.    

At their most simplistic, PROs measure the function and pain that a patient experiences before and after surgery.  FORCE-TJR goes beyond the basics, including risk-adjusted, US national benchmarks for peri-operative adverse events, PROs, and early implant failure in both CMS patients, and the 45% of TJR patients who are under 65 years of age.  FORCE-TJR provides hospitals and surgeons risk-adjusted, comparative reports to document PROs, readmission rates, and adverse events, compared to risk-adjusted national benchmarks.

With a PRO capture rate of 96% pre-TJR and 85% post-TJR, FORCE-TJR has an unprecedented data completion rate.  We’ve found the key is understanding that it takes more than IT for successful data collection.  Many systems that collect PROs are hospital centric, but the patient’s primary relationship is with the surgeon from the time TJR is scheduled through the first year post-surgery. Thus, the brief hospital stay is a small part of the process and hospitals have been less successful in collecting post-discharge outcomes. Patients touch multiple EHRs during an episode of TJR: surgical office, pre-op prep visits, in-hospital, post-operative physician and rehabilitation. In order to maximize PRO collection and adverse event surveillance, the FORCE-TJR web-based system follows the patient across the continuum of the episode to different settings.  The data is then either interoperable with the EHR or downloaded to the EHR for data storage.   

In most cases, the payer is the only one that has a full accounting of a patient’s healthcare use while the hospital or surgeon is at a loss because they don’t know the total ER use, hospital readmissions, and PRO after surgery.  FORCE-TJR captures the total experience of the patient through longitudinal data.  Reaching patients in their homes after surgery is an important option because substantial variation exists in the timing of orthopedic office visits following TJR; also, most patients do not return to the surgical hospital, making hospital collection of PROs unlikely. Data for patients with the most successful outcomes may not be captured with office-based PROs, as patients with optimal pain relief and functional gain are more likely to miss a postoperative office visit than are patients with persistent pain or limitations.

In a value-based healthcare system, we think the surgeons and hospitals with the most complete information are the ones who will succeed. 

The ultimate measure of whether TJR is successful is if the patient has less pain and more mobility. CMS proposes that these PROs be measured 9-12 months after surgery when patients have peaked in their recovery.  In contrast, currently, TJR is a “success” if the implant doesn’t fail.  Real value in health care is whether it helps a patient live well with a chronic illness or recover from an acute illness. Patients are rarely asked for their own assessment of their health, pain or disability.  But who better to tell us how they feel before – and after – treatment? 

As the healthcare industry emphasizes patient-centered care and patient engagement, PROs are expected to play an increasing role in assessing performance and determining the effectiveness of different treatments. 

Value-based payments, with an emphasis on measuring and reporting quality and improvement in care, are part of CMS’ effort to tie 90% of payments to incentive programs by 2018.  It may be mandatory only for TJR now, but value-based payments are spreading fast.  Keep an eye on hips and knees; they’ll have lessons for us all.  

Patricia D. Franklin, MD, MBA, MPH, is Professor and Director of Clinical and Outcomes Research in the Department of Orthopedics and Physical Rehabilitation at the University of Massachusetts Medical School.


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