Orthopaedists and other medical professionals are keenly aware of the shift that has been occurring in recent years from volume-based to value-based care—a shift that gained even more attention with the repeal of the Sustainable Growth Rate (SGR) and the creation of its replacement, the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. As described in this issue's cover story on MACRA, the Centers for Medicare & Medicaid Services (CMS) recently released the MACRA proposed rule, providing for the first time a detailed description of how the new physician reimbursement framework has been designed.

Academy leadership and staff members are combing through the proposed rule and coordinating formal written comments with specialty orthopaedic societies. Although it will take some time to digest the nearly 1,000-page rule and fully understand its implications, it is clear the Academy's efforts to develop quality measures specific to our specialty—work performed largely by the Performance Measures Committee—will play a critically important role in orthopaedic surgeons' ability to successfully navigate and participate in MACRA in the future.

Overview of performance measures
The AAOS firmly believes that orthopaedic surgeons are the most qualified medical professionals to develop and assess measures for evaluating the quality of care patients receive for musculoskeletal injuries and conditions. As such, the Academy formed the Performance Measures Committee in 2014, under the Council on Research & Quality (CORQ), and charged the new committee with leading the development of high-quality, evidence-based performance measures. These measures, which are derived from evidence-based clinical practice guidelines, fall into the following categories:

• Process performance measures: Describe a specific action that was completed. There should be a scientific basis for believing that the process, when executed well, will increase the probability of achieving a desired outcome.
• Structural performance measures: Reflect the conditions in which providers care for patients. These measures can provide valuable information about staffing and the volume of procedures performed by a provider.
• Outcome performance measures: Assess the result of the care experienced by a patient.
• Patient experience performance measures: Use feedback from patients and their families/caregivers about their experience and/or engagement in decision making around care.
• Composite performance measures: Combine two or more measures, each of which individually reflects quality of care, into a single performance measure with a single score.
• Patient-reported outcome performance measures (PRO-PM): Aggregate information that has been shared by the patient without interruption and has been collected into a reliable, valid measure of performance.

The AAOS adopted its measure development process from the "blueprint" developed by CMS and the National Quality Forum (NQF) measure development criteria. This stepwise approach takes approximately 18 months to complete and encompasses measure conceptualization, specification, testing, and implementation, as well as use and continuation of maintenance (Fig. 1).

In 2015, the AAOS began developing orthopaedic performance measures on osteoarthritis (OA) function & pain assessment as well as management of hip fractures in the elderly. This year, work will begin on developing sets for management of anterior cruciate ligament injuries and treatment of glenohumeral OA. The committee has a goal of beginning development of two new measure sets each calendar year.

PQRS and the OPS Measure Set
But the AAOS is not the only organization that has been focused on developing performance measures, which brings us to the Physician Quality Reporting System (PQRS), one element of MACRA's Merit-based Incentive Program System (MIPS) payment pathway (see "More about PQRS 2016: What You Need to Know."). Measures are classified according to the six National Quality Strategy (NQS) domains based on the NQS priorities. Under the proposed rule, clinicians would report six measures; however, in 2016, eligible professionals are required to report at least nine quality measures that cover at least three of the NQS domains, one of which must be a cross-cutting measure.

The Performance Measures Committee has studied the PQRS measures and determined those that are relevant to orthopaedics. These measures, known as the Orthopaedic Preferred Specialty (OPS) Measure Set, were approved by the AAOS Board of Directors during the 2016 AAOS Annual Meeting. The OPS Measure Set is designed to help orthopaedic surgeons choose measures that satisfy the 2016 PQRS reporting requirements. The measure set is organized according to specialty and contains 16 general measures such as body mass index screening and pain and function assessment that are applicable across orthopaedic specialties. The OPS Measure Set is available on the AAOS website under "Quality/Performance Measures Resources/Physician Quality Reporting System (PQRS)/Choose Your Measures/2016 Orthopaedic Preferred Specialty Measure Set."

Outcome measures
Patient-reported outcomes (PROs) are another important piece in the quality measurement puzzle. In the last year, the Quality Outcome Data (QOD) Work Group, appointed by the Council on Research and Quality (CORQ), investigated opportunities for the AAOS to partner with organizations such as the American Joint Replacement Registry and the National Surgical Quality Improvement Program (NSQIP) to facilitate collection of outcomes data by orthopaedic surgeons. The QOD Work Group, headed by David S. Jevsevar, MD, MBA, chair, and Kevin J. Bozic, MD, MBA, oversight chair, was also charged with evaluating platforms/systems—including the Patient Reported Outcomes Measurement Information System (PROMIS)—as well as other PROs to suggest ways Academy members can use appropriate instruments for data collection.

The QOD Work Group's goal was to provide members with a user-friendly, economical way of collecting outcomes data that can be incorporated into the electronic health record, with the ultimate goal of serving as a resource for diagnosis and treatment decisions. In addition, collecting PROs will also help physicians meet the requirements of the Comprehensive Care for Joint Replacement (CJR) model.

By sending out a survey to solicit input from orthopaedic specialty societies, representatives of which acted as site or disease-specific subject matter experts, the QOD Work Group obtained data on the important PROs in various areas of orthopaedics. After obtaining these data, the QOD recommended three general quality-of-life outcomes: the Veterans Rand 12, or VR-12; any of the PROMIS 10 or computer-adaptive testing (CAT); and EuroQol (EQ-5D). In addition, for each specialty area, the work group recommended regional, anatomic, and diagnosis-specific PROs.

As described by Dr. Jevsevar (see "Collecting Patient-Reported Outcomes," AAOS Now, May 2016), the goal is for collection of PRO data to become part of the routine flow of an orthopaedist's office. Data collection, which ideally would be completed before the patient comes to the office, may occur via a web-based or smart phone application. As Dr. Jevsevar acknowledges, however, there are very few healthcare organizations currently able to do this. At the least, however, he recommends that practices begin evaluating how to integrate collection of PROs in their practices, if they have not already begun doing so.

Quality measurement: Where are we headed?
The need for orthopaedists to focus on collecting and reporting performance measures and outcome measures will only continue to grow as the federal government places an ever-greater emphasis on value-based care. The Performance Measures Committee will continue its efforts to define these measures and communicate them to AAOS members, always keeping the nuances of musculoskeletal care in mind and obtaining input from all key stakeholders.