Published 9/1/2016
Kent Jason Lowry, MD; Adolph J. Yates Jr, MD

The Evolving State of TJA Performance Measures

Metrics focus on care processes, procedures, and outcomes
Performance measures, capturing the quality of care provided by surgeons and hospitals, are an increasingly important reality. Performance measures for total joint arthroplasty (TJA) have been an early focus for Medicare and other payers due to the volume of surgeries, the cost, and the potential for reimbursement through alternative payment models (APMs). The most readily applied APM for TJA is an episode of care bundled payment. Performance measures enable the monitoring of care quality through the episode of care as the patient transitions from diagnosis to treatment to rehabilitative care.

Concurrent with the development of APMs have been the efforts by the Centers for Medicare & Medicaid Services (CMS) to measure and subsequently reward or penalize hospitals and physicians based on the "value" of care they provide. The Value-Based Purchasing (VBP) program for hospitals is ongoing. The Physician Quality Reporting System (PQRS) program for physicians will soon be replaced by the Merit-Based Incentive Payment System (MIPS) for most surgeons, except for those in an approved Advanced APM.

CMS has also accelerated its bundled payment program, moving beyond voluntary participation to the Comprehensive Care for Joint Replacement (CJR) model, which is now mandatory in 23 percent of U.S. hospitals. Surgeons are expected to share both risk and reward in these bundles, although they cannot be the initiators. A new rule proposal from CMS in July of 2016 makes the CJR eligible as an Advanced APM, which creates a pathway for surgeons to be qualified providers and able to take the Advanced APM route rather than MIPS. (See "CMS Proposes Update to Existing CJR Model."). Because these models are increasingly hospital-based, surgeons must be concerned about hospital metrics as well.

Performance measurement development is a complicated, multi-stakeholder process. More than 25 different performance measures related to joint replacement care currently exist. These measures have been developed over the past 6 years or are currently under development by at least five different organizations, including CMS, the American Association of Hip and Knee Surgeons (AAHKS) and The Joint Commission.

CMS performance measures
The following two CMS performance measures currently have the most impact on hospitals and arthroplasty surgeons:

  • the hospital-level 30-day, all-cause, risk-standardized readmission following elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (National Quality Forum [NQF] 1551)
  • the hospital-level risk-standardized complication rate following elective primary THA and/or TKA (complications occurring from the date of index admission to 90 days post discharge) (NQF 1550)

Both were developed and are maintained by CMS and the Yale Center for Outcomes Research and Evaluation (CMS/Yale CORE). Both are now part of the VBP and contribute to potential losses for poorly performing hospitals. Because TJA is one of the measured and specified conditions under the CMS Hospital Readmissions Reduction Program, an "excess" number of 30-day readmissions after TJA (NQF 1551) could lead to as high as 3 percent penalty across all of a hospital's CMS payments.

The complication measure, NQF 1550, is becoming part of the 2 percent risk associated with the VBP equation. A third CMS measure, the hospital-wide HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) score, also affects the VBP equation.

A fourth measure calculates the risk-adjusted episode of cost for TJA; it is another CMS/Yale-CORE product and was introduced through the 2016 Inpatient Prospective Payment System rule as a way of measuring "efficiency" in the VBP program. This measure bypassed the NQF endorsement process.

The TJA complication measure (NQF 1550) and the HCAHPS score are part of a quality formula that determines a provider's eligibility for reward under the CJR program. They are also used to determine what percentage discount in price the hospital needs to meet.

Another CMS/Yale CORE measure in development is the TJA Patient-Reported Outcomes Measure (PROM). Although it is not yet in use for scoring, there are incentives for reporting this measure under the CJR quality formula. CMS accepted the suggestions of a consortium of stakeholders—including the AAOS and the AAHKS—to use the following tools for this measure:

  • HOOS-JR (short-form hip disability and osteoarthritis outcome score) or KOOS-JR (short-form knee injury and osteoarthritis outcome score) and
  • VR-12 (Veterans RAND health survey) or PROMIS 10 (Patient-Reported Outcomes Measurement Information System)

Using these tools and a few risk factor questions results in a 20-item THA outcome questionnaire and a 21-item TKA outcome questionnaire.

Additionally, the CMS-sponsored Health Care Purchasing Learning and Action Network (HCPLAN) encourages private sector payers to standardize their approaches to developing APMs. CMS has specified that its consensus group expects the quality of TJA bundles to be measured by NQF 1550, NQF 1551, and HCAHPS.

AAHKS performance measures
The individual surgeon has been able to take part in PQRS, which currently promotes four TKA measures. AAHKS has also played a significant role in this performance measure development process.

In January 2013, AAHKS released the final draft of the total knee performance measure set. It was endorsed by the American Medical Association's Physician Consortium for Performance Improvement ® process. Four of the seven measures developed by AAHKS were subsequently accepted by CMS for PQRS reporting and will most likely continue as elements within MIPS. Under both PQRS and MIPS, however, the reporting is required to come through a registry. The American Joint Replacement Registry (AJRR) is working on providing that conduit. Most of the elements in the AAHKS TKA measure set are listed as also being acceptable within the MIPS program.

AAHKS has also begun developing a total hip performance measure set, currently in draft form. It is expected to be finalized later this year, and will then be submitted for endorsement by CMS. Based on the time it took for CMS to endorse the TKA measures, it is reasonable to expect that the THA measures will be endorsed as soon as 1 year from their completion.

The Joint Commission performance measures
Concurrent with the AAHKS efforts, The Joint Commission is developing a set of combined TKA/THA performance measures. The preliminary draft was released in January 2016. These measures are being developed as part of The Joint Commission's certification program for joint replacement and are currently undergoing site testing and validation. Although these measures are being developed separately from the AAOS and AAHKS, both societies have provided feedback during The Joint Commission's public comment period.

NQF-endorsed measures
The NQF is a not-for-profit, nonpartisan, membership-based organization that works to catalyze improvements in health care. It does not develop performance measures, but it promotes those measures that meet rigorous standards for development, and serves as the gold standard for endorsement.

Most recently, NQF endorsed joint replacement measures submitted by the following organizations: Minnesota Community Measurement, a nonprofit focused on improving care in Minnesota; Optum, a healthcare innovation company with ties to United Healthcare; and Focus on Therapeutics Outcomes, a company focused on patient functional outcome data reporting for the rehabilitation industry.
These NQF-endorsed measures are not currently part of the CMS hospital metrics. However, their NQF-endorsed status could result in some of them being selected as potential MIPS measure candidates.

Both NQF 1550 and 1551 are to be reviewed by the NQF this summer for re-endorsement.

AHRQ measures
With the multiple measure development processes previously highlighted, the Agency for Healthcare Research and Quality (AHRQ) is serving as the national quality measures clearinghouse for performance measures. It represents a "one-stop" site, summarizing performance measures under consideration by the federal government. It is important to appreciate that the AHRQ site is currently being populated and will continue to be updated. The information obtained from this site was made public-facing in May 2016.

Patient-reported outcomes
As patient-reported outcomes gain traction as a prioritized quality metric, several organizations have begun developing patient-reported outcome measures (PROMs). These organizations may have unique perspectives, resulting in increasing variability across PROMs. Table 1 (on page 30) lists existing PROMs, their developers, their data collection time frame, and recommended PROM tools.

To address variations in these measures, a PROM multi-stakeholder summit was held in 2015. The summit's goal was "to obtain a consensus regarding the patient-reported outcomes (PRO) and risk variables suitable for total hip and knee arthroplasty performance measures," for development of a specific CMS-sponsored PROM for arthroplasty. This summit recommended that PROM tools for TJA be limited to a general health form (VR-12 or PROMIS-10) and a disease-specific tool (HOOS-JR or KOOS-JR). Additionally, the summit recommended that CMS consider "a staged approach in selecting the candidate risk variables."

The development and implementation of joint replacement performance measures has been accelerated by CMS, outside consultants and stakeholders, and AAHKS. Due to the considerable cost of measure development, third-party payers do not appear to be interested in providing their own measures.

The CMS document "Future Areas for Orthopedic Measure Development" provides insight into the future direction of performance measurement development. This includes a significant focus on PROMs; the CMS version of PROMs is awaiting the data being collected through the CJR incentive and further refinement by the Yale-CORE group.

Kent Jason Lowry, MD, is a member of the AAOS Performance Measures Committee; Adolph J. Yates Jr, MD, is the chair of the AAHKS Evidence Based Medicine Committee and serves on the National Quality Forum Surgical Committee.

References for Table 1: