Symposium provides varied practice perspectives on mandated PROMs collection

There has been talk about incorporation of patient-reported outcomes (PROs) for years in orthopaedics, but new requirements by federal payers such as the Centers for Medicare & Medicaid Services (CMS) are putting collection of these data front and center for many orthopaedic surgeons. At the 2025 AAOS Annual Meeting, AAOS Past President Kevin J. Bozic, MD, MBA, FAAOS, joined a panel of speakers who discussed some of the ins and outs of PROs and patient-reported outcome measures (PROMs), their potential value, and early learnings from different practice settings. Symposium DD, “Strategies for Success in the CMS PROMs Mandate,” was cohosted by the American Association of Hip and Knee Surgeons.

Although new, PROMs are here to stay, according to Dr. Bozic, who is chair of the Department of Surgery and Perioperative Care at the Dell Medical School at the University of Texas at Austin. However, being evaluated should be nothing new to surgeons, he said.

Whether today or in the past, surgeons have been evaluated with a variety of measures. These have included structural measures, such as the meaningful adoption and use of electronic health records, process measures such as administration of antibiotics, experience measures such as reviews on Yelp! or Google, and quality and safety measures such as readmission rates.

“In our field, are these the things we want to be measured on?” Dr. Bozic asked. “I could give a patient the safest, highest-quality operation with no complications or readmissions, but if I didn’t improve their health, I have done nothing for them.”

What is the mandate?
James I. Huddleston, MD, FAAOS, professor of orthopaedic surgery at Stanford Healthcare, provided attendees with an overview of the new CMS requirements as they relate to PROMs for total hip and knee arthroplasty. Essentially, the field is being called to shift away from using PROMs only in research to collecting these important data in clinical practice.

Since July 2024, PROM data have been required on patients aged 65 or older who are enrolled in Medicare fee-for-service and have elective inpatient total hip and knee arthroplasty. The goal of the measure is to quantify pain and functional improvements with validated measures. CMS will publicly report the percentage of patients who achieve substantial clinical benefit from the procedures, defined at a threshold of 22 points on the Hip Disability and Osteoarthritis Outcome Score, Joint Replacement (also known as HOOS, JR) or 20 points on the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (also known as KOOS, JR). For hospitals that do not report a complete dataset for a minimum 50% of all eligible patients, CMS will reduce by 25% the Annual Payment Update for all Medicare Fee-for-Service Part A claims, including non-orthopaedic claims.

“There are now a lot of resources available through the Academy to learn about PROMs,” Dr. Huddleston said. The AAOS “PROMs in Practice” resources are available online at aaos.org/PROMs.

Integration of PROMs in academic practice
How is data collection going? The answer to that question may vary based on the practice setting. Michael Bolognesi, MD, FAAOS, an adult hip and knee reconstruction specialist at Duke University, discussed some strategies for achieving success with mandatory CMS PROMs as experienced from the perspective of an academic medical center.

“In order to meet the 50% postoperative threshold, we felt we needed to get 100% preoperative participation,” Dr. Bolognesi shared.

Their current infrastructure triggers a preoperative PRO assignment as soon as a case is scheduled. The process features a combination of digital infrastructure (email reminders) supported by personal touchpoints. When the process started in July, they had 88% preoperative completion of PROs; by August, it was 100%, where it remained through the time he presented the data, Dr. Bolognesi said. The real challenge will be collecting postoperative data, he acknowledged.

Overall, the effort has required substantial resources across the health system. However, “our current efforts have laid the foundation for the upcoming ambulatory expansion that is coming from CMS,” Dr. Bolognesi said, adding that Duke is already participating in voluntary reporting for ambulatory PROMs.

Private practice experience
Wendy Wong, MD, FAAOS, an orthopaedic surgeon at Golden State Orthopedics & Spine, detailed her yearslong work to implement collection of PROMs in her California-based private practice. As the surgeon champion of the idea, she estimated having spent at least 75 hours of uncompensated time during the first two years advocating for and implementing PROMs. Today, she spends about 15 to 20 minutes a month. Her practice has invested more than $200,000 out of overhead on the idea. One of the biggest lessons learned, she shared, was the need for a physician champion — preferably one in each service line.

During her presentation, Dr. Wong detailed some of the ins and outs of how and when her practice collects the data. Although the journey has been frustrating, her practice has been able to leverage the data in several ways.

First, the practice can use the data for internal quality review. “Outcome data are powerful for the surgeons,” Dr. Wong said. “They have become more engaged knowing that we are watching and looking at these data.”

In addition, the practice is able to leverage PROMs data for negotiating co-management agreements with hospitals, negotiating contracts with payers, educating staff, recruiting physicians, marketing, and more.

Safety-net hospital experience
Although she believes in the importance of value-based healthcare, Meghan Brown, MD, of the University of New Mexico, said her institution and practice catchment area may lack the critical infrastructure to meet the CMS PROMs mandate.

“Our hospital system is the primary safety net, tertiary referral center, and only level 1 trauma center [in New Mexico],” Dr. Brown said. “We cover the entire state, as well as 19 independently recognized tribal areas.” This means the University of New Mexico is a healthcare system responsible for a racially, ethnically, and socioeconomically diverse patient population, with a high percentage of public payers.

“For a hospital that has a majority public payer base, we are operating at a deficit,” she explained, and the mandate for PROMs adds an additional administrative cost to a system already operating on razor-thin margins.

As her health system started an attempt to implement collection of PROM data, they ran into a variety of barriers, including community barriers such as lack of cell coverage and broadband access. Although they have continued to adapt their approach, Dr. Brown acknowledged that there is a very good chance that their collection average will be less than 50%, failing the mandate. The problems faced by her institution are shared by similar systems throughout the country.

“We should try to include a broader representation of those that don’t work in a major system when these policies are considered and developed in the future,” Dr. Brown said.

Leah Lawrence is a freelance writer for AAOS Now.