Orthopedic practices often call patient-reported outcomes a burden. Kevin Bozic, MD, hears that as a sign they aren’t using them.
“I personally believe that patient-reported outcomes and measurement of patient-reported outcomes are absolutely essential to providing high-value musculoskeletal care,” said Dr. Bozic, chair of the Department of Surgery and Perioperative Care at Dell Medical School at The University of Texas at Austin and an adult reconstructive surgeon at UT Dell Medicine’s Musculoskeletal Institute.
The argument carries more weight each year. CMS’ mandatory Transforming Episode Accountability Model, which began Jan. 1, holds more than 700 hospitals accountable for cost and quality across five surgical episodes, including lower extremity joint replacement and spinal fusion. Quality measures, patient-reported outcomes among them, can cut a hospital’s reconciliation payment by 10% to 20%. In July, CMS finalized CJR-X, a mandatory, nationwide joint replacement bundle, starting Jan. 1, 2028, that will make most inpatient hospitals accountable for the surgery, hospitalization and first 90 days of recovery.
Dr. Bozic, who has spent more than 15 years in hip and knee arthroplasty, said mandates alone won’t make PROs useful. A physician treating hypertension checks blood pressure at every visit; one treating diabetes checks hemoglobin A1c. A surgeon treating musculoskeletal disease should measure pain and function the same way. “The CMS mandates are just a stick for those practices that aren’t routinely using it,” he said. “You can only beat people over the head with the stick so much. If they don’t find it valuable and useful, they’re not going to do it — both the patients and the clinicians.”
The stick keeps growing
Orthopedics is already measuring more. More than 750 institutions submitted patient-reported outcome measures for the American Joint Replacement Registry’s 12th annual report, up from 496 sites at the end of 2022, according to the registry’s 2023 report.
The pressure is reaching individual surgeons, too. Starting Jan. 1, 2027, CMS’ Ambulatory Specialty Model will score orthopedic surgeons, neurosurgeons and pain specialists who treat low back pain on quality and cost against regional peers, Becker’s reported. Payers and hospital partners increasingly want baseline and follow-up scores as proof that a lower-cost outpatient case delivers the same result.
Eric Makhni, MD, a sports medicine orthopedic surgeon at Detroit-based Henry Ford Health, has made the business case plainly: A practice that claims high-value care has to prove it, and “PROMs is the way to do that,” he told Becker’s.
Dr. Bozic’s point is that practices responding only to that pressure will keep feeling the burden. Those that build PROs into care will get value from the same data.
Measure, don’t collect
Dr. Bozic pushes back on the word itself. “Even just the word ‘collect’ implies that it’s a passive action,” he said. “If you’re collecting the data, you’re probably not using it, and it’s probably not of value to you as a clinician or your patients.”
He hears often that PROs are a burden. His reply: so is imaging, and no one objects because clinicians and patients both use it during the visit. “We don’t collect; we measure,” he said. “And, we measure and use them.”
For Dr. Bozic, the most important time point comes before he ever meets the patient. He wants a baseline of physical and mental health ahead of the first visit. Many practices don’t trigger measurement until after a decision to operate, which he said leaves much of the value on the table.
On which measures to use, he pointed practices to the subspecialty recommendations on the American Academy of Orthopaedic Surgeons’ PROMs website. Shared measures give the field useful benchmarks. Beyond that, each practice should choose what matters to it and its patients. For him, mental health makes the list. “I think it definitely influences the treatment decisions and the potential outcomes,” he said.
How to get 100% capture
Survey fatigue is real, but Dr. Bozic said the fix starts in the exam room. “The first and most important thing is you actually have to use it,” he said. “If you’re not using it in the visit with the patient, there’s no motivation to fill it out.”
His team gets baseline surveys from every patient before the first visit. Patients complete them ahead of time about 30% to 40% of the time, he estimated. Those who haven’t get an iPad at check-in, hear that the survey is an important part of their care and are roomed once they finish.
That only works when everyone, from the front desk to the clinical team, explains why the information matters. The physician then reviews the results with the patient during the visit.
Follow-up surveys need the same discipline. Dr. Bozic repeats measurement at every visit while a patient weighs surgery, because a change in hip scores since the last visit helps guide the decision. After surgery, he doesn’t need six or eight time points. When a survey is coming, the physician should say so and say why. “Otherwise, it’s not going to hold weight with the patient,” he said.
Cleveland Clinic learned the same lesson. Its outcomes team found it was collecting too many measures at too many time points, then pared down to a standardized set gathered at key moments in the patient journey.
Vendor or EHR: Both work, with tradeoffs
Dr. Bozic’s team has used several third-party vendors and now runs PROs through the EHR. Vendors offer polished tools: automated texts at set time points, messages that appear to come from the physician, and strong analytics and visualization. But they sit outside the EHR, which can make the data harder to pull up and share with patients during a visit.
The EHR route is clunkier. A patient portal such as MyChart serves many purposes, so patients may not see it as the place to report how they feel. The payoff is integration: results appear at the point of care, where clinicians can review them like any lab value.
Neither choice matters as much as the habit behind it, he said. “Both of those pale in comparison to whether or not you’re actually using the data in the visit.”
The numerator of the value equation
Dr. Bozic frames PROs through Michael Porter’s definition of value in healthcare: the outcomes that matter to patients, achieved per dollar spent. “It’s the numerator of that equation,” he said. “You can’t actually measure, let alone improve value, unless you measure the outcome from the patient’s perspective.”
Medicare has caught on, he said. Given what it spends on hip and knee replacement, it should at least measure pain and functional status, the outcomes that matter most to those patients. The next step is using that data to make decisions. Payers, employers and other purchasers still need education on why it matters in contracting.
On timing, Dr. Bozic said three months after surgery is about right for a follow-up measure. Measure sooner and you likely miss the full benefit. His own practice also measures earlier than that.
Tracking over time pays off in the exam room. When a patient says they don’t feel better, he can show what they reported before surgery next to what they report now; memory of preoperative pain often fades. And if a patient’s function scores drop sharply at a one-year visit, “something’s changed,” he said — whether it involves the joint replacement or not.
His bar for a high-value practice: one that measures PROs, uses them at the first encounter and uses them to help patients decide. “If you’re not measuring pain and functional status from the patient’s perspective in some validated way, it’s hard to say you’re practicing high-value care,” he said.
The mistake to avoid
The most common misstep Dr. Bozic sees in new PRO programs is treating them as another mandated data-collection burden. He urged leaders to start with clinical questions instead:
- Can the data help triage patients and make clinics more efficient by showing, ahead of time, who on the team should see each patient?
- Can it help patients make informed decisions about which treatment fits?
- Can it show how specific techniques affect outcomes?
He compared the moment to the Hitech Act, when federal incentives, and later penalties, pushed practices from paper charts to EHRs. Many saw the switch as a burden at first. Then they learned to use discrete data to work more efficiently and serve patients better.
“The reimbursement piece is just a stick,” he said. “The carrot is, how can I use this data to add value to my practice — to both me and my patients?”
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
