Implementing and Leveraging Patient Reported Outcomes in Value Based Healthcare - Business Plan

Fellowship Paper

Business Strategy

Debbie Darby MBA, FACMPE

The healthcare reimbursement landscape has undergone several changes over the last few decades.  Cost control methods implemented through the Health Maintenance Organization Act of 1973, the Prospective Payment System and the introduction of DRG’s in the 1980’s have all attempted to curtail the continually rising cost of healthcare in the United States.  As Medicare enrollment grows, the healthcare portion of the GDP is expected to rise to 19.4% by 2027.  

With the end of the Sustainable Growth Rate legislation and the enactment of MACRA (Medicare Access and Chip Reauthorization), the shift to value- based healthcare has gained momentum.  Through the implementation of the Quality Payment Program, providers have the option to participate in the MIPS (Merit Based Incentive Payment System) program or an AAPM (Advanced Alternative Payment Model) in order to receive bonus payments under the new law and avoid financial penalties.  Through these programs, there is an opportunity to increase physician Medicare reimbursement.  With this paradigm shift, the need to prove quality of care has become more important not only from a financial perspective but also because of the increase in the transparency of healthcare.

CMS’ push to engage patients in their own healthcare has led to increases in physician-patient communication through the use of patient portals as well as the publication of Providers’ Quality Measures results through Physician Compare, published by CMS (Centers for Medicare and Medicaid Services).  Shared decision making is encouraged by Medicare as is the patient’s perspective of the care that is rendered.  Additionally, CMS has demonstrated its focus on quality through the implementation of CAHPS and CG-CAHPS, which can be used for quality reporting.  Through the use of validate surveys, functional assessments of hip and knee replacement surgery were part of the Physician Quality Reporting System and continue to be reportable quality measures under MIPS.

Commercial carriers typically and historically have followed Medicare guidelines so it is expected that they will eventually use quality methodology for reimbursement as well. As healthcare costs rise, commercial carriers also continue to look for ways to control their own spending.  Prior authorizations for surgical procedures are increasingly harder to secure and medical necessity is often used as a denial mechanism in the commercial carrier world. Paying for value instead of volume will replace managed care in the longer term. As these commercial carriers progress toward bundled payment arrangements in the ambulatory setting, surgical outcomes will play an important role in determining success.

This proposal is two-fold:  implement quality tracking and leverage it with commercial carriers and use in marketing initiatives to increase patient volumes by proving benchmarked quality outcomes. Specifically, this proposal focuses on the use of both PROMIS 10 General Physical Health and PROMIS 10 General Mental Health surveys for both surgical and non-surgical patients and Hoos, JR. and Koos Jr. outcomes surveys for knee and hip arthroplasty.  Results from these validated survey tools can be benchmarked through clinical registries and used for increasing market share as well as negotiating contractual rates with commercial carriers
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About the Author

Debbie Darby MBA, FACMPE
Chief Operating Officer Bone & Joint Clinic of Baton Rouge, Inc

Debbie Darby, MBA, CMPE, is certified as a Lean Six Sigma Green Belt and has worked in the orthopedic surgery setting for 30 years. She oversees the daily operations of a mid-sized clinic with 16 physician providers and more than 120 employees.


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