Safety Net Hospitals Are at Risk for Major Financial Penalties With New Centers for Medicare & Medicaid Services...

Starting in 2027, the Centers for Medicare & Medicaid Services (CMS) will penalize hospitals that do not have complete paired patient-reported outcome measures (PROMs) data on at least 50% of patients undergoing inpatient total hip (THA) and knee arthroplasty (TKA). Patients must also meet the minimum substantial clinical benefit (SCB) threshold for Hip Disability and Osteoarthritis Outcome Score Joint Replacement and Knee Injury and Osteoarthritis Outcome Score Joint Replacement scores (22 and 20 points, respectively). The purpose of this study was to identify the risk factors for patients who did not have complete paired PROMs and did not meet the minimum SCB following surgery.

We included 5,165 primary THA and TKA patients between 2022 and 2023 at 22 hospitals. We collected data on demographics, medical comorbidities, insurance types, and socioeconomic status. Surveys were collected 90 to zero days preoperatively and 300 to 425 days postoperatively, consistent with CMS rules. A multivariate regression analysis was performed to identify independent risk factors for not meeting new CMS PROMs requirements.

There were 764 patients (14.8%) who met the CMS paired PROMs reporting requirement, whereas 554 (72.5%) met the SCB threshold. Risk factors for failing to meet paired PROMs collections included higher Charlson Comorbidity Index (odds ratio (OR) 1.10, 95% confidence interval (CI): 1.01 to 1.19, P = 0.049), Medicare insurance (OR 1.27, 95% CI: 1.04 to 1.52, P = 0.016), and lower socioeconomic status (OR 2.08, 95% CI: 1.37 to 3.33, P = 0.001). There were no risk factors identified for failing to meet the SCB PROMs threshold in multivariate analysis.

Overall, paired PROMs data collection was far below the CMS 50% threshold, suggesting all hospitals may face substantial financial risk beginning in 2027. Safety net facilities caring for THA and TKA patients who have greater medical complexity and lower socioeconomic status are at an even higher risk for penalties for noncompliance.