Proving Value with PROs: How to use data in payer negotiations

Key Takeaways

• PROs boost financial value: PROs are key to linking care quality with financial incentives from payers.

• PROs strengthen payer negotiations: Collecting PRO data helps practices prove superior care and secure better reimbursement terms.

• Tech simplifies PRO collection: The automation of PRO collection makes it easier to leverage data for clinical and financial gains.

As the healthcare industry continues to shift toward value-based care models, patient-reported outcomes (PROs) are gaining significant attention. PROs offer a powerful tool for providers to measure and improve the effectiveness of care. For the first time, PROs are now being tied to financial value in healthcare, especially as government and private payers increasingly require this data to justify reimbursement rates.

One of the most notable examples of this shift comes from the Centers for Medicare & Medicaid Services (CMS), THA/TKA PRO-PM program, which now mandates PRO submission for elective hip and knee replacements to avoid financial penalties. This requirement is a clear signal of the growing importance of the patient’s voice in healthcare decisions, and private payers are following suit.

How one multispecialty practice is leveraging PROs

A multispecialty practice in the PatientIQ network has taken this mandate as an opportunity to innovate. By collecting and analyzing PRO data, they are not only improving patient outcomes but also gaining leverage in payer negotiations to secure better reimbursement terms. Here’s how they’re doing it:

1. Embracing a culture of care quality: The practice has adopted a culture of patient-centered care, collecting and acting on feedback throughout the care journey. Whether it's adjusting medication based on post-op pain scores or addressing discrepancies in patient-reported pain, this approach signals a deep commitment to improving care quality.

2. Proving superior performance: PROs provide hard data that demonstrates a practice’s clinical performance compared to regional and national benchmarks. This practice uses this data to highlight its success in delivering better outcomes, creating a strong narrative for payers during contract negotiations.

3. Demonstrating clinical decision-making: PROs offer valuable insights into which patients are best suited for specific treatments. By using pre-operative PROs to select surgical candidates, the practice can demonstrate responsible and evidence-based care to payers, further strengthening their case for favorable terms.

Unlocking PRO value with the right tools: introducing PatientIQ

Collecting and leveraging PRO data may seem complex, but using the right platform can make all the difference. Technology solutions like PatientIQ’s cloud-based platform offer automation, easy data access, and integration with electronic health records (EHRs), simplifying the process for providers. Practices that invest in these technologies will be better equipped to navigate the growing demands of value-based care, and unlock both clinical and financial benefits.