Threats to PROMs

October 10, 2023


Over the last decade, patient-reported outcome (PRO) data has emerged as a primary metric for assessing the effectiveness of orthopedic procedures. It has gained prominence in various value-based payment models and is now a mandatory requirement for hospitals performing total hip and knee replacements. These payer initiatives are actively promoting the adoption of patient-reported outcome measures (PROMs). At CODE, our mission is to assist clinicians in efficiently collecting, utilizing, and loving outcome data- so naturally, we’re excited about the integration of PROMs into the healthcare delivery model. Nonetheless, we have identified some issues that are cause for concern. We believe if these issues are not addressed, it could unravel years of work that has been done driving PROs in musculoskeletal quality programs.

The Burden Of PROM Licensing

The landscape of PROMs presents varying licensing scenarios: some are free, some are free with licensing agreements, and some entail both licensing agreements and fees.

In 2015, the American Academy of Orthopedic Surgeons (AAOS) issued an information statement regarding PROMs which advocated that the tools are ‘easily administered, validated, and free to use’. To which CODE responded with a simple AMEN. Back in 2015, this was a true statement for many PROM instruments. Overtime, however, this landscape has changed, and in the present state, it is rare to find a tool that is truly ‘free to use’. An alarming trend has emerged  of profit thirsty companies acquiring PROM’s copyright, and subsequently commercializing utilization. To access such PROMs, users must sign contracts, pay fees, and then gain access to the survey and its scoring instructions. Ownership of the license/agreement can be restrictive, often limited to direct contracts with healthcare professionals. In such cases, hospitals sign agreements, pay fees, and subsequently extend usage rights to vendors. Conversely, some licensing arrangements allow vendors to secure licenses independently, significantly simplifying the process. The pricing models associated with using the PROM  tools vary, but there are a few common approaches.

  • Annual License: This model charges an annual fee per organization, with potential variations based on usage. For instance, the cost may differ for research studies compared to ongoing quality assessments. Whether the contract is with the vendor or the hospital, this model is straightforward.
  • Per-Survey Fees: Some models charge per survey utilized, often on a quarterly basis. This approach involves ongoing administrative work to track usage and results in variable costs.
  • Vendor Premiums: A current trend involves imposing a premium, typically a percentage increase over the baseline cost, on vendors. This can add complexity to pricing negotiations.

Outside of these fee structures, CODE has noticed a growing trend where companies demand backdated payments for PROM tools they’ve recently acquired. This occurs when healthcare organizations start using a tool that was initially free. Later, the tool changes ownership and is commercialized, and the owning entity requests retroactive fees. Juggling the growing number of PROM tool acquisitions and the associated unexpected costs is no easy feat, especially with the initially ‘free’ tool being baked into a CMS related quality measure, which turns the situation into both a financial and ethical issue. 

In addition to the pure cost, the complexities of obtaining and managing licensing agreements carry a heavy administrative burden. Add on nondirect fees tied to the actual fees, and many providers and vendors are priced out of the market, and simply can not afford to use PROMs.

The Burden to Patients- Sloppy Digital Communication

The phenomenon of survey fatigue is well known, and very real. But there is another emerging threat that has a more devastating impact on capture rate than survey fatigue- digital overcommunication. Let us unpack that for you a bit. 

The healthcare landscape has witnessed a surge in patient-facing digital products, particularly in response to the COVID-19 pandemic. While the ability to activate navigation, PROMs, and educational features at the touch of a button seems appealing, the reality demands a much more thoughtful approach.

Patients already receive numerous messages for each healthcare encounter, including appointment reminders and patient experience surveys. This baseline noise can be overwhelming. Introducing additional elements such as navigation systems with tasks, reminders, and educational videos requires careful consideration. 


man running away from flying envelopes spawning out of a laptop screen

As part of our CODE implementation process, we conduct patient communication audits, revealing an overwhelming influx of emails, texts, app notifications, and calls before scheduled appointments and procedures. We’ve seen a significant increase in communication from ‘sensor’ products, payers, and Durable Medical Equipment (DME) providers, often without our clients’ awareness. Maintaining the integrity and usefulness of your independent patient-facing digital strategy is important; but factoring in how your partners are contacting patients is equally necessary. Organizations must coordinate with ancillary partners to stay aware of all patient communication touchpoints.

Communication to the patient should be coordinated, clear, and classy. Otherwise, that will lead to patients ignoring messages, including those asking patients to fill out PROMs.

Hospitals & Providers Competing for PROMs

In today’s market, hospitals and private practices report to CMS via different quality programs- for example, Merit-based Incentive Payment System (MIPS) impacts private practices, while inpatient prospective payment system (IPPS) impacts hospitals, and both programs have metrics for total joint replacement patients that include administering PROMs. This creates a situation where patients often find themselves in the middle, receiving survey requests from both the hospital and the provider entities.

Understandably, patients find it impractical and time consuming  to complete both sets of surveys, which results in the completion of only one. To hit metrics like 50% survey response rates, we are seeing hospitals and providers ‘fight’ over the PROMs- they tell the patient to ‘ignore’ the PROM sent by the other organizations. This strategy may work in the short term, but ultimately is not viable and can damage the hospital provider relationship. 

The good news is modern technology provides a solution to competing PROM demands. By leveraging partners like CODE Technology, patients can complete a single survey, and the data can be efficiently shared with multiple entities. While implementing any solution can be daunting, it offers an effective means of streamlining data collection in the healthcare sector, ensuring both patients’ convenience and improved healthcare outcomes.

The Complexity of PROM Usage as part of the Prior Authorization Process

Many prior authorization processes now require the submission of PRO data: this makes sense as it helps quantify how a patient feels about their pain and function. Factoring patient-perspective into a  treatment plan is a pillar of the value-based care philosophy the healthcare industry is leaning towards. But as insurance providers collect more patient data, it raises some important questions: How are they using this PRO data, and what unintended consequences might come from it? We might not have all the answers to the first question yet, but we’re starting to gather insight  to the second one. Payers are starting to deny procedures if the PROM survey results are not below a certain threshold.

prior authorization form with a stamp that says 'denied'

We are seeing a phenomenon in our registry that this type of prior authorization situation prompts an over-corrective action from the providers, who encourage patients to fill out the PROM to the greatest degree of disability possible. Patients readily comply with this request, because they are afraid of the surgery getting denied. There are several states in the US where PROMs for total joint surgery is required as part of the prior authorization process, and in those states, the PROM scores  are notably low across the board when compared to the rest of CODE’s national registry, exemplifying this phenomenon. While the causative factors are multifaceted, the pressure to quantify surgical necessity within prior authorization processes creates complexities in PRO utilization, ultimately skewing medical data—a significant challenge in contemporary healthcare.


In conclusion, PROM data is exceedingly valuable, but there are potential threats that could drastically undue years of work that has been embedded in patient reported information into care delivery models. These problems need to be understood by all parties involved, and addressed in creative and collaborative fashion by the hospitals, providers, and payers.

Let’s Talk More About Patient Reported Outcomes

If you’re ready to tackle these challenges and ensure the continued success of patient-reported outcomes in healthcare, let’s connect and explore solutions together. Contact us today to start the conversation.