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Comments for the Record
Hearing before the Health Subcommittee of the House Ways and Means Committee
Hearing on Innovation in Healthcare,
Held April 26, 2018
The Focus on Therapeutic Outcomes (FOTO) measurement system has been a leader of innovative healthcare technology practices for more than 2 decades. We are grateful to the Committee for its attention to the importance of innovation, and for this opportunity to comment on the topic. In short, the FOTO measurement system
  • has made use of innovative science and technology approaches to measure, report and encourage value-driven care since 1994;
  • uses the most scientifically advanced methods of measurement including computer adaptive testing (CAT) administration of patient-reported outcome measures (PROM) and risk adjustment;
  • administers patient-focused assessments via a web-based system that provides results to patients and clinicians in real-time for immediate use in the clinic;
  • focuses on assessing the construct of functional status as well as the number of treatment visits per episode of care;
  • has acquired an extensive database of nearly 22 million patient assessments; and
  • is used by 22,000 individual providers and 4800 provider groups (clinics) across all 50 states.
In this correspondence we will focus on the following points:
  • Patient perception is the single most optimal basis for assessing quality and controlling costs in healthcare. 
  • Patient-Reported Outcome Measures (PROMs) provide the best vehicle to represent patient perception, and PROMs must be carefully selected based on the best science and clinical reasoning.
  • Risk-adjustment goes hand-in-hand with PROMs to enable assessment of quality that is accurate and unclouded by confounding factors. PROM + risk adjustment = performance measure.
  • Technology and science must be leveraged to enable efficiency, validity and reliability in today’s busy clinical environments. Providers need the tools that will minimize their time spent on administrative duties, such as gathering outcomes, and maximize their time with patients, thus prioritizing patients over paperwork.
  • A value-based payment pilot study using FOTO performance measures resulted in a 12% cost saving. A real life example of successful implementation of a value-based payment program using this approach will be described.
  • Risk for provider bias when using PROMs is manageable.

Patient Perception

The patient’s perception is the most accurate mode to measure the impact of access to healthcare on the patient’s function and quality of life.1 While other modes of measurement such as provider (clinician)-rated, are useful adjuncts, the single most important indicator is the patient’s perception. The patient is in the best position to judge his/her status on a day to day basis. In the absence of a patient’s ability to assess his/her status (e.g., the presence of cognitive deficits), the next most suitable respondent should be a family member or caregiver who observes the patient’s day to day functioning. The healthcare provider should be considered as the third choice as proxy for judging a patient’s status.

Secondly, patient perception is strongly related to efforts to control healthcare spending. Perception drives behavior, and behavior drives cost. If the patient does not perceive he/she is better, he/she will continue to seek healthcare services.

Patient reported outcome measures (PROMs)

PROMs provide the best vehicle to represent patient perception and for assessing the ultimate outcomes of care such as improved functional status or quality of life.2 In contrast, most provider-rated measures (such as process measures or provider-assessed function) are most suitable as tools to guide clinical decision making. They should not be considered the outcomes of care; instead they should be used in pursuit of the ultimate outcome based on PROMs. PROMs must be carefully selected based on the target construct and the best available scientific properties including validity, reliability, and responsiveness.

Risk Adjustment

Risk-adjustment is essential to an accurate and dependable measurement system. Measurement results must be comparable between providers and the most scientifically sound risk-adjustment methods available must be employed to achieve this. While PROMs provide the optimal basis for assessing quality in value-based payment programs, risk-adjustment can account for differences between providers and the complexity of patients seen. The best risk adjustment models: 3,4

  • Include a wide range of constructs and individual variables that represent patient characteristics known to influence patient outcomes of function and duration/amount of care. As an example, the risk adjustment model for low back pain in the FOTO system includes 13 constructs with over 70 separate variables. Examples of constructs include age, gender, severity, and surgical history.
  • Are based on the most advanced scientific methods available. FOTO uses linear regression methods which account for the individual influence of each variable. This is more specific than simpler approaches that place patient groups into large categories (e.g., using average outcome of patients aged 45-64 is not a very specific way to risk adjust).
  • Are based on large sample sizes to help increase statistical confidence in the results. For example, FOTO orthopedic models are based on sample sizes ranging from tens to hundreds of thousands of patient episodes.

Research has demonstrated that risk adjustment matters. Deutscher and colleagues4 examined data from 414,125 patients with low back pain treated during 2014-2016 by 12,569 clinicians from 3,048 outpatient rehabilitation clinics from all 50 states. The study concluded that 70% of clinics were improperly ranked on quality levels for their patient care due to lack of risk-adjusted profiling of functional outcomes.

Performance Measure

The optimal measure of providers’ performance combines PROMs and risk adjustment. Put simply, performance measure = PROM + risk adjustment. This is consistent with how the term “performance measure” is defined by the National Quality Forum, the independent measure ratifying entity created by Congress. 5,6 It is also important to be aware that performance measures require additional levels of validity and reliability. That is, beyond the validity and reliability of the PROM on the patient-level alone, a performance measure must additionally demonstrate that it possess rigorous psychometrics, i.e., is valid and reliable for differentiating the performance of providers.

Leveraging Technology and Science

Technology and science must be leveraged to enable efficient employment of valid reliable and responsive measurement systems in today’s busy clinical environments. Providers need the tools that will minimize their time spent on administrative duties, such as gathering outcomes, in order to maximize their time with patients. This is consistent with CMS’ recent initiative in support of “patients over paperwork.” Furthermore, we must limit undue burdens on patients. FOTO has extensive experience in the following areas:

  • Computer Adaptive Testing (CAT) provides computer-administered assessments that are tailored to each individual patient’s functional ability level. CAT is based on modern mathematical principles, including item response theory. Using CAT results in reduced patient burden by minimizing the number of functional questions the patient must respond to in order to obtain a precise estimate of the patient’s functional ability level. 7,8
  • Electronic health record (EHR) integration: FOTO integrates with EPIC, Cerner and over 15 rehabilitation industry EHR and documentation systems. This reduces staff burden and provides efficiency to the workflow.
  • Real-time reporting for both the provider and patient. Immediately upon the patient’s completion of a computer survey in the FOTO system, the patient’s results are seamlessly and conveniently scored by the system and provided directly to the provider and patient in a user-friendly format and inserted into the EHR. Providing such immediate results facilitates efficient discussions between provider and patient about functional status, expectations for care and establishing realistic treatment goals.
  • Transferring functional outcomes data into meaningful and useful states: This is not a simple task and is best addressed using science and technology services. FOTO has been streamlining this process and using its robust database to enable risk-adjusted benchmarked comparisons nationwide. FOTO’s measures are available to the public, and therefore it is possible for providers to administer the measures manually in-house as well as the data gathering, scoring, real-time provider/patient reporting, aggregating, categorizing, risk-adjustment and group-level reporting. However, FOTO provides valuable services to reduce the amount of time and resources that the provider would expend, the expertise needed to perform those activities, and the ability to compare against a robust national benchmark.

Performance measurement incentivizes providers to improve

Not only do these systems and processes facilitate patient motivation and compliance, but Placing risk-adjusted functional outcomes data directly into the hands of the provider facilitates the desired paradigm shift from focusing on how many units may be billed during an episode of care toward a focus on optimizing effectiveness and efficiency of care. 9 Based on frequent reports from providers who use FOTO’s services, providers who use FOTO data feel encouraged to seek out knowledge and skills development toward getting patients better, faster. This can lead to cost-savings by preventing unnecessary utilization. In the FOTO system, providers see their outcomes data reported on two main levels:

  1. Individual patient - each individual patient’s results at the time of the patient encounter, and:
  2. Aggregated - all care episodes risk-adjusted and aggregated together to demonstrate overall functional gains and efficiency for the provider’s patient population as a whole relative to a national benchmark. This is the level on which the provider’s performance should be evaluated.

During a patient’s encounter with the provider, using measures based on the patient’s perception promotes data-driven clinical decision making with the patient at the center. When patient-focused data is made readily available to the provider and patient, the provider is more likely to focus on treatment interventions that will improve patient-perceived function and to do so sooner than later. 10,11

Cost Savings Using FOTO Performance Measures in a Value-Based Payment Program

In 2006 FOTO provided the results of a pilot value-based payment study that was commissioned by the CMS.12 In the study, FOTO presented the results of a study based on a Value-Based Payment Algorithm (VBPA) for outpatient rehabilitation therapy reimbursement. The model consisted of a 9-cell matrix (Figure 1) that measured each patient’s risk-adjusted functional change and therapy utilization relative to national data. Following completion of therapy care, each patient was scored as “Above Expected,” “Expected,” or “Below Expected” relative to a combined “value” score considering both functional improvement and cost. Results of the study included that simulating the Value-Based Payment Algorithm on retrospective data demonstrated a 12 % cost savings (reduction in reimbursement to providers).12

Figure 3 9-cell matrix for value-based payment algorithm


Example of Successful Implementation of VBPA by a large payer

Since the 2009 pilot study described above, the VBPA has been successfully implemented by a number of payers, including Minnesota’s second largest private health plan, Health Partners (HP). HP implemented the VBPA with Therapy Partners (TP), a large management services organization for independent rehabilitation therapy clinics. Their model called for HP to pay TP clinics a slightly larger rate for each patient visit but also implement a percentage withhold which could be earned back (rewarded) based on both utilization (efficiency) and functional improvement (effectiveness). The HP VBPA program and its success were reported to the Health Subcommittee of the House Ways and Means Committee related to a hearing on the topic of Programs that Reward Providers Who Deliver High Quality and Efficient Care February 7, 2012. 13 Success of the venture included that rehabilitation therapists gained a greater focus on quantifiable patient outcomes, and they managed their patients’ episodes of care on average between 6-7 visits compared to the national risk-adjusted average of 9-10 visits. Thus, the costs of care were relatively lower and more efficient. The payer, HP, benefitted in a number of ways, not the least of which was a cost savings substantial enough that HP opted to bonus TP 20% above and beyond the 80% of the withhold amount that TP actually earned. Another direct cost benefit was that HP was able to eliminate the need to perform costly utilization management processes for TPI practices and has saved significant money and time by allowing TPI to manage their care based on FOTO predictions and outcome data.13

Minimizing Risk for Provider Bias of PROM Results

While assessing the patient’s perception may be the most non-biased method for measuring the performance of the provider (vs. providers rating themselves), when it comes to patient self-reported measures, there is a chance that a provider could bias the PROM results, e.g., by coaching the patient to answer questions a certain way or avoiding collection of certain data on a patient who did not seem to be progressing well. 

FOTO has a long history of detecting and developing processes to minimize risks of provider bias. It is our experience that very few providers intentionally bias their patients, but from time to time a well-intentioned provider may act on a concern that the patient must respond accurately, where “accurate” is defined as the provider’s perception. To that end, FOTO trains providers to follow processes when administering the PROMs.

Examples of processes to minimize risk of provider bias include:

  • Standards for Administration - providing and requiring training on defined standards for how assessments should and should not be administered to patients. This includes, but is not limited to, what to say and what not to say to patients when they are taking the assessments, how to assist patients who ask for help, all with the intent of maintaining the established validity of the PROMs and the process as a whole.
  • Proxy and Recorder Modes of Administration - providing definitions and documentation to determine instances in which the patient does not respond for him/herself. For example, if the patient requires a proxy respondent, the reason (e.g., cognitive deficit) and who served as proxy (e.g. spouse, family member, caregiver, with provider being the least preferred option) must be designated in the FOTO system. A recorder respondent may be used when the patient can respond for themselves, but he/she needs someone else to enter the response into the FOTO system such as in the case of low reading level, eyesight limitations or hand/arm problems limiting ability to use a computer mouse or touchscreen.
  • Completion Rates - providing formal feedback about what percentage of a provider’s patients completed a full episode of PROM assessments. The higher the completion rate, the lower the risk that “cherry-picking” has occurred.

FOTO would appreciate the opportunity to talk with Chairman Roskam and the Ways & Means Committee members and their staff, as well as any other interested parties, to offer insight about pay-for-performance policies using data from Patient-Reported Outcome Measures (PROMs) and risk-adjusted-based performance measures with the goal of improving both quality and value.


  1. Porter ME, Larsson S, Lee TH. Standardizing patient outcomes measurement. N Eng J Med. 2016;374(6):504-506.
  2. Guyatt GH, Feeny DH, Patrick DL. Measuring health-related quality of life. Ann Intern Med. 1993;118(8):622-629.
  3. Iezzoni LI. Risk adjusting rehabilitation outcomes: an overview of methodologic issues. Am J Phys Med Rehabil. 2004;83:316-326.
  4. Deutscher D, Werneke MW, Hayes D, Mioduski JE, Cook KF, Fritz J, Woodhouse LJ, Stratford PW. Impact of risk-adjustment on provider ranking for patients with low back pain receiving physical therapy. JOSPT 2018 (in press).
  5. National Quality Forum. Pay-for-Performance Programs: Guiding Principles and Design Strategies. October 2005.
  6. National Quality Forum: Measuring performance. http://www.qualityforum.org/Measuring_Performance/Measuring_Performance.aspx. Accessed May 10, 2018.
  7. Swaminathan H, Hambleton R. Fundamentals of item response theory. Newbury Park [CA]: Sage Publications; 1991. In: Stephanie Nikolaus, JMIR Human Factors. 2014;1(1):e4.
  8. Sands WA, Waters BK, McBride JR, editors. Computerized adaptive testing: from inquiry to operation. Washington, DC: American Psychological Association; 1997.
  9. Institute of Medicine (U.S.). Committee on Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington, D.C.: National Academy Press; 2001.
  10. Bingham CO, 3rd, Noonan VK, Auger C, Feldman DE, Ahmed S, Bartlett SJ. Montreal Accord on Patient-Reported Outcomes (PROs) use series - Paper 4: patient-reported outcomes can inform clinical decision making in chronic care. J Clin Epidemiol. 2017;89:136-141.
  11. . Deutscher D, Horn SD, Dickstein R, Hart DL, Smout RJ, Gutvirtz M, Ariel I. Associations between treatment processes, patient characteristics, and outcomes in outpatient physical therapy practice. Arch Phys Med Rehabil. 2009;90(8):1349-1363.
  12. Hart DL, Connolly JB. Pay-for-Performance for Physical Therapy and Occupational Therapy: Medicare Part B Services. Final Report. Grant #18-P-93066/9-01: Health & Human Services/Centers for Medicare & Medicaid Services; 2006. http://www.cms.hhs.gov/TherapyServices/downloads/P4PFinalReport06-01- 06.pdf.
  13. Therapy Partners statement for Programs that reward providers who deliver high quality and efficient care. For Hearing before the health subcommittee of the House Ways and Means Committee. February 7, 2012. https://cdn2.hubspot.net/hubfs/442011/docs/P4P/TPI%20Statement%20for%20Ways%20and% 20Means.pdf?t=1525981211937 Accessed May 10, 2018.