CMS IPF Supporting Statement A_updated on 2013_04_01_508

Supporting Statement – Part A
New Procedural Requirements for the FY 2016 Inpatient Psychiatric Facility
Quality Reporting Program (IPFQR Program)

A. Background
Pursuant to section 1886(s)(4) of the Social Security Act, as amended by sections 3401 and
10322 of the Affordable Care Act, starting in FY 2014, and for subsequent fiscal years, Inpatient
Psychiatric Facilities (IPF) shall submit pre-defined quality measures to the Centers for Medicare
& Medicaid Services (CMS). The IPFs that fail to report on the selected quality measures will
have their IPF PPS payment updates reduced by 2.0 percentage points. To comply with the
statutory mandate, we are updating the Inpatient Psychiatric Facilities Quality Reporting
(IPFQR) Program for FY 2016.
For the FY 2016 IPFQR Program, we will continue to collect the six (6) National Quality Forum
(NQF)-endorsed process measures developed by The Joint Commission (TJC) that were used in
reporting Fiscal Years 2014 and 2015 (listed below). We also intend to collect three (3)
additional NQF reviewed process measures and propose voluntary submission of data on a fourth
measure. These measures are listed below.
Current Measure Set
Measure ID

Measure Description

HBIPS-2

Hours of Physical Restraint Use (NQF #0640)

HBIPS-3

Hours of Seclusion Use (NQF #0641)

HBIPS-4

Patients Discharged on Multiple Antipsychotic Medications (NQF #0552)

HBIPS-5

Patients Discharged on Multiple Antipsychotic Medications with
Appropriate Justification (NQF #0560)

HBIPS-6

Post-Discharge Continuing Care Plan Created (NQF #0557)

HBIPS-7

Post-Discharge Continuing Care Plan Transmitted to Next Level of Care
Provider Upon Discharge (NQF #0558)

New Proposed Measure Set
Measure Type Measure and NQF Status

Measure Title

Process

0576 Endorsed

Follow-up After Hospitalization for Mental Illness

Process

M2753 Not Endorsed

SUB-1 Alcohol Use Screening

Process

M2754 Not Endorsed

SUB-4 Alcohol & Drug Use: Assessing Status
After Discharge

The voluntary submission measure is a yes/no statement regarding the use of a standardized
instrument to assess the patient experience of care. This measure will not impact a facility’s
FY2016 payment determination. Due to an interest in collecting this information, it has been
included in the burden calculation.

In selecting the proposed quality measures, we strive to achieve several objectives. First, the
measures should relate to the National Quality Strategy aims of better care, healthy populations
and communities, and affordable care. Second, the measures should be tailored to the needs of
improved quality in the inpatient psychiatric setting; thus, the measures selected are most
relevant to IPFs. Finally, the measures should be minimally burdensome to the IPFs.

B. Justification
1. Need and Legal Basis
Section 1886(s)(4)(C) of the Act requires that, for FY 2014 (October 1, 2013 through September
30, 2014) and each subsequent fiscal year, each psychiatric hospital and psychiatric unit shall
submit to the Secretary data on quality measures as specified by the Secretary. Such data shall be
submitted in a form and manner, and at a time, specified by the Secretary.
In implementing the IPFQR Program, we believe that the development of a quality reporting
program that is successful in promoting the delivery of high quality health care services in the
IPF setting is of paramount importance. Therefore, in our effort to provide services to the IPFs
and implementing the statutorily mandated IPFQR Program, we are proposing some procedural
requirements.
Section 1886(s)(4)(E) of the Act requires the Secretary to establish procedures for making public
the data submitted by IPFs under the quality reporting program. In order for CMS to publish the
measure rates, IPFs would need to submit the Notice of Participation (NOP) form. By such
submission, IPFs indicate their agreement to participate in the IPFQR Program and that they
shall submit the required data pertaining to the ten (10) quality measures and additionally,
consent to publicly report their measure rates on a CMS website. We are mindful and respectful
that IPFs may choose not to participate or may choose to withdraw from the IPFQR Program. To
this end, our procedures include the necessary steps IPFs will have to take to indicate their intent.
As part of our procedural requirements, we are also requiring the IPFs to acknowledge the
accuracy and completeness of the data submitted. We seek to collect information on valid,
reliable, and relevant measures of quality and to share this information with the public; therefore,
IPFs will have to submit the Data Accuracy and Completeness Acknowledgement (DACA)
form. Other forms the IPFs may need to submit (depending on their decision to participate or
their specific needs) will be the Notice of Participation Form, Decline to Participate Form,
Participation Withdrawal Form, Reconsideration Request Form, and Extraordinary
Circumstance/Disaster Extension or Waiver Request Form.
2. Information Users
• IPFs: The IPF main focus is to examine individual IPFs’ specific care domains and types
of patients and compare present performance to past performance and to national
performance norms; IPFs use Quality Measures to evaluate the effectiveness of care
provided to specific types of patients and, in the context of investigating processes of
care, to individual patients; to continuously monitor quality improvement outcomes over
time, and to objectively assess their own strengths and weaknesses in the clinical services

they provide; and to address the care-related areas, activities, and/or behaviors that result
in effective patient care, and alert themselves to needed improvements. Such information
is essential to IPFs in initiating quality improvement strategies. This information can also
be used to improve IPFs’ financial planning and marketing strategies.
•

State Agencies/CMS: Agency profiles are used in the process of comparing an IPF’s
results with its peer performance. The availability of peer performance enables state
agencies and CMS to identify opportunities for improvement in the IPF and to evaluate
more effectively the IPF’s own quality assessment and performance improvement
program.

•

Accrediting Bodies: National accrediting organizations such as The Joint Commission
(TJC) or state accreditation agencies may wish to use the information to target potential
or identified problems during the organization’s accreditation review of that facility.

•

Beneficiaries/Consumers: Since November 2003, the Hospital Inpatient Quality
Reporting (HIQR) Program has been publicly reporting quality measures. The IPFQR
program will also be publicly reporting data through a CMS.gov website. This provides
information for consumers and their families about the quality of care provided by
individual hospitals, allowing them to see how well patients of one facility fare compared
to other facilities and to the state and national average. The information is presented in
consumer-friendly language and provides a tool to assist consumers in the selection of a
hospital.

CMS will use the information submitted related to the 10 proposed measures listed in the tables
above to identify opportunities for improvement in the coordination of care and to effectively
target quality improvement initiatives to meet the statutory requirements of the Affordable Care
Act Sections 3401 and 10322 as mandated for the agency. The information gathered will in turn
be made available to IPFs for their use in specifying areas of need for internal quality
improvement initiatives.
The HBIPS Measures were chosen because TJC has utilized them for three years to evaluate and
assess related quality of care in their member IPFs. CMS determined that these same measures
and the data collection definitions that have been tested and proven to improve quality of care
provided and to identify areas of need for quality of care improvement are valuable within all
CMS-certified IPFs. Documentation on the TJC website provided at the link below provides
details to show how reporting on these measures has brought attention to the actions necessary to
improve the care provided related to the measures.
http://www.jointcommission.org/assets/1/6/TJC_Annual_Report_2011_9_13_11_.pdf.
One priority area currently unaddressed in the IPFQR Program is that of patient and family
engagement and experience of care. On the “List of Measures Under Consideration for
December 1, 2012,” CMS included NQF #0726, “Inpatient Consumer Survey of Inpatient
Behavioral Healthcare Services” (ICS). The MAP provided input on this measure supporting its
inclusion in the IPFQR Program. Although this specific measure is endorsed by NQF, CMS is
recommending, in the short term, to propose a structural measure of whether the facility assesses
patient experience of inpatient behavioral health services using a standardized instrument. This

will be collected through the Web-Based collection tool as a yes/no question; facilities that
answer “Yes” will be asked to indicate the name of the survey that they administer.
The “Follow-up After Hospitalization for Mental Illness” (Measure 0576) was identified as a
high-impact measure for improving care for the vulnerable dual eligible population. This
NQF-endorsed measure addresses several principles of the National Quality Strategy (NQS)
while focusing on the person-centered episode of care. Information regarding this measure,
including evidence of its impact, can be found at the link below.
http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=70617

The SUB-1 and SUB-4 measures are specified by TJC to evaluate and assess quality of care for
inpatient hospitals. CMS has determined that these measures relate to important aspects of the
NQS that have not been covered by the existing measure set, and that these measures will help to
improve quality of care and the patient-centered aspect of care across multiple settings.
Documentation on the TJC website provided at the link below provides details on the
specification of these measures.
http://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_quality_measures.
aspx.

3. Use of Information Technology
IPFs will be able to utilize electronic means to submit/transmit their forms and data via a CMSprovided secure web-based tool, which will be available on the QualityNet (QNet) website. IPF
users will be required to open an account to set up secure logins and then will be able to
complete all the necessary forms/applications as may be applicable to their circumstance (i.e.,
NOP, DACA, Request for Reconsideration, etc.). We have included copies of these forms
within this package.
A Web-based Measure online tool will be used for data entry through the QualityNet
website. Data will be stored to support retrieving reports for hospitals to view their measure
rates/results. Hospitals will be sent a preview report via QualityNet Exchange prior to release of
data to on the CMS website for public viewing.
4. Duplication of Efforts
Hospitals that are currently collecting and reporting this data to TJC can use the same
information to report to CMS, which avoids duplication of efforts and reduces burden to the
IPFs. It will be a new effort for non-TJC member IPFs, but the opportunity to include these other
IPFs in the quality improvement process is seen as highly important to the quality of care for
CMS patients and supports the mandates of the ACA.
5. Small Business
Information collection requirements were designed to allow maximum flexibility specifically to
small IPF providers participating in the IPFQR program. This effort will assist small IPF
providers in gathering information for their own quality improvement efforts. For example, we

will be providing a help-desk hotline for troubleshooting purposes and 24/7 free information
available on the QualityNet website through a Questions and Answers (Q&A) functionality.
6. Less Frequent Collection
We have designed the collection of quality of care data to be the minimum necessary for
reporting of psychiatric data on measures considered to be meaningful indicators of psychiatric
patient care by the National Quality Forum. To this end, we are requiring yearly data submission.
7. Special Circumstances
Although IPF participation is voluntary, all eligible IPFs must submit their data to receive the
full market basket update for a given fiscal year. If data is not submitted to CMS, the IPF will
receive a reduction of 2 percentage points from their Annual Payment Update (APU).
8. Federal Register Notice/Outside Consultation
CMS is supported in this initiative by TJC, National Quality Forum (NQF), and the Agency for
Healthcare Research and Quality (AHRQ). These organizations, in conjunction with CMS, will
provide technical assistance in developing and/or identifying quality measures, and assist in
making the information accessible, understandable, and relevant to the public.
A 60-day Federal Register Notice will be included as part of the proposed regulation that is
expected to be displayed in April 2013.
9. Payment/Gift to Respondent
No other payments or gifts will be given to respondents for participation.
10. Confidentiality
All information collected under this initiative will be maintained in strict accordance with
statutes and regulations governing confidentiality requirements, which can be found at 42 CFR
Part 480. In addition, the tools used for transmission of data are considered confidential forms of
communication and are HIPAA-compliant.
11. Sensitive Questions
No case-specific clinical data elements will be collected for the IPFQR program. Pursuant to 42
CFR Part 480, no case-specific clinical data will be collected or released to the public.
12. Burden Estimate (Total Hours and Wages)
Until FY 2014, IPFs had not been required to report quality data to CMS. However, they have
been required to report quality measures to other entities such as TJC or state survey and other
certification organizations. Therefore, although IPFs had not reported on quality measures to

CMS, they have some familiarity with and experience in reporting of quality data. In our burden
calculation, we have included the time used for chart abstraction and for training personnel on
collection of chart-abstracted data, aggregation of the data, as well as training for submitting the
aggregate-level data through QualityNet. Because IPFs have been submitting 6 of the 10
measures to CMS, the amount of training required to submit data should be reduced to training
for facilities new to the program and training on the collection of data and submission only for
the four new measures.
The burden estimates for data collection related to the proposed measures for the IPFQR
Program are calculated for the IPFs based on the following data:
• There are approximately 2,200 IPF facilities nationwide (based on the total number of
facilities as of January 2013).
• The average IPF facility handles 271 cases per year (based on total claims and
number of facilities from the last data available).
• The average IPF facility handles approximately 68 cases per quarter.
• 2,200 IPF facilities, with approximately 271 cases per facility, results in a total of
596,200 cases per year.
• The average time spent per each psychiatric measure per patient chart abstraction is
approximately one half of an hour (based on 2007 GAO measure abstraction work
effort survey – GAO-07-320).
• The time spent for abstracting each measure is 30 minutes per case (including 25
minutes of clinical time and five minutes of administrative time submitting the data).
• The total number of cases to be submitted for each measure varies based on
measure-specific sampling criteria (see Table A).
Table A

1

Annual
Sampling
Rate

Effort
per
Case

Annual
Effort per
Facility

NQF
Number

Measure
ID

Measure Description

0640

HBIPS-2

Hours of Physical Restraint Use

All Patients
(271/facility)

½ hour

135.5 hours

0641

HBIPS-3

Hours of Seclusion Use

All Patients
(271/facility)

½ hour

135.5 hours

0552

HBIPS-4

Patients Discharged on Multiple
Antipsychotic Medications

176/facility 1

½ hour

88 hours

0560

HBIPS-5

Patients Discharged on Multiple
Antipsychotic Medications with
Appropriate Justification

176/facility

½ hour

88 hours

0557

HBIPS-6

Post-Discharge Continuing Care
Plan Created

176/facility

½ hour

88 hours

Measure specifications indicate that for quarterly population between 44 and 220, a minimum of 44 cases must be
abstracted, yielding 176 cases per year for NQF 0552, 0560, 0557, and 0558.

Annual
Sampling
Rate

Effort
per
Case

Annual
Effort per
Facility

NQF
Number

Measure
ID

0558

HBIPS-6

Post-Discharge Continuing Care
Plan Transmitted to Next Level
of Care Provider Upon
Discharge

176/facility

½ hour

88 hours

N/A

SUB-1

Alcohol Use Screening

271/facility 2

½ hour

135.5 hours

N/A

SUB-2

Alcohol & Drug Use Assessing
Status After Discharge

271/facility

½ hour

135.5 hours

0576

FUH

Follow-Up After Hospitalization
for Mental Illness

271/facility 3

½ hour

135.5 hours

N/A

N/A

New Voluntary Structural
Measure – Facility Assessment
of Patient Experience of Care

Annual
Acknowledge
ment Only

½ hour

½ hour

Annual
Total

1,030
hours/facility

Measure Description

The Paperwork Reduction Act costs related to wages is based on the Bureau of Labor Statistics
(BLS) 4 wage estimates for healthcare workers that are known to engage in chart abstraction (e.g.,
$31.71/hour). This calculated for the 1,030 hours for chart abstraction, and data submission is
$32,661.30 annual cost for each facility. The total annual cost for all IPFs is $71,854,860.
The estimated burden for training personnel for data collection and submission for current and
future measures is 6 hours per facility. (This is reduced from the previous years because the
majority of participating facilities will have been trained for prior years and will only need to be
trained for new measures and associated reporting.) The cost for this training, based on an hourly
rate of $31.71, is $190.26 training costs for each IPF, which totals $418,572 for all
facilities. The all-inclusive program total for each facility is $32,851.56, and for all facilities it is
$72,273,532 (See Table B).
Table B
Tasks

2

Hours per
IPF

Total Hours
for All IPFs

Wage
Rate

Cost per
IPF

Total Cost
for All IPFs

Chart-Abstracted
Measure Data Collection
and Submission

1030

2,266,000

$31.71

$32,661.30

$71,854,860

Training

6

13,200

$31.71

$190.26

$418,572

Totals

1036

2,279,200

$32,851.56

$72,273,432

Average caseload of 271 patients per year is below the threshold for sampling for SUB-1 and SUB-2.
Sampling is not consistent with using this measure at the facility level.
4
BLS May 2010 National Occupational Employment and Wage Estimates - United States
http://www.bls.gov/oes/current/oes_nat.htm#31-0000
3

The NoP and the DACA forms are required to be filled out only once for each data submission
period. All others forms are optional. It is estimated that these forms should take less than five
minutes to complete, thus the burden related to this activity is negligible.
Three factors increase the burden in comparison to the burden calculation previously submitted.
These factors are the impact in number of measures to, the increase in salary rates over prior
years, and a decrease in the average amount of training required for each participating facility.
This yields an overall increase in burden of 215 hours and $8,366.13 dollars per facility. (See
Table C)
Table C
Total Hours
per IPF

Total Cost
per IPF

Total Program
Hours

Total Program
Cost

Prior Total Burden

821

$24,194.87

1,429,361

$42,123,268.67

New Total Burden

1036

$32,661

2,279,200

$72,273,432

Amount of Increase

215

$8,366.13

849,839

$30,150,163.33

13. Capital Costs (Maintenance of Capital Costs)
There are no capital costs being placed on IPFs.
14. Cost to Federal Government
The data for the IPFQR program measures will be reported directly to the QualityNet website
utilizing existing system functionality. A support contractor will be utilized to provide help desk
and Q&A assistance as well as the monitoring and evaluation effort for the program. There will
be minimal costs for development of the data entry tools because, as described earlier, the
development is part of an existing software development contract.
The labor cost for IPFQR program oversight is estimated as follows:
• Current year 1.0 FTE (2,080 hours) at GS-13 salary = $106,839
• For subsequent years 1.0 FTE (2,080 hours) at GS-13 salary = $106,839
15. Program or Burden Changes
The number of IPF hospitals is constantly changing. As of January 2013, there are approximately
1,900 IPFs that fall under the program. This has been changed in the information under section
12 from 1,741 IPFs.
As shown above, this program has increased the number of measures included in its data
collection requirements. The CMS program reduces the reporting burden for quality of care
information collected by allowing hospitals to abstract data directly into electronic systems in
lieu of submitting paper charts, or to utilize electronic data that they already report to the Joint

Commission (JCO) for accreditation. The long-term vision for the IPFQR program is to allow
hospitals to submit data directly from their electronic health records, which we anticipate will
reduce burden substantially. The 2012 Electronic Reporting Pilot (76 FR 74490) is an important
step in the transition from paper to electronic reporting.
16. Publication/Tabulation Dates
CMS will not be employing any sampling techniques or statistical methods. CMS is not the
measure steward and does not have ownership of the measure specifications. However, IPFs will
have to comply with the measure specifications (including sampling and validation techniques)
set forth by measure stewards.
IPFs will submit their measures through a web-based measures tool on the QualityNet website.
After IPFs have previewed their data and agree to publicly report their measure rates, CMS will
publicly display the measure rates on the CMS website. The following is the planned schedule
of activities to reach these objectives.
Date

Scheduled Activity

4/13/2013

Proposed Rule Published

8/2/2013

Final Rule Published

10/1/2013

Measures Publicly Announced

1/1/2014

Start of Reporting Period

1/1/2014

Notice of Participation Begins

12/31/2014

End of Reporting Period

7/1/2014

Begin Data Submission

8/15/2014

End Submission Deadline

8/15/2014

Deadline to Submit Notice of Participation

8/15/2014

Deadline to Withdraw from the IPFQR Program

8/15/2014

Deadline to Complete Data Accuracy and Completeness Acknowledgement
(DACA)

9/20/2014

Beginning of Preview Period for Public Reporting

10/19/2014

End of Preview Period for Public Reporting

QT 1 FY 15

Public Posting on CMS.gov

17. Expiration Date
We request an exemption from displaying the expiration date because these tools will be used on
a continuous basis by hospitals reporting quality data.