Section 10322 of the Affordable Care
Act authorizes the establishment of a new quality reporting program
for Inpatient Psychiatric Facilities (IPFs). It builds on a
voluntary Inpatient Psychiatric Facilities Quality Reporting
(IPFQR) program which remains in effect. The IPFQR began with an
initial set of 6 measures for FY 2014 and FY 2015 and for the IPPS
2016 and subsequent years; will add an additional 4 for a total of
10 IPFQR measures.IPFs failing to submit the quality measures will
receive a 2% reduction in their Annual Payment Update (APU). In an
effort to minimize burden and maximize efficiency, CMS has
leveraged existing systems within CMS to collect aggregated and
calculated measure rates from the IPFs, in a form, manner and time
as specified by CMS, via a secure portal known as the QualityNet
Web site beginning of October 1, 2012 for FY2014 payment
determination year. These procedural requirements involve
submitting necessary forms (e.g. Notice of Participation Form,
Reconsideration Request Form, Disaster Waiver Form, etc.) to comply
with the IPFQR Program and align with current CMS reporting
requirements for other hospital quality reporting programs. When
adding new measures, the law requires CMS, when "feasible and
practical" to select measures put forward by "one or more national
consensus building entities". Section 3013 of the Affordable Care
Act (ACA) modified by Section 931 of the Public Health Service Act
requires CMS to perform a gap analysis for needed quality measures
every three years. Section 3014 of the ACA modified Section 1890(b)
of the Social Security Act requires CMS to develop quality and
efficiency measures through a "consensus-based entity".
Consequently, the Measure Applications Partnership (MAP), convened
by the National Quality Forum (NQF), was formed to develop measures
consistent with these requirements.
The number of IPF hospitals is
constantly changing. For purposes of the FY 2016 and FY 2017 IPFQR
Program final rule, there are approximately 1,626 IPFs eligible for
the Program. The number of measures included in its data collection
requirements have increased. Specifically, for the FY 2016 payment
determination and subsequent years, 2 new measures were added, and
for the FY 2017 payment determination, 4 new measures were added.
This Program reduces the reporting burden for quality of care
information collected by allowing hospitals to abstract data
directly into electronic systems instead of submitting paper
charts, or to utilize electronic data that they already report to
the Joint Commission (JCO) for accreditation. In our effort to
foster alignment across quality reporting programs, we are removing
the Extraordinary Circumstances Exception form and the
Reconsideration Request form, and now submitting these forms as
part of the Hospital Inpatient Quality Reporting (HIQR) Program's
PRA package (OMB control number 0938-1022). While the currently
approved iteration of this IPF package inadvertently excluded the
burden for completing these forms, this package, consequently, does
not set out any burden changes pertaining to removing either of
these forms. Importantly, burden changes would also not apply since
the 15 minutes for chart abstraction also includes the time for
completing and submitting any forms related to the measures. For
purposes of the FY 2016 and FY 2017 IPFQR Program final rule, we
are revising the HBIPS Measure Data Collection form, SUB-1 Measure
Data Collection form, Vendor Authorization form, and Data Accuracy
Acknowledgement to reflect minor updates. We are also updating the
Notice of Participation Agreement such that it now can be used by
IPFs to also indicate their intent not to participate or withdraw
from the Program. We are in turn removing the previous Decline to
Participate form and Participation Withdrawal form from this year's
PRA package. Because these changes are minor, we do not anticipate
any measureable increase in burden on IPFs associated with these
changes. We are also adjusting our burden estimates, -We estimate
that there will be approximately 574 fewer IPF facilities (or 1,626
facilities) nationwide eligible to participate in the IPFQR
Program. -We estimate that the average facility submits measure
data on 556 cases per year (previously 271 cases per year). -1,626
IPF facilities, with approximately 556 cases per facility, results
in a total of 904,056 cases per year. -Beginning in FY 2016,
participating IPFs will need to submit data on 10 measures. Because
IPFs have been submitting 8 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 2 new measures. - Beginning in FY
2017, participating IPFs will need to submit data on 14 measures.
Because IPFs have been submitting 10 of the 14 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 4 new measures. -For
this year's PRA package, we are adding the Use of an Electronic
Health Record and Assessment of Patient Experience of Care form,
and the TOB and IMM Data Collection form. We anticipate only a
negligible burden on IPFs to complete and submit these forms.
Changes to the Program for the FY 2016 and FY 2017 payment
determinations, including more measures on which to report and an
increase in the wage rate, leads to an increase in the total
Program burden. For the FY 2017 payment determination and
subsequent years, hourly burden per IPF increases by 431.5 hours
and by 701,619 hours across all IPFs, while total cost per IPF
increases by $27,366 and by $44,496,677 across all IPFs.
On behalf of this Federal agency, I certify that
the collection of information encompassed by this request complies
with 5 CFR 1320.9 and the related provisions of 5 CFR
1320.8(b)(3).
The following is a summary of the topics, regarding
the proposed collection of information, that the certification
covers:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a
benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control
number;
If you are unable to certify compliance with any of
these provisions, identify the item by leaving the box unchecked
and explain the reason in the Supporting Statement.
Form CMS-10432 Inpatient Psychiatric Facility Quality Reporting Program
CMS-10432 - Supporting Statement A [rev 8-15-2014 by OSORA PRA].docx
Inpatient Psychiatric Facility Quality Reporting Program