Prior to
publication of the final rule, the agency should provide a summary
of all comments related to the information collection requirements
contained in the rule and any changes made in response to these
comments.
Inventory as of this Action
Requested
Previously Approved
09/30/2017
36 Months From Approved
09/30/2017
904,056
0
904,056
1,939,005
0
1,939,005
0
0
0
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. As shown above, this Program has increased the number
of measures included in its data collection requirements.
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. The long-term vision for this 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. 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 as follows: -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.
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 05-01-2015 by OSORA PRA].docx
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