CMS-10210 Statement A - FY 2018 IPPS Final Rule - Final

Supporting Statement – Part A

Quality Measures and Procedures for the Hospital Inpatient Quality Reporting Program for the FY 2020 IPPS Annual Payment Updates

A. Background

The Centers for Medicare & Medicaid Services (CMS) seeks to empower consumers to make more informed decisions about their health care and to promote higher quality of care through its quality reporting programs. The Hospital Inpatient Quality Reporting (IQR) Program was first established to implement Section 501(b) of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) (Pub. L. 108-173), which authorized CMS to pay hospitals that successfully reported quality measures a higher annual update to their payment rates. It builds on a voluntary Inpatient Quality Reporting Program, which remains in effect. The Hospital IQR Program, formerly known as the Reporting Hospital Quality Data for Annual Payment Update Program, began with an initial set of 10 measures. Section 5001(a) of the Deficit Reduction Act of 2005 (DRA) (Pub. L. 109-171) revised the mechanism used to update the standardized amount for payment for hospital inpatient operating costs. This is reflected in Sections 1886(b)(3)(B)(viii)(I) and (II) of the Social Security Act, which provide that the annual payment update (APU) will be reduced for any “subsection (d) hospital” that does not submit certain quality data in a form and manner, and at a time, specified by the Secretary.

Section 5001(a) of the DRA also expanded the scope of the Hospital IQR Program, requiring CMS to add new measures. Sections 1886(b)(3)(B)(viii)(III) through (V) of the Social Security Act required CMS to “adopt the baseline set of performance measures as set forth in the November 2005 report by the Institute of Medicine of the National Academy of Sciences,” instructed the Secretary to “add other measures that reflect consensus among affected parties,” and allowed the Secretary to “replace any measures or indicators in appropriate cases.” When adding new measures, the law required CMS when “feasible and practical” to select measures put forward by “one or more national consensus building entities.”

Many provisions of the Affordable Care Act (ACA) drove further additions to these measure sets, and by linking Hospital IQR Program data to value-based purchasing, increased both the importance of Hospital IQR Program data and the need for a broad range of indicators. Section 931 of the Public Health Service Act requires that CMS “identify, not less often than triennially, gaps where no quality measures exist and existing quality measures that need improvement, updating or expansion.” Section 1886(q)(8)(C)(i) of the Social Security Act requires public reporting of readmission rates and to require subsection (d) hospitals to submit all data that CMS determines it needs to calculate and publicly report readmission rates.

Section 1886(o) of the Social Security Act mandates CMS’ transition from a passive supplier of health care to an active purchaser of quality care.  According to Section 1886(o)(2)(A) of the Social Security Act, CMS must select measures for the Hospital Value-Based Purchasing (VBP) Program from among measures (other than measures of readmissions) in the Hospital IQR Program. Consistent with this legislation, CMS established a Hospital VBP Program, beginning effective with payment adjustments on FY 2013 discharges, which qualifies hospitals for financial incentives based on their performance on a defined set of quality measures selected for the Hospital VBP Program from those reported under the Hospital IQR Program.

1. Hospital IQR Program Quality Measures

a. Introduction

The FY 2020 APU determination will be based on Hospital IQR Program data reported and supporting forms submitted by hospitals on chart-abstracted measures and electronic clinical quality measures (eCQMs) between January 2018 and December 2018. In an effort to reduce burden, a variety of different data collection mechanisms are employed, with every consideration taken to employ data and data collection systems already in place.

b. New Measures

We note that in the FY 2018 Inpatient Prospective Payment System (IPPS)/Long-Term Care Hospital (LTCH) PPS final rule, we did not finalize any new measures for the FY 2020 payment determination. In the FY 2018 IPPS/LTCH PPS final rule, we finalized voluntary data collection of the Hybrid Hospital-Wide 30-Day Readmission measure with a 6-month measurement period in CY 2018 and data submission to the CMS data receiving system anticipated for the fall of 2018, as further discussed below. As a voluntary measure, there would be no impact on payment determinations for hospitals choosing not to report on this measure.

c. Measures Finalized for Removal

We did not finalize any measures for removal in the FY 2018 IPPS/LTCH PPS final rule.

d. Electronic Clinical Quality Measures (eCQMs)

Previously, in the FY 2017 IPPS/LTCH PPS final rule, for the CY 2017 reporting period/FY 2019 payment determination and the CY 2018 reporting period/FY 2020 payment determination, we required that hospitals must submit one full calendar year of data for 8 self-selected eCQMs among the available eCQMs in the Hospital IQR Program (81 FR 57150 through 57159). We also finalized a policy that hospitals are required to submit all four calendar quarters of eCQM data on an annual basis by the end of two months following the end of the reporting period calendar year (e.g., by February 28, 2018 for the CY 2017 reporting period) (81 FR 57172).

In the FY 2018 IPPS/LTCH PPS final rule, we finalized modifications to the eCQM reporting requirements previously finalized for the CY 2017 reporting period/FY 2019 payment determination and the CY 2018 reporting period/FY 2020 payment determination, such that hospitals are required to submit one, self-selected calendar quarter of data on 4 eCQMs. Addtionally, we finalized a modification to the previously finalized eCQM data validation process for the Hospital IQR Program beginning with the FY 2020 payment determination. Specifically, we finalized that hospitals selected for validation submit 8 cases per quarter, for one quarter for the FY 2020 payment determination, and 8 cases per quarter, for one quarter for the FY 2021 payment determination.

e. Forms Used in the Data Collection Process

In order to facilitate the quality data reporting programs, several forms are necessary. These forms include:

• Hospital Inpatient Quality Reporting Notice of Participation

• Hospital Inpatient Quality Reporting (IQR) Program Data Accuracy and Completeness Acknowledgement (DACA)

• Hospital Compare Request for Withholding Data from Public Reporting Form

• Centers for Medicare & Medicaid Services (CMS) Inpatient Prospective Payment System (IPPS) Quality Reporting Programs Measure Exception Form for PC, ED, and HAI Data Submission

• CMS Quality Reporting Program APU Reconsideration Request Form

• Hospital Inpatient Quality Reporting (IQR) Program Validation Educational Review Form

• Hospital Value-Based Purchasing (VBP) Program Review and Corrections Request Form

• Hospital Value-Based Purchasing (VBP) Program Appeal Request Form

• Hospital Value-Based Purchasing (VBP) Program Independent CMS Review Request Form

• Centers for Medicare & Medicaid Services (CMS) Quality Reporting Program Extraordinary Circumstances Exceptions (ECE) Request Form

• CMS Hospital IQR Program Validation Review for Reconsideration Request Form

• Validation templates for each of the following measures:

• Central line-associated bloodstream infection (CLABSI);

• Catheter-associated urinary tract infection (CAUTI);

• Methicillin-resistant Staphylococcus Aureus (MRSA); and

• Clostridium Difficile infection (CDI).

Only the Hospital Inpatient Quality Reporting (IQR) Program Data Accuracy and Completeness Acknowledgement (DACA) form must be completed by all hospitals participating in the Hospital IQR Program each year. This form only requires a hospital to check a box affirming the accuracy and completeness of the data reported. The remainder of the forms are exceptions, exemptions, or one time only forms, and hospitals may not need to complete any of these forms in any given year.

The Hospital Compare Request for Withholding Data from Public Reporting Form is being modified to include the names of all applicable quality reporting and pay-for-performance programs, to update the form submission information (which includes providing the form submission deadline for claims-based measures), and to update the measures listed for the upcoming preview period and Hospital Compare release.

The CMS Quality Reporting Program APU Reconsideration Request Form is being modified to add a signature line for the designated provider personnel’s signature.

We note that we are submitting the Hospital Inpatient Quality Reporting (IQR) Program Validation Educational Review Form for the first time with this PRA package, based on our finalized proposal to allow hospitals to use the educational review process to correct validation scores for the first three quarters of validation in the event that CMS has calculated an incorrect validation score. As discussed further below in section B.12.e, any additional burden associated with this form would be included in the burden for “all other forms used in the data collection process” and is expected to be negligible, as this form would not be filled out by hospitals on a regular basis.

Additionally, we are resubmitting the Centers for Medicare & Medicaid Services (CMS) Quality Reporting Program Extraordinary Circumstances Exceptions (ECE) Request Form to note a terminology modification. Specifically, we will refer to this policy as “Extraordinary Circumstances Exceptions” (instead of “Extraordinary Circumstances Exemptions/Extensions”) for the Hospital IQR Program, beginning October 1, 2017, to align terminology with other quality reporting and pay-for-performance programs that have policies to provide exceptions from program requirements to facilities that have experienced extraordinary circumstances.

The Validation templates for the CLABSI, CAUTI, MRSA, and CDI measures in the Hospital IQR Program are updated annually to reflect the annual changes in fiscal year and beginning reporting quarter, as well as new CDC pathogen lists, with each new selection of hospitals for validation.

All of the other information collection forms listed above will continue to be used in the Hospital IQR Program without any modifications and are not being revised with this PRA package.

B. Justification

1. Need and Legal Basis

Continued improvement of the quality measure set is consistent with the letter and spirit of both the DRA and the ACA. CMS’ transition from a passive reporter of quality information to an active purchaser of care under the Hospital VBP Program in particular raises the stakes for meaningful quality measurement in a manner that reflects the breadth of quality care delivered in the hospital.

To begin participation in the Hospital IQR Program, all hospitals must complete a Hospital Inpatient Quality Reporting Notice of Participation. The Notice of Participation explains the participation and reporting requirements for the program. Subsection (d) hospitals covered under Section 5001(b) of the DRA must complete this Notice of Participation. The form explains that in order to receive the full market basket update (or APU), the hospitals are agreeing to allow CMS to publish their data for public viewing according to Sections 1886(b)(3)(B)(viii)(I) and (II) of the Social Security Act. Hospitals not covered under Section 5001(b) of the DRA may also wish to voluntarily submit data and have their data published for public viewing. In order to accommodate those hospitals, and to allow hospitals covered under Section 5001(b) of the DRA to submit data on measures that may not be required under Sections 1886(b)(3)(B)(viii)(I) and (II) of the Social Security Act, a separate section of the participation form has been developed. This participation portion gives CMS permission to collect and publish data that are voluntarily submitted by a hospital. These hospitals may choose to suppress a measure or measures prior to their posting on the CMS Hospital Compare website. In order to reduce burden, a hospital that indicated its intent to participate will be considered an active Hospital IQR Program participant until the hospital submits a withdrawal to CMS. Hospitals that no longer wish to participate in the Hospital IQR Program or those that no longer wish to submit data for publishing on Hospital Compare can notify CMS of their decision via the same Notice of Participation form discussed above.

Annually, subsection (d) hospitals covered under Section 5001(b) of the DRA must complete a Hospital Inpatient Quality Reporting (IQR) Program Data Accuracy and Completeness Acknowledgement (DACA) form at the end of each reporting year. This requirement was added based on a U.S. Government Accountability Office report from 2006 that recommended that CMS require hospitals to “formally attest to the completeness of the quality data that they submit.” This form is simply an acknowledgement that the data a hospital has submitted are complete and accurate and is completed annually.

Hospitals that submit data not required by Sections 1886(b)(3)(B)(viii)(I) and (II) of the Social Security Act may elect to have those data withheld from public reporting by completing the Hospital Compare Request for Withholding Data from Public Reporting Form. Once the form is submitted, data can be withheld for the quarter in which the form is submitted. However, the data will be released on Hospital Compare for subsequent releases unless the hospital submits a new Request for Withholding Data from Public Reporting Form indicating the measures the hospital would like to withhold from public reporting for the period. This form is being modified to include the names of all applicable quality reporting and pay-for-performance programs, to update the form submission information (which includes providing the form submission deadline for claims-based measures), and to update the measures listed for the upcoming preview period and Hospital Compare release.

CMS performs a random selection of up to 600 subsection (d) hospitals participating in the Hospital IQR Program on an annual basis for validation of chart-abstracted measures. Each hospital selected for validation is to produce a list of patients/lab results associated with the particular measure being validated. This process includes the use of validation templates for each of the CLABSI, CAUTI, MRSA, and CDI measures. In the FY 2015 IPPS/LTCH PPS final rule (79 FR 50262 through 50273), we adopted our policy to divide these 600 hospitals selected for validation into two halves: approximately 300 would need to produce the CLABSI and CAUTI templates and the other 300 hospitals would need to only produce the MRSA and CDI templates. In the FY 2017 IPPS/LTCH PPS final rule, we expanded the existing process for validation of Hospital IQR Program data to include eCQM data validation for up to 200 randomly selected hospitals, for a total of up to 800 hospitals for validation for the FY 2020 payment determination and subsequent years (81 FR 57174 through 57178).

Hospitals that do not treat the conditions or do not have treatment locations defined for the National Healthcare Safety Network’s (NHSN) Healthcare-Associated Infection (HAI) measures used in the Hospital IQR Program (CLABSI, CAUTI, and Surgical Site Infection) have the option to either complete the enrollment process with NHSN and indicate that they do not have patients who meet the measures requirements or they can submit a CMS Inpatient Prospective Payment System (IPPS) Quality Reporting Programs Measure Exception Form for PC, ED, and HAI Data Submission. Hospitals that do not have an Obstetrics Department and do not deliver babies may use this form for the PC-01: Elective Delivery measure. In addition, hospitals that do not have an Emergency Department (ED) and do not provide emergency care may use this form for the ED-1: Median Time from ED Arrival to ED Departure Time for Admitted ED Patients measure and the ED-2: Admit Decision Time to ED Departure Time for Admitted Patients measure. This Measure Exception Form will reduce the burden of completing the entire NHSN enrollment process or entering zero denominator information for inapplicable measures for the hospitals that meet the exception requirements.

When CMS determines that a hospital did not meet one or more of the Hospital IQR Program requirement(s), the hospital may submit a request for reconsideration to CMS using the CMS Quality Reporting Program APU Reconsideration Request Form, by the deadline identified on the Hospital IQR Program Annual Payment Update Notification Letter it received. For reconsideration requests related specifically to the validation requirements, hospitals may use the CMS Hospital IQR Program Validation Review for Reconsideration Request Form.

In the FY 2018 IPPS/LTCH PPS final rule, we finalized a policy that hospitals may use the educational review process to correct disputed chart-abstracted measure validation results for the first three quarters of validation. To submit a formal request, hospitals can utilize the Educational Review Request Form listed in section A.1.e of this file. We note that should the results of an educational review not be favorable to a hospital, a hospital also may request reconsideration of those results using the CMS Hospital IQR Program Validation Review for Reconsideration Request Form.

In the FY 2018 IPPS/LTCH PPS final rule, we finalized our proposal to refer to our existing policy of allowing a hospital to request an exception or extension from quality measure data reporting in the event of an extraordinary circumstance as “Extraordinary Circumstances Exceptions” (instead of “Extraordinary Circumstances Exemptions/Extensions”) for the Hospital IQR Program, beginning October 1, 2017, to align terminology with other quality reporting and pay-for-performance programs that have policies to provide exceptions from program requirements to facilities that have experienced extraordinary circumstances. Consequently, we are resubmitting the Extraordinary Circumstances Exception (ECE) Request Form in this PRA package to note this terminology modification.

The Validation templates for the CLABSI, CAUTI, MRSA, and CDI measures in the Hospital IQR Program are updated annually to reflect the annual changes in fiscal year and beginning reporting quarter, as well as new CDC pathogen lists, with each new selection of hospitals for validation. Currently, the templates are only utilized by up to 600 hospitals annually that have been selected for validation (400 hospitals are randomly selected for validation and up to 200 additional hospitals are chosen based on targeting criteria (78 FR 50833)). In the FY 2017 IPPS/LTCH PPS final rule, CMS finalized an expansion of the existing validation process to also include validation of eCQM data for up to 200 hospitals (for a total of 800 hospitals to be selected for annual validation), beginning with the FY 2020 payment determination (81 FR 57174 through 57178).

As noted above, we must select measures for the Hospital VBP Program from among measures (other than measures of readmissions) in the Hospital IQR Program. Hospitals may appeal the calculation of their performance assessment with respect to the performance standards, as well as their Total Performance Score (TPS), for the Hospital VBP Program. Hospitals may review and request recalculation of their hospital’s performance scores on each condition, domain, and TPS using the Hospital Value-Based Purchasing (VBP) Program Review and Corrections Request Form within 30 calendar days of the posting date of the Value-Based Percentage Payment Summary Report. Hospitals may submit an appeal using the Hospital Value-Based Purchasing (VBP) Program Appeal Request Form within 30 calendar days of the date of receiving an adverse determination from CMS on their review and corrections request. Hospitals may submit a Hospital Value-Based Purchasing (VBP) Program Independent CMS Review Request Form within 30 days after they receive an adverse determination from CMS on their appeal.

2. Information Users

CMS will use the information collected from the Hospital IQR Program for the Hospital VBP Program to set payment adjustments for value-based purchasing. Specifically, the Hospital VBP Program uses data from the Hospital IQR Program to calculate scores for individual measures, which are then combined across different domains to calculate a hospital’s Total Performance Score (TPS) for a given program year in the Hospital VBP Program.  CMS uses the TPS and estimated base-operating diagnosis-related group (DRG) amounts to calculate the exchange function slope and payment adjustment factors for each hospital included in the Hospital VBP Program. Hospitals participating in the Hospital VBP Program receive a value-based incentive payment based on the hospital’s TPS for the program year, after an initial withhold of 2.00% to the base operating DRG payment amount as required by statute.  Hospitals’ incentive payment amounts are calculated for each individual program year using a linear scale, and are recalculated for each year of the program.  The total amount available for value-based incentive payments is equal to the total amount of reduced payments for all hospitals, and varies from year to year.  

The information from the Hospital IQR Program will be made available to hospitals for their use in internal quality improvement initiatives. CMS provides confidential feedback reports that hospitals may use to assess their performance and operationalize quality improvement activities throughout the quality reporting period. These reports include the data that CMS has collected from the hospital and the hospital’s claims, and some also include information about how the hospital’s data look relative to the performance of other hospitals. For example, the Facility, State and National (FSN) Report allows hospitals to compare their performance related to a specific measure during a specific timeframe, to the average performance of other hospitals at the state and national levels. In addition, the Hospital VBP Program Baseline Measures Report allows hospitals to compare their performance for each measure to the Program’s benchmarks and achievement thresholds, which are obtained from the scores of all hospitals. These reports allow hospitals time to assess how their current performance in each measure could be scored in the upcoming Hospital VBP payment determinations, while there is still time to target improvement activities related to specific measures so that their performance and scores can be maximized.

The information from the Hospital IQR Program is used by CMS to direct its contractors to focus on particular areas of improvement and to develop quality improvement initiatives. Medicare beneficiaries experience a high rate of preventable readmissions, which are burdensome to patients and families, as well as costly. Quality Innovation Network-Quality Improvement Organizations (QIN-QIOs), under contract with CMS, use readmissions data from CMS to assist communities to reduce avoidable readmissions. For example, the QIN-QIO program helps communities with high readmission rates form local coalitions, identify the factors driving avoidable hospital readmissions in their area, and find ways to better coordinate care and to encourage patients to manage their health more actively.

Under the current 11th Statement of Work, CMS has directed the QIN-QIOs to reduce readmissions by 20% over a five-year period, to provide quality improvement technical assistance, and to support value-based program initiatives. The Hospital IQR Program includes 30-day readmissions measures for the following conditions: acute myocardial infarction (AMI), coronary artery bypass graft (CABG) surgery, chronic obstructive pulmonary disease (COPD), heart failure (HF), total hip arthroplasty and/or total knee arthroplasty (HIP-KNEE), hospital-wide all-cause unplanned (HOSP-WIDE), pneumonia (PN), and stroke (STK). CMS has tasked the Hospital Inpatient Value, Incentives, and Quality Reporting Outreach and Education Support Contractor with supporting CMS, QIN-QIOs, providers, and vendors to achieve success in the public reporting of quality measures and the direct improvement of quality of care.

Most importantly, the information from the Hospital IQR Program is available to beneficiaries, as well as to the public, to provide hospital information to assist them in making decisions in choosing their health care providers. CMS sometimes conducts focus groups or market testing prior to publicly reporting hospital quality data on the Hospital Compare website in order to get feedback on ways to make the website more user-friendly. Feedback from these focus groups have helped CMS understand how beneficiaries and consumers use Hospital Compare. Under emergency circumstances, consumers choose hospitals based on proximity, reputation, prior experience, or their doctor’s recommendation. For childbirth or elective hospital admissions, when patients and their family members may have the time and motivation to consider options and engage in informed decision making, they have expressed interest in emergency department wait times, information about the hospital’s (and physician’s) track record in treating their condition, staff credentials, staffing ratios, and a hospital’s recognized areas of expertise, as well as to take into consideration their doctor’s recommendation.

We refer readers to section A.1.e of this document for more details on the specific forms that are being used for the Hospital VBP Program.

3. Use of Information Technology

To assist hospitals in standardizing data collection initiatives across the industry, CMS continues to improve data collection tools in order to make data submission easier for hospitals (e.g., the collection of electronic patient data in EHRs for eCQMs, the collection of data from paper medical records for chart-abstracted measures, or the collection of data from clinical registries for structural measures), as well as increase the utility of the data provided by the hospitals.

For the claims-based measures, this section is not applicable, because claims-based measures can be calculated based on data that are already reported to the Medicare program for payment purposes. Therefore, no additional information technology will be required of hospitals for these measures.

4. Duplication of Similar Information

The information to be collected is not duplicative of similar information collected by CMS. The purpose of this effort is to reduce the reporting burden for the collection of quality of care information by allowing hospitals to submit electronic data in lieu of submitting paper charts or to utilize electronic data that they currently report to The Joint Commission for accreditation. As required by statute, CMS maintains a set of quality measures which a hospital must report in order to receive the full APU and to qualify for payment incentives under the Hospital VBP Program. Except as otherwise noted above, all measures are aligned with The Joint Commission whenever possible. The Joint Commission-accredited hospitals already collect and submit data on all chart-abstracted measures and eCQMs in the expanded set.

5. Small Business

Information collection requirements were designed to allow maximum flexibility specifically to small hospitals wishing to participate in hospital reporting. This effort will assist small hospitals in gathering information for their own quality improvement efforts. We define a “small hospital” as one with 1-99 inpatient beds. The Hospital IQR Program includes approximately 990 participating small hospitals in the FY 2019 program year.

6. Less Frequent Collection

We have designed the collection of quality measure data to be the minimum necessary for data validation and for calculation of summary figures to be used as reliable estimates of hospital performance. Data collection may vary (monthly, quarterly, annually, etc.) based on how a quality measure is specified.

7. Special Circumstances

Although participation in the Hospital IQR Program is voluntary on the part of subsection (d) hospitals, all eligible hospitals must submit these data and meet all other Hospital IQR Program requirements in order to receive their full APU for the given fiscal year. If a hospital does not submit the required data and meet all other Hospital IQR Program requirements, it would be subject to a reduced APU for a given fiscal year.

8. Federal Register Notice/Outside Consultation

The FY 2018 IPPS/LTCH PPS final rule published on August 14, 2017 (82 FR 37990). Comments were submitted on this notice, and responded to accordingly.

In the FY 2018 IPPS/LTCH PPS proposed rule, we proposed to modify the eCQM reporting requirements finalized for the CY 2017 reporting period/FY 2019 payment determination, such that hospitals would be required to report on 6 eCQMs and to submit 2 self-selected calendar quarters of data. Additionally, we proposed to modify the eCQM reporting requirements for the CY 2018 reporting period/FY 2020 payment determination, such that hospitals would be required to report on 6 eCQMs and to submit data for the first three calendar quarters of 2018. We also proposed to modify our existing eCQM data validation process for the Hospital IQR Program beginning with the FY 2020 payment determination; specifically, we proposed to require 8 cases to be submitted per quarter for 2 quarters for eCQM validation (16 cases in total) for the FY 2020 payment determination and 8 cases to be submitted per quarter for 3 quarters for eCQM validation (24 cases in total) for the FY 2021 payment determination, if our proposals to modify the eCQM reporting requirements as described above would be finalized as proposed.

CMS is supported in this initiative by The Joint Commission, National Quality Forum (NQF), Measure Applications Partnership, Centers for Disease Control and Prevention, and Agency for Healthcare Research and Quality. These organizations collaborate with CMS on an ongoing basis, providing technical assistance in developing and/or identifying quality measures, and assisting in making the information accessible, understandable, and relevant to the public.

9. Payment/Gift to Respondent

Under Section 1886(b)(3)(B)(viii) of the Social Security Act, hospitals are required to submit all Hospital IQR Program measure data for which the data source is the hospital’s medical records (for example, chart-abstracted measure data and eCQM data, but not claims data) in order to receive their full APU and to qualify for additional Hospital VBP Program incentives under Section 1886(o) of the Social Security Act. 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 for Quality Improvement Organizations, 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 Health Insurance Portability and Accountability Act (HIPAA) compliant. The CMS clinical data warehouse also voluntarily meets or exceeds the HIPAA standards.

11. Sensitive Questions

Case-specific clinical data elements will be collected and are necessary to calculate statistical measures. These statistical measures are the basis of all subsequent improvement initiatives derived from this collection and cannot be calculated without the case specific data. These sensitive data will not, however, be released to the public. Only hospital-specific data will be released to the public after consent has been received from the hospital for the release. The patient-specific data remaining in the CMS clinical data warehouse after the data are aggregated for release for public reporting will continue to be subject to the strict confidentiality regulations in 42 CFR Part 480.

12. Burden Estimate (Total Hours & Wages)

a. Background

Under Section 1886(b)(3)(B)(viii)(V) of the Social Security Act, we are required to add other measures that reflect consensus among affected parties and, to the extent feasible and practicable, must include measures set forth by one or more national consensus building entities.  In the FY 2018 IPPS/LTCH PPS final rule, we are not finalizing any new measures for the Hospital IQR Program, however, we are finalizing refinements to two existing measures and other modifications to program requirements for the FY 2020 payment determination and subsequent years.  These burden estimates include voluntary reporting of a new Hybrid Hospital Wide Readmission (HWR) measure, as well as other activities that potentially impact burden for hospitals.  The burden estimates exclude burden associated with the NHSN and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) measures, which are submitted under separate OMB control numbers.

For the purposes of burden estimation, we assume all of the activities associated with the Hospital IQR Program for 3,300 IPPS hospitals and 1,100 non-IPPS hospitals will be completed by Medical Records and Health Information Technicians. These staff are qualified to complete the tasks associated with the chart-abstraction of patient data from medical records, the submission of electronic data from EHRs, the submission of data to clinical registries, and the completion of any of the other applicable forms associated with activities related to the Hospital IQR Program.

We note the hourly labor cost used in this PRA package for the FY 2018 IPPS/LTCH PPS final rule ($36.58) differs from that previously used in the PRA package for the FY 2018 IPPS/LTCH PPS proposed rule ($32.84) because an updated median hourly wage estimate has become available. This labor rate was obtained from the Bureau of Labor Statistics, for a Medical Records and Health Information Technician professional.  The labor performed can be accomplished by these staff with a median hourly wage in general medical and surgical hospitals of $18.29 per hour;¹ however, obtaining data on other overhead costs is challenging. Overhead costs vary greatly across industries and organization size. In addition, the precise cost elements assigned as “indirect” or “fringe/overhead” costs, as opposed to direct costs or employee wages, are subject to some interpretation at the organizational level. Therefore, we have chosen to calculate the cost of overhead at 100% of the median hourly wage. This is necessarily a rough adjustment, both because fringe benefits and overhead costs vary significantly from employer to employer, and because methods of estimating these costs vary widely from study to study. Nonetheless, there is no practical alternative and we believe that doubling the hourly wage to estimate total cost is a reasonably accurate estimation method. Therefore, using these assumptions, we estimate an hourly labor cost of $36.58 ($18.29 base salary + $18.29 fringe/overhead). As a result of the availability of this more recent wage data, we have updated the wage rate used in these calculations in the FY 2018 IPPS/LTCH PPS final rule and this corresponding PRA package.

b. Modified Estimates for the FY 2019 Payment Determination

We note that in the FY 2018 IPPS/LTCH final rule, we finalized a modification to the eCQM reporting requirements for the CY 2017 reporting period/FY 2019 payment determination, such that hospitals are required to report one, self-selected calendar quarter of data for 4 eCQMs, as opposed to submitting one full calendar year of data for 8 eCQMs, as previously finalized in the FY 2017 IPPS/LTCH PPS final rule (81 FR 57150 through 57159). Consequently, we expect actual reporting burden for CY 2017 eCQM reporting to be less than our previously finalized estimates, which are approved under this OMB control number.

With regard to the Hospital IQR Program requirements for the FY 2019 payment determination, we estimate a total burden decrease of 20,533 hours across all participating hospitals, as compared to our previous estimates, due to the finalized modifications to eCQM reporting requirements, such that hospitals must submit one, self-selected calendar quarters of data for 4 eCQMs for the CY 2017 reporting period. Using our estimated wage rate of $36.58, we estimate a cost decrease of approximately $751,097 across all participating hospitals. The estimated total burden decrease was calculated as follows:

Consistent with previous years, we believe the total burden associated with the eCQM reporting requirements will be similar to that previously outlined in the Medicare EHR Incentive Program Stage 2 final rule (77 FR 54126 through 54133). Under that program, the burden estimate for a hospital to report 1 eCQM is 10 minutes per record per quarter. We believe this estimate is accurate and appropriate to apply to the Hospital IQR Program because we align the eCQM reporting requirements between both programs. Therefore, using the estimate of 10 minutes per record per quarter, we anticipate our policy to require: (1) reporting on 4 of the available eCQMs; and (2) submission of one, self-selected calendar quarter of eCQM data, will result in a burden reduction of 4 hours and 40 minutes (280 minutes) per hospital for the FY 2019 payment determination, as compared to the burden estimate for eCQM reporting for the FY 2020 payment determination as finalized in the FY 2017 IPPS/LTCH PPS final rule (81 FR 57150 through 57159). This estimate was calculated by considering the burden difference between the eCQM reporting requirements newly finalized for the CY 2017 reporting period/FY 2019 payment determinations (10 minutes per record x 4 eCQMs x 1 quarter = 40 minutes for 1 quarter of reporting) and the eCQM reporting requirements previously finalized in the FY 2017 IPPS/LTCH PPS final rule (81 FR 57157 through 57159) and approved previously under this OMB control number (10 minutes per record x 8 eCQMs x 4 quarters = 320 minutes for 4 quarters of reporting). Through these calculations (40 minutes – 320 minutes), we arrived at a reduction of 280 annual minutes per hospital, or 4 hours and 40 minutes per hospital, for the FY 2019 payment determination.

In total, for the FY 2019 payment determination, we expect our policy to require hospitals to report data on 4 eCQMs for one, self-selected calendar quarter (as compared to our previously finalized requirement to report data on 8 eCQMs for 4 quarters) to represent an annual burden reduction of 15,400 hours across all 3,300 IPPS hospitals participating in the Hospital IQR Program (-280 minutes per hospital / 60 minutes per hour x 3,300 hospitals = -15,400 hours) and a reduction of 5,133 hours across 1,100 non-IPPS hospitals (-280 minutes per hospital / 60 minutes per hour x 1,100 hospitals = -5,133 hours), for a total reduction of 20,533 hours. In total, we expect a cost decrease of $751,097 ($36.58 hourly wage x -20,533 annual hours = -$751,097) across 4,400 IPPS and non-IPPS hospitals.

Table 1. Modified Hospital IQR Program eCQM Reporting Burden Calculations for the FY 2019 Payment Determination

Measure Set	Estimated time per record (minutes) FY 2019 payment determination	Number reporting quarters per year FY 2019 payment determination	Number of hospitals reporting	Average number records per hospital per quarter	Annual burden (hours) per hospital	Calculation for FY 2019 payment determination
OTHER ACTIVITIES All Hospitals (3,300 IPPS + 1,100 non-IPPS)
Reporting four electronic Clinical Quality Measures (IPPS)	40	1	3,300	1	0.67	2,200
Reporting four electronic Clinical Quality Measures (Non-IPPS)	40	1	1,100	1	0.67	733

We reiterate that we are amending our approved estimates for the FY 2019 payment determination and our finalized policy changes result in a burden reduction compared to the previously approved FY 2019 payment determination estimates under this OMB control number. We are requesting approval of this modified burden estimate for the FY 2019 payment determination.

c. Estimates for the FY 2020 Payment Determination

With regard to the Hospital IQR Program requirements for the FY 2020 payment determination, we estimate a total burden decrease of 26,799 hours associated with our finalized policy changes. Using our estimated wage rate of $36.58, we estimate a total cost decrease of approximately $980,307 across all participating hospitals. The estimated total burden decrease was calculated as follows:

Consistent with previous years, we believe the total burden associated with the eCQM reporting requirements will be similar to that previously outlined in the Medicare EHR Incentive Program Stage 2 final rule (77 FR 54126 through 54133). Under that program, the burden estimate for a hospital to report 1 eCQM is 10 minutes per record per quarter. We believe this estimate is accurate and appropriate to apply to the Hospital IQR Program because we align the eCQM reporting requirements between both programs. Using the estimate of 10 minutes per record per quarter, we anticipate our policy to require: (1) reporting on 4 of the available eCQMs; and (2) submission of one, self-selected quarter of eCQM data, will result in a burden decrease of 4 hours and 40 minutes per hospital for the FY 2020 payment determination, as compared to the burden estimate of eCQM reporting for the FY 2020 payment determination as finalized in the FY 2017 IPPS/LTCH PPS final rule (81 FR 57150 through 57159). This estimate was calculated by considering the burden difference between the eCQM reporting requirements newly finalized for the CY 2018 reporting period/FY 2020 payment determination (10 minutes per record x 4 eCQMs x 1 quarters = 40 minutes for 1 quarter of reporting) and the eCQM reporting requirements previously finalized in the FY 2017 IPPS/LTCH PPS final rule (81 FR 57157 through 57159) and approved previously under this OMB control number (10 minutes per record x 8 eCQMs x 4 quarters = 320 minutes for 4 quarters of reporting). Through these calculations (40 minutes – 320 minutes), we arrived at a decrease of 280 annual minutes per hospital, or 4 hours and 40 minutes per hospital, per year for the FY 2020 payment determination. This represents a burden decrease of 15,400 hours (280 minutes per hospital / 60 minutes per hour x 3,300 hospitals) across 3,300 IPPS hospitals and a burden decrease of 5,133 hours (280 minutes per hospital / 60 minutes per hour x 1,100) across 1,100 non-IPPS hospitals, for a total reduction of -20,533 hours related to eCQM reporting for the FY 2020 payment determination. In total, we expect a cost decrease of $751,097 ($36.58 hourly wage x -20,533 annual hours = -$751,097) across 4,400 IPPS and non-IPPS hospitals.

In previous years (79 FR 50347), we estimated a burden of 1 hour and 20 minutes (or 80 minutes) per record for validation of eCQM data. Applying the time per individual submission of 1 hour and 20 minutes (or 80 minutes) per record for 8 records that hospitals must submit for validation, we estimate a total burden of approximately 11 hours (80 minutes x 8 records / 60 minutes per hour) for each hospital selected for eCQM validation for the FY 2020 payment determination. We estimate the total burden would be approximately 2,200 hours across the 200 IPPS hospitals selected for eCQM validation (1 hour per hospital x 200 hospitals = 2,200 hours). As compared to our previously estimated total burden estimate for eCQM validation of 8,533 hours in the FY 2017 IPPS/LTCH PPS final rule (81 FR 57261), this represents a burden reduction of approximately 6,333 hours across up to 200 hospitals selected for eCQM validation (2,200 hours estimated in this final rule - 8,533 hours estimated in the FY 2017 IPPS/LTCH PPS final rule = - 6,333 hours). Using the estimated hourly labor cost of $36.58, we estimate an annual cost reduction of $231,661 (6,333 hours x $36.58 per hour) across the 200 hospitals selected for eCQM validation due to our policy to decrease the number of records collected for validation from 32 records to 8 records for the FY 2020 payment determination.

Also, we finalized voluntary reporting of the Hybrid Hospital-Wide 30-Day Readmission (HWR) measure. This measure is comprised of both claims-based data as well as a set of 13 core clinical data elements from patient EHRs. We do not expect any additional burden on hospitals to report the claims-based portion of this measure because these data are already reported to the Medicare program for payment purposes. Additionally, hospitals may voluntarily submit the 13 core clinical data elements and the 6 data elements required for linking with claims data for this measure using the same submission requirements required for eCQM reporting. Accordingly, we expect the burden associated with voluntarily reporting of this measure to be similar to our estimates for eCQM reporting (that is 10 minutes per measure per quarter). Consistent with estimates for previous voluntary reporting of quality measures, such as the eCQM reporting pilot, we believe up to approximately 100 hospitals will voluntarily report the EHR-derived data for the Hybrid HWR measure. Using the estimate of 10 minutes per measure per quarter, we anticipate that voluntary reporting of the Hybrid HWR measure will result in a burden increase of 0.67 hours (40 minutes) per hospital for the FY 2020 payment determination (10 minutes per record x 1 measure x 4 quarters / 60 minutes per hour = 0.67 hours). In total, for the FY 2020 payment determination, we expect voluntary reporting of the Hybrid HWR measure to represent an annual burden increase of 67 hours across up to 100 IPPS hospitals voluntarily participating (40 minutes per hospital / 60 minutes per hour x 100 hospitals = 67 hours). We expect this to represent a cost increase of $2,451 ($36.58 hourly wage x 67 annual hours) across up to 100 IPPS hospitals voluntarily submitting data for this measure.

Overall, we estimate: (1) a decrease of 15,400 hours for IPPS hospitals due to finalized modifications to our eCQM reporting requirements; (2) a decrease of 5,133 hours for non-IPPS hospitals due to finalized modifications to our eCQM reporting requirements; (3) a decrease of 6,333 hours for IPPS hospitals due to finalized modifications to our eCQM data validation process; and (4) an increase of 67 hours due to the voluntary reporting of the Hybrid HWR measure. In total, for the FY 2020 payment determination, we estimate a decrease of approximately 26,799 hours across 4,400 IPPS and non-IPPS hospitals due to finalized changes set forth in the FY 2018 IPPS/LTCH PPS final rule.

Please note that in addition to the revised estimates described above due to changes finalized in the FY 2018 IPPS/LTCH PPS final rule, we have revised our prior burden estimates based on the availability of additional, more current information. Specifically, we have revised our estimates for the reporting of chart-abstracted measures (ED/IMM, VTE, Sepsis, and PC-01) by non-IPPS hospitals using the average number of non-IPPS hospitals actually reporting these measures over the prior 4 quarters for which data are currently available (4^th quarter 2015 through 3^rd quarter 2016). We also have revised the number of records for population and sampling from 8 to 4 to reflect the reduction of measure sets used in the Hospital IQR Program from 8 measure sets to 4 measure sets, and revised the number of HAI Validation quarters from 3 to 4 to reflect the validation of 4 quarters of HAI data in the Hospital IQR Program.

Table 2. Burden Calculations for the Hospital IQR Program Measure Set and Other Activities for the FY 2020 Payment Determination

Measure Set	Estimated time per record (minutes) - FY 2020 payment determination	Number reporting quarters per year - FY 2020 payment determination	Number of hospitals reporting	Average number records per hospital per quarter	Annual burden (hours) per hospital	Calculation for FY 2020 payment determination
CHART ABSTRACTION
IPPS Hospitals (3,300)
Emergency department (ED) throughput/Immunizations (IMM)	28	4	3,300	260	485	1,599,074
Venous thromboembolism (VTE)	7	4	3,300	198	92	304,997
Sepsis Measure	60	4	3,300	100	400	1,320,000
Perinatal care (PC)	10	4	3,300	76	51	167,200
Subtotal IPPS chart-based					1027.66	3,391,271
Non-IPPS Hospitals (1,100)
Emergency department (ED) throughput/Immunizations (IMM)	35	4	898	55	128.33	115,243
Venous thromboembolism (VTE)	7	4	412	27	13	5,191
Sepsis measure	60	4	362	25	100	36,200
Perinatal care (PC)	10	4	334	21	14	4,676
Subtotal Non-IPPS chart-based						161,311
Subtotal IPPS and Non-IPPS chart-based						3,552,582
OTHER ACTIVITIES All Hospitals (3,300 IPPS + 1,100 non-IPPS)
Population and sampling for 4 ongoing measure sets	15	4	4,400	4	4	17,600
Review reports for claims-based measure sets	60	4	4,400	1	4	17,600
HAI Validation Templates (CLABSI, CAUTI)	1,200	4	300	1	80	24,000
HAI Validation Templates (MRSA, CDI)	960	4	300	1	64	19,200
Reporting four electronic Clinical Quality Measures (IPPS)	40	1	3,300	1	0.67	2,200
Reporting four electronicClinical Quality Measures (non-IPPS)	40	1	1,100	1	0.67	733
eCQM Validation	80	1	200	8	11	2,200
All other forms used in the data collection process and structural measures	15	1	4,400	1	0.25	1,100
Hybrid Hospital-Wide 30-Day Readmission Voluntary Measure	10	4	100	1	0.67	67
Subtotal other activities						84,700
Total						3,637,282

Given the policies outlined in the FY 2018 IPPS/LTCH PPS final rule, and the listed “Other Activities”, we estimate a total burden decrease of 43,741 hours for the FY 2020 payment determination (3,681,023 hours previously finalized for the FY 2019 payment determination – 3,637,282 requested for the FY 2020 payment determination). Taken with our estimated wage rate of $36.58 per hour, we estimate a total cost decrease of approximately $1,600,046. We are requesting approval of this burden estimate for the FY 2020 payment determination.

d. Estimates for the FY 2021 Payment Determination

As compared to the estimates previously finalized under the FY 2017 IPPS/LTCH PPS final rule for validation of eCQM data, we expect a decrease in burden as a result of our modifications to the previously finalized eCQM validation process for the FY 2021 payment determination. In previous years (79 FR 50347), we estimated a burden of 1 hour and 20 minutes per record for validation of eCQMs. Applying the time per individual submission of 1 hour and 20 minutes (or 80 minutes) for the 8 records that hospitals are required to submit for the FY 2021 payment determination, we estimate a total burden of approximately 11 hours (80 minutes x 8 records / 60 minutes per hour) for each hospital selected for participation in eCQM validation. We further estimate that the total burden would be approximately 2,200 hours across the 200 IPPS hospitals selected for eCQM validation (11 hours per hospital x 200 hospitals = 2,200 hours). As compared with our total burden previously estimated to be 8,533 hours in the FY 2017 IPPS/LTCH PPS final rule (81 FR 57261) for eCQM validation for the FY 2020 payment determination (which is the same as for the FY 2021 payment determination), this would represent a decrease of approximately 6,333 hours across up to 200 IPPS hospitals selected for eCQM validation for the FY 2021 payment determination (2,200 hours estimated in this final rule for the FY 2021 payment determination – 8,533 hours estimated in the FY 2017 IPPS/LTCH PPS final rule = -6,333 hours). Using the estimated hourly labor cost of $36.58, we estimate an annual cost reduction of $231,661 (6,333 hours x $36.58 per hour) across the 200 IPPS hospitals selected for eCQM validation due to the decrease in the number of records collected from 32 records to 8 records for the FY 2021 payment determination.

Table 3. Hospital IQR Program eCQM Validation Burden Calculations for the FY 2021 Payment Determination

Measure Set	Estimated time per record (minutes) - FY 2021 payment determination	Number reporting quarters per year - FY 2021 payment determination	Number of hospitals reporting	Average number records per hospital per quarter	Annual burden (hours) per hospital	Calculation for FY 2021 payment determination
OTHER ACTIVITIES All Hospitals (3,300 IPPS + 1,100 non-IPPS)
eCQM Validation	80	1	200	8	11	2,200

e. Additional Information on Burden Estimates

Time estimates for activities other than abstracting charts, including completion of web-based forms for structural measures, completion of the forms listed in section A.1.e above other than the HAI Validation Templates, routine reporting of population and sampling numbers for ongoing measures, set up and reporting of population and sampling for new measures, and review of reports were made in consultation with our Hospital IQR Program support contractor, which is responsible for routine interface with hospitals and Quality Improvement Organizations regarding Hospital IQR Program requirements. We define “all other forms used in the data collection process” as the forms listed in section A.1.e above other than the HAI Validation Templates, which are included in the burden estimate for validation. Consistent with estimates in the FY 2016 IPPS/LTCH PPS final rule, we estimate a burden of 15 minutes per hospital to complete all applicable forms and also to report structural measure data. The estimate of 15 minutes includes all previously adopted structural measures in the Hospital IQR Program (80 FR 49762).

The burden associated with “all other forms used in the data collection process” is expected to be negligible, as they will not be filled out by hospitals on a regular basis. Because the CMS Quality Reporting Program Extraordinary Circumstances Exceptions (ECE) Request Form will be used across nine quality reporting programs (Hospital Inpatient, Inpatient Psychiatric Facility, PPS-Exempt Cancer Hospital, Hospital Value Based-Purchasing, Hospital-Acquired Condition Reduction, Hospital Readmissions Reduction, Hospital Outpatient, Ambulatory Surgical Center, and the End Stage Renal Disease Quality Incentive Program), we included a burden calculation using this form as an example of “all other forms” within this PRA package. This form is intended to be submitted by participants only in the event of an extraordinary circumstance or disaster if they seek an extension or exemption from data reporting requirements due to such extraordinary circumstance. In CY 2016, 86 ECE requests were submitted by hospitals for an extension or exception from reporting requirements in the Hospital IQR Program, of which 69 ECE requests were for an exception from the first year of required eCQM reporting for CY 2016 discharge data. Based on our estimation of 15 minutes per record to submit the ECE Request Form, the total burden calculation for the submission of 86 ECE requests was 1,290 minutes (or 21.5 hours) across 3,300 IPPS hospitals. Note that non-IPPS hospitals have no need for this form because they participate in quality data reporting on a voluntary basis. We were conservative in our estimate (provided in Table 2 above) of 1,100 hours across IPPS and non-IPPS hospitals, thus this 21.5 hours ECE Request Form burden estimation is accounted for in that figure.

13. Capital Costs (Maintenance of Capital Costs)

There are no capital costs.

14. Cost to Federal Government

The cost to the Federal Government includes costs associated with the collection and validation of the data. These costs are estimated at $10,050,000 annually for the validation and quality reporting contracts. Additionally, this program takes three CMS staff at a GS-13 level to operate. GS-13 approximate annual salary is $92,000 for an additional cost of $276,000.

For the claims-based measures, the cost to the Federal Government is minimal. CMS uses data from the CMS National Claims History system that are already being collected for provider reimbursement; therefore, no additional data will need to be submitted by hospitals for claims-based measures.

15. Program or Burden Changes

As described above in section A.1.d, in the FY 2018 IPPS/LTCH PPS final rule, we finalized modifications to our previously finalized eCQM reporting requirements, such that hospitals will be required to report one, self-selected calendar quarter of data for 4 of the available eCQMs for each of the CY 2017 reporting period/FY 2019 payment determination and the CY 2018 reporting period/FY 2020 payment determination. These policies represent a reduction in burden as compared with the eCQM reporting requirements previously finalized in the FY 2017 IPPS/LTCH PPS final rule for the CY 2017 reporting period/FY 2019 payment determination and the CY 2018 reporting period/FY 2020 payment determination. Additionally, in the FY 2018 IPPS/LTCH PPS final rule, we finalized a modification to the previously finalized eCQM validation process, such that hospitals selected for eCQM validation are required to submit 8 cases per quarter for one calendar quarter (for a total of 8 cases) for each of the FY 2020 and FY 2021 payment determinations. In addition, to advance the goal of encouraging hospitals to submit quality data directly from their EHRs, in the FY 2018 IPPS/LTCH PPS final rule, we finalized voluntary reporting of the Hybrid HWR measure in CY 2018, in which participating hospitals will voluntarily submit a set of 13 core clinical data elements from patient EHRs to be combined with claims data for measure calculation.

To summarize the burden changes due to the policy changes finalized in the FY 2018 IPPS/LTCH PPS final rule as summarized immediately above, in total for the FY 2019 payment determination, we estimate a decrease in annual burden of 20,533 hours across 4,400 IPPS and non-IPPS hospitals associated with our finalized policy changes. Using our estimated wage rate of $36.58, we estimate a total cost decrease of approximately $751,097. In total for the FY 2020 payment determination, we estimate a net decrease in annual burden of 26,799 hours across 4,400 IPPS and non-IPPS hospitals associated with our finalized policy changes. Using our estimated wage rate of $36.58, we estimate a total cost decrease of approximately $980,307. We note that for the FY 2020 payment determination, the eCQM policy modifications described in section A.1.d above result in an overall burden decrease of 12,266 hours between the total burden hours in the proposed rule and the total burden hours provided in this information collection request submitted in connection with the final rule. This decrease of 12,266 hours reflects burden change due to changes in agency policy. The total decrease of 43,741 hours also reflects additional agency policy changes as described for the eCQM reporting requirements for the FY 2019 payment determination, eCQM data validation requirements for the FY 2020 and FY 2021 payment determination, and voluntary reporting of the Hybrid HWR measure for FY 2020, as described above in section B.12.c.

The long-term vision for the Hospital IQR Program is to encourage hospitals to submit data directly from their EHRs, which we anticipate will reduce burden substantially. Incrementally requiring hospitals to electronically report more quality measure data will further our goal to improve patient outcomes by providing more robust and timely data to support quality improvement efforts while also reducing reporting burden for hospitals. Although the eCQM reporting requirements finalized in the FY 2018 IPPS/LTCH PPS final rule, as compared with the requirements previously finalized in the FY 2017 IPPS/LTCH PPS final rule, reduce the overall number of eCQMs required for reporting (from 8 to 4 eCQMs) and reduce the number of required calendar quarters of data that must be reported (from 4 quarters to 1 quarter), we believe retaining the requirements from the CY 2016 reporting period/FY 2018 payment determination (one quarter of data for 4 eCQMs) to allow hospitals greater time and flexibility to improve eCQM reporting capabilities balances hospital reporting burden with gradual expansion of electronic quality measure data collection.

16. Publication/Tabulation Data

The goal of the data collection is to tabulate and publish hospital-specific data. We will continue to display quality information for public viewing as required for the Hospital IQR Program by Section 1886(b)(3)(B)(viii)(VII) of the Social Security Act and for the Hospital VBP Program by Section 1886(o)(10) of the Social Security Act. Hospital IQR Program data from this initiative are currently used to populate the Hospital Compare website, medicare.gov/hospitalcompare. Data are presented on Hospital Compare in a format mainly aimed towards consumers, patients, and the general public; providing access to hospital-specific quality measure performance rates along with state and national performance rates. For certain outcome and cost measures, data are presented on Hospital Compare in performance categories of Better, No Different, or Worse than the National Rate. More detailed hospital-specific measure data, including the data used for Hospital Compare, are also available to the public as downloadable files at https://data.medicare.gov. Hospital quality data on Hospital Compare are updated on a quarterly basis. One of the goals of the Hospital IQR Program is to publicly display data on all measures adopted for the Program. We note, however, that in certain circumstances we may decide to delay public display as we evaluate the accuracy of the measure data (for example, public display of Sepsis measure and eCQM data are currently delayed as we conduct data validation).

17. Expiration Date

We display the approved expiration date on each of the forms listed above in section A.1.e, which would become available on our QualityNet website’s Hospital IQR Program and Hospital VBP Program pages (www.qualitynet.org). We will also display the approved expiration date prominently on our QualityNet website’s Hospital IQR Program pages used to document our measure specifications and reporting guidance.

18. Certification Statement

We are not claiming any exceptions to the Certification for Paperwork Reduction Act Submissions Statement.

1 Occupational Outlook Handbook. Available at: https://www.bls.gov/oes/current/oes292071.htm

27