IPFQR Supporting Statement v2 (rev 05-17-2018 by OSORA PRA)

IPFQR Supporting Statement v2 (rev 05-17-2018 by OSORA PRA).docx

Inpatient Psychiatric Facility Quality Reporting Program (CMS-10432)

OMB: 0938-1171

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Supporting Statement

Revised and New Procedural Requirements for the FY 2019 Inpatient Psychiatric Facility

Quality Reporting (IPFQR) Program

CMS-10432, OMB 0938-1171


Background


Pursuant to section 1886(s)(4) of the Social Security Act, as amended by sections 3401 and 10322 of the Patient Protection and Affordable Care Act (ACA), starting in fiscal year (FY) 2014, and for subsequent FYs, Inpatient Psychiatric Facilities (IPF) shall submit pre-defined quality measures to the Centers for Medicare & Medicaid Services (CMS). IPFs that fail to report on the selected quality measures and comply with other administrative requirements will have their IPF prospective payment system (PPS) payment updates reduced by 2.0 percentage points. To comply with the statutory mandate, we are proposing to update the Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program for FY 2020. This package addresses the proposed changes to the IPFQR program in the FY 2019 IPF PPS proposed rule. These proposals are adoption of a new measure removal factor, removal of eight measures, and removal of the requirement that facilities submit data on sample size counts. Details of the effect of these proposals on estimated burden are provided in section 15, below.


This information collection request is associated with the May 8, 2018 (83 FR 21104) Inpatient Psychiatric Facility Prospective Payment System (IPF PPS) proposed rule: CMS-1690-P (RIN 0938-AT32). As indicated below, the proposed rule would remove 8 of the 18 measures from the IPFQR Program and remove one of the five non-measure data elements.


  1. 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 FY, each psychiatric hospital and psychiatric unit paid under the Inpatient Psychiatric Facility Prospective Payment System (IPF PPS) shall submit to the Secretary data on quality measures as specified by the Secretary (42 CFR 412.404(b)). Such data shall be submitted in a form and manner, and at a time, specified by the Secretary.

The following is a list of measures currently approved under this information collection request and a brief explanation of their inclusion in the IPFQR program.

  • The Hospital-Based Inpatient Psychiatric Services (HBIPS)-2, HBIPS-3, and HBIPS-5 measures collect information on hours of physical restraint use, hours of seclusion use, and patients discharged on multiple antipsychotic medications with appropriate justification respectively. These are NQF-endorsed measures (NQF #0640, NQF #0641, and NQF #0560). Documentation on the website of The Joint Commission (TJC), the measure steward, has more detail on the specification of these measures: http://www.jointcommission.org/assets/1/6/TJC_Annual_Report_2011_9_13_11_.pdf.

    • In the FY 2019 IPF PPS proposed rule, we are proposing to remove HBIPS-2 and HBIPS-3 from the IPFQR Program measure set beginning with the FY 2020 payment determination.


  • The SUB-1, SUB-2 and SUB-2a, and SUB-3 and SUB-3a measures provide information on substance use screening, substance use brief intervention offered or provided, and substance use treatment or referral offered or provided at discharge, respectively. These are NQF-endorsed measures (NQF #1661, NQF #1663, and NQF #1664). Documentation on the website of TJC, the measure steward, has more detail on the specification of these measures: http://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_quality_measures.aspx. 

    • In the FY 2019 IPF PPS proposed rule, we are proposing to remove SUB-1 from the IPFQR Program measure set beginning with the FY 2020 payment determination.


  • The TOB-1, TOB-2 and TOB-2a, and TOB-3 and TOB-3a measures provide information on tobacco use screening, tobacco use brief intervention offered or provided, and tobacco use treatment or referral offered or provided at discharge, respectively. These are NQF-endorsed measures (NQF #1651, NQF #1654, and NQF #1656). Documentation on the website of TJC, the measure steward, has more detail on the specification of these measures: http://www.jointcommission.org/assets/1/6/HIQR_Jan2015_v4_4a_1_EXE.zip.

    • In the FY 2019 IPF PPS proposed rule, we are proposing to remove TOB-1 and TOB-3 and TOB-3a from the IPFQR Program measure set beginning with the FY 2020 payment determination.


  • The Follow-up After Hospitalization for Mental Illness (FUH) measure provides information on the percentage of discharges for which patients receive follow-up within 7 and 30 days of discharge. This is an NQF-endorsed measure (NQF #0576). The measure steward for this measure is the National Committee for Quality Assurance (NCQA), and more detail on the specification is available on the NQF website: http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=70617



  • The Transition Record with Specified Elements Received by Discharged Patients (Discharges from an Inpatient Facility to Home/Self Care or Any Other Site of Care) and the Timely Transmission of Transition Record (Discharges from an Inpatient Facility to Home/Self Care or Any Other Site of Care) measures provide information on the completeness and timeliness of the transition records provided to patients and transmitted to the next level care provider upon discharge. These are NQF-endorsed measures (NQF #0647 and NQF #0648). Documentation on the website of the American Medical Association (AMA) convened Physician Consortium for Performance Improvement (PCPI), the steward for these measures, has more detail on the specification of these measures: http://www.thepcpi.org/page/PCPIMeasures.






In summary, for the FY 2020 Payment Determination and subsequent years, we are proposing to remove the following measures from the IPFQR Program:

  • Hours of Physical Restraint Use (HBIPS-2, NQF #0640)

  • Hours of Seclusion Use (HBIPS-3, NQF #0641)

  • Tobacco Use Screening (TOB-1, NQF #1651)

  • Tobacco Use Treatment or Referral Offered or Provided at Discharge and Tobacco Use Treatment at Discharge (TOB-3 and TOB-3a, NQF #1656)

  • Alcohol Use Screening (SUB-1, #1661)

  • Influenza Immunization Coverage Among Healthcare Personnel (NQF #0431)

  • Assessment of Patient Experience of Care

  • Use of an Electronic Health Record


Removing these eight (8) measures from the Program would leave ten (10) required measures.

  • Patients Discharged on Multiple Antipsychotic Medications with Appropriate Justification (HBIPS-5, NQF #0560)

  • Tobacco Use Treatment Provided or Offered and Tobacco Use Treatment (TOB-2 and TOB-2a, NQF #1654)

  • Alcohol Use Brief Intervention Provided or Offered and Alcohol Use Brief Intervention (SUB-2 and SUB-2a, NQF #1663)

  • Alcohol Use and Other Drug Use Disorder Treatment Provided or Offered at Discharge and Alcohol and Other Drug Use Disorder Treatment at Discharge (SUB-3 and SUB-3a, NQF #1664)

  • Follow-up After Hospitalization for Mental Illness (FUH, NQF #0576)

  • Influenza Immunization (IMM-2, NQF #1659)

  • Transition Record with Specified Elements Received by Discharged Patients (Discharges from an Inpatient Facility to Home/Self Care or Any Other Site of Care) (NQF #0647)

  • Timely Transmission of Transition Record (Discharges from an Inpatient Facility to Home/Self Care or Any Other Site of Care) (NQF #0648)

  • Screening for Metabolic Disorders

  • Thirty-day All-Cause Unplanned Readmission Following Psychiatric Hospitalization in an IPF (NQF #2860)


Section 1886(s)(4)(E) of the Act requires the Secretary to establish procedures for making public the data submitted by IPFs under the IPFQR Program. For CMS to publish the measure rates, IPFs are required to submit the Notice of Participation (NOP) form. By such submission, IPFs indicate their agreement to participate in the IPFQR Program and submit the required data pertaining to the ten (10) quality measures for the FY 2020 payment determination. In addition, IPFs give their consent to publicly report their measure rates on a CMS website. CMS is 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 that IPFs must take to indicate their intent to participate or withdraw.


As part of our procedural requirements, we require that IPFs acknowledge the accuracy and completeness of submitted data. We seek to collect information on valid, reliable, and relevant measures of quality, and to share this information with the public; therefore, IPFs must submit the Data Accuracy and Completeness Acknowledgement (DACA) form. In our effort to foster alignment across quality reporting programs, we now include the Extraordinary Circumstances Exception form and the Reconsideration Request form as part of the Hospital Inpatient Quality Reporting (IQR) Program’s PRA package (OMB control number 0938-1022; CMS-10210). While IPFs may also need to complete and submit these forms, the associated burden is addressed in the Hospital IQR Program PRA package.

    1. Information Users


  • IPFs: The primary ways an IPF will use the information are: to examine the individual IPFs’ specific care domains and types of patients; to compare present performance to past performance and to national performance norms; to use quality measures to evaluate the effectiveness of care provided to specific types of patients; to monitor quality improvement outcomes over time; to assess their own strengths and weaknesses in the clinical services that they provide; to address care-related areas, activities, or behaviors that result in effective patient care; and to alert themselves to needed improvements. Such information is essential to IPFs in initiating quality improvement strategies. This information can also be used to improve an IPF’s financial planning and marketing strategies.

  • State Agencies/CMS: Agencies will use the data to compare 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 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: The IPFQR Program publicly reports data through a CMS website. This data provides information for consumers and their families on the quality of care provided by individual facilities, allowing them to compare patient outcomes between facilities and against the state and national average. The website provides information in consumer-friendly language and offers a tool to assist consumers with selecting a hospital.

    1. Use of Information Technology


IPFs can utilize electronic means to submit/transmit their forms and data via a CMS-provided secure web-based tool, which is available on the QualityNet website. IPF users are 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 (e.g., NOP or DACA). We have included copies of these forms within this package.


A web-based measure online tool is used for data entry through the QualityNet website. Data are stored to support retrieving reports for hospitals to view their measure rates/results. Facilities are sent a preview report via QualityNet Exchange prior to release of data on the CMS website for public viewing. 


    1. Duplication of Efforts


Facilities that currently collect and report data on TJC measures can use the same information to report to CMS on TJC measures remaining in the IPFQR Program, which avoids duplication of efforts and reduces burden to the IPFs. As for collection of the FUH and Thirty-day All-cause Readmission Following Hospitalization in an IPF, CMS will collect such data using Medicare Part A and Part B claims; therefore, reporting these measures will pose no additional information collection burden on IPFs.


    1. Small Business


Information collection requirements are designed to allow maximum flexibility specifically to small IPF providers participating in the IPFQR Program. This effort assists small IPF providers in gathering information for their own quality improvement efforts. For example, we provide 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.


    1. Less Frequent Collection


We have designed the collection of quality of care data to be the minimum necessary for reporting of data on measures considered to be meaningful indicators of psychiatric patient care. To this end, we only require a single, annual report of measure data from facilities.


    1. Special Circumstances


There are no special circumstances that would require an information collection to be conducted in a manner that requires respondents to:

• Report information to the agency more often than quarterly;

• Prepare a written response to a collection of information in fewer than 30 days after receipt of it;

• Submit more than an original and two copies of any document;

• Retain records, other than health, medical, government contract, grant-in-aid, or tax records for more than three years;

• Collect data in connection with a statistical survey that is not designed to produce valid and reliable results that can be generalized to the universe of study,

• Use a statistical data classification that has not been reviewed and approved by OMB;

• Include a pledge of confidentiality that is not supported by authority established in statute or regulation that is not supported by disclosure and data security policies that are consistent with the pledge, or which unnecessarily impedes sharing of data with other agencies for compatible confidential use; or

• Submit proprietary trade secret, or other confidential information unless the agency can demonstrate that it has instituted procedures to protect the information's confidentiality to the extent permitted by law.


    1. Federal Register Notice/Outside Consultation


Federal Register Notice


The May 8, 2018 (83 FR 21104), proposed rule (CMS-1690-P, RIN 0938-AT32) serves as the 60-day Federal Register notice. The notice was placed on public inspection April 27, 2018, at 4:15 pm. Comments are due no later than 5 p.m. on June 26, 2018.


Outside Consultation


CMS is supported in this initiative by TJC, the NQF, and the Agency for Healthcare Research and Quality (AHRQ). These organizations, in conjunction with CMS, will provide technical assistance in developing or identifying quality measures, and assist in making the information accessible, understandable, and relevant to the public.


    1. Payment/Gift to Respondent


No other payments or gifts will be given to respondents for participation. Although participation in the IPFQR Program is voluntary (i.e., not required by Medicare Conditions of Participation), all eligible IPFs must submit their data to receive the full market basket update for a given FY. If data are not submitted to CMS, the IPF receives a reduction of 2 percentage points from its Annual Payment Update (APU) unless CMS grants an exception.


    1. Confidentiality


All information collected under this initiative is 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 Health Insurance Portability and Accountability Act (HIPAA)-compliant. Further, the program requires submission of aggregate data, thereby eliminating the need to transmit confidential or patient level information.


Pursuant to 42 CFR part 480, no case-specific clinical data will be collected or released to the public.


    1. Sensitive Questions


There are no sensitive questions associated with this collection. Specifically, the collection does not solicit questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private.


    1. Burden Estimate (Total Hours and Wages)


The following burden calculations include the time required for chart abstraction and for training personnel on collection of chart-abstracted data and aggregation of the data, training for submitting aggregate-level data through QualityNet, and time required for submitting non-measure specific patient population data (e.g., population counts by payer).


We estimate that there are approximately 1,734 facilities eligible to participate in the IPFQR Program (based on the most recent eligibility data). Because historical data indicates that almost all facilities participate, and because we wish to be conservative in our estimates, we estimated that all eligible facilities will participate in the IPFQR Program.


Wage Estimates



To derive our cost estimates, we used data from the U.S. Bureau of Labor Statistics’ May 2016 National Occupational Employment and Wage Estimates for all salary estimates (www.bls.gov/oes/current/oes_nat.htm ). In this regard, the following table presents the mean hourly wage, the cost of fringe benefits, and the adjusted hourly wage.


Occupation Title

Occupation Code

Mean Hourly Wage ($/hr)

Fringe Benefits and Overhead ($/hr)

Adjusted Hourly Wage ($/hr)

Medical Records and Health Information Technician

29-2071

18.29

18.29

36.58



Per OMB Circular A-76, in calculating direct labor, agencies should not only include salaries and wages, but also “other entitlements” such as fringe benefits.1 However, obtaining data on other overhead costs is challenging. Overhead costs vary greatly across industries and firm sizes. In addition, the precise cost elements assigned as “indirect” or “overhead” costs, as opposed to direct costs or employee wages, are subject to some interpretation at the firm level. Therefore, we have chosen to calculate the cost of overhead at 100 percent of the mean 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.


Information Collection/Reporting Requirements and Associated Burden Estimates


Measure Data Collection and Reporting The FY 2018 IPPS/LTCH PPS final rule2, for the FY 2020 payment determination and subsequent years, we had adopted eighteen (18) measures. As discussed above, the FY 2019 IPF PPS proposed rule would remove eight (8) of those measures from the Program, leaving the following ten (10) required measures.


The FUH measure and the Thirty-day all-cause unplanned readmission following Psychiatric hospitalization in an Inpatient Psychiatric Facility measures are calculated from Part A and Part D claims and therefore have no associated burden.


NQF Number

Measure ID

Measure Description

Estimated Cases (per facility)

Effort per Case (hours)

Annual Effort (per facility) (hours)

IPFs

Annual Effort (Total) (hours)

Cost

0560

HBIPS-5

Patients Discharged on Multiple Antipsychotic Medications with Appropriate Justification

848

0.25

212

1,734

367,608

13,447,101

1663

SUB-2 and SUB-2a

Alcohol Use Brief Intervention Provided or Offered

848

0.25

212

1,734

367,608

13,447,101

1654

TOB-2 and TOB-2a

Tobacco Use Treatment Provided or Offered and Tobacco Use Treatment

848

0.25

212

1,734

367,608

13,447,101

0576

FUH

Follow-up After Hospitalization for Mental Illness*

0

0

0*

1,734

0

0

1664

SUB-3 and SUB-3a

Alcohol Use and Other Drug Use Disorder Treatment Provided or Offered at Discharge and Alcohol and Other Drug Use Disorder Treatment at Discharge

848

0.25

212

1,734

367,608

13,447,101

1659

IMM-2

Influenza Immunization

848

0.25

212

1,734

367,608

13,447,101

0647

n/a

Transition Record with Specified Elements Received by Discharged Patients (Discharges from an Inpatient Facility to Home/Self Care or Any Other Site of Care)

848

0.25

212

1,734

367,608

13,447,101

0648

n/a

Timely Transmission of Transition Record (Discharges from an Inpatient Facility to Home/Self Care or Any Other Site of Care)

848

0.25

212

1,734

367,608

13,447,101

n/a

n/a

Screening for Metabolic Disorders

848

0.25

212

1,734

367,608

13,447,101

2860

n/a

Thirty-day all-cause unplanned readmission following Psychiatric hospitalization in an Inpatient Psychiatric Facility*

0

0

0*

1,734

0

0

TOTAL

848

0.25

212

1,734

2,940,864

107,576,805

*CMS will collect this data using Medicare Part A and Part B; therefore, these measures will not require facilities to submit data on any cases.


Non-Measure Data Collection and Reporting Continuing for FY 2020 and subsequent payment determinations, IPFs must submit to CMS aggregate population counts for Medicare and non-Medicare discharges by age group, and diagnostic group, and sample size counts for measures for which sampling is performed. Our currently approved iteration estimates that it will take each facility approximately 2.5 hours to comply with this requirement. Because we are proposing to remove one of the five data elements (see section 15, below), we estimate this will reduce the burden by 20% (i.e., one-fifth), leaving 80% or 2.0 hours per submission.


Tasks

IPFs

Hours per IPF

Total Hours for All IPFs

Wage Rate ($/hr)

Cost per IPF ($)

Total Cost for All IPFs ($)

Non-measure Data Collection and Submission

1,734

2.0

3,468

36.58

73.16

126,859


Notice of Participation, Data Accuracy Acknowledgement, and Vendor Authorization Form The NOP must be completed once per facility and the DACA form must be filled out only once for each data submission period. The Vendor Authorization form is optional. While it is estimated that these forms should take less than 5 minutes to complete, the 15 minutes per measure estimated for chart abstraction also includes the time for completing and submitting any forms related to the measures.


Annual Burden Summary


Requirement

Respondents

Responses

Time (hours)

Cost ($)

Measure Data Collection and Reporting

1,734

1,470,432

(1,734 x 848)

2,940,864

107,576,805

Non-Measure Data Collection and Reporting

1,734

3,468

126,859

Notice of Participation, Data Accuracy Acknowledgement, and Vendor Authorization Form*

n/a

n/a

n/a

n/a

TOTAL

1,734

1,470,432

2,944,332

107,703,664

*The 15 minutes per measure estimate for chart abstraction under Measure Data Collection and Reporting also includes the time for completing and submitting any forms.


Information Collection Instruments and Instruction/Guidance Documents


Notice of Participation

Screening for Metabolic Disorders collection form FY 2020.pdf

CMS IPF DACA Paper Form_FY2020.pdf

CMS IPF HBIPS Data collection paper form_FY2020.pdf

CMS IPF Vendor Auth_paperform_FY2020.pdf

Data Collection Tool for Transition Record Measures.pdf

Non Measure Data Collection Tool.pdf

SUB TOB IMM collection form FY 2020.pdf


    1. Capital Costs (Maintenance of Capital Costs)


There are no capital costs being placed on IPFs.


  1. Cost to Federal Government


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 the development is part of an existing software development contract. 


The labor cost for IPFQR Program oversight is estimated as 1.0 FTE (2,080 hours) at GS-13 (step 5) salary (at $109,900/year) for staff located in the Washington-Baltimore area.


  1. Program or Burden Changes


Except where noted, the following changes are associated with our FY 2019 IPF PPS proposed rule (May 8, 2018; 83 FR 21104) for the FY 2020 IPFQR Program.


Notice of Participation, Data Accuracy Acknowledgement, and Vendor Authorization Form


No changes.


Measure Data Collection and Reporting


For the FY 2020 Payment Determination and subsequent years, we proposing to remove 8 (eight) of the currently approved measures from the IPFQR Program. We estimate the following burden reduction based on the removal of those measures:


NQF Number

Measure ID

Measure Description

IPFs

Estimated Cases (per facility)

Effort per Case (hours)

Annual Effort (per facility) (hours)

Annual Effort (Total) (hours)

0640

HBIPS-2

Hours of Physical Restraint Use

1,684

(848)

0.25

(212)

(357,008)

0641

HBIPS-3

Hours of Seclusion Use

1,684

(848)

0.25

(212)

(357,008)

1661

SUB-1

Alcohol Use Screening

1,684

(848)

0.25

(212)

(357,008)

1651

TOB-1

Tobacco Use Screening

1,684

(848)

0.25

(212)

(357,008)

1656

TOB-3 and TOB-3a

Tobacco Use Treatment Provided or Offered at Discharge and Tobacco Use Treatment at Discharge

1,684

(848)

0.25

(212)

(357,008)

431

n/a

Influenza Vaccination Coverage Among Healthcare Personnel

1,684

(40)

0.25

(10)

(16,840)

n/a

n/a

Assessment of Patient Experience of Care


0

0

0

0

n/a

n/a

Use of an Electronic Health Record


0

0

0

0

 TOTAL

1,684

848

0.25

(10 - 212)

(1,801,880)

*CMS will collect this data using Medicare Part A and Part B; therefore, these measures will not require facilities to submit data on any cases.


We propose to adjust our currently approved number of facilities from 1,684 facilities (CURRENT) to 1,734 facilities (PROPOSED). Our estimated number of cases per facility is unchanged as is our per response estimate.


NQF Number

Measure ID

Measure Description

Estimated Cases (per facility)

Effort per Case (hours)

CURRENT Annual Effort (Total) (hours)**

PROPOSEDAnnual Effort (Total) (hours)***

Difference

0560

HBIPS-5

Patients Discharged on Multiple Antipsychotic Medications with Appropriate Justification

848

0.25

357,008

367,608

10,600

1663

SUB-2 and SUB-2a

Alcohol Use Brief Intervention Provided or Offered

848

0.25

357,008

367,608

10,600

1664

SUB-3 and SUB-3a

Alcohol and Other Drug Use Disorder Treatment Provided or Offered at Discharge and Alcohol and Other Drug Use Disorder Treatment at Discharge

848

0.25

357,008

367,608

10,600

0576

FUH

Follow-up After Hospitalization for Mental Illness*

0

0

0*

0

0

1656

TOB-3 and TOB-3a

Tobacco Use Treatment Provided or Offered at Discharge and Tobacco Use Treatment at Discharge

848

0.25

357,008

367,608

10,600

1659

IMM-2

Influenza Immunization

848

0.25

357,008

367,608

10,600

647

n/a

Transition Record with Specified Elements Received by Discharged Patients (Discharges from an Inpatient Facility to Home/Self Care or Any Other Site of Care)

848

0.25

357,008

367,608

10,600

648

n/a

Timely Transmission of Transition Record (Discharges from an Inpatient Facility to Home/Self Care or Any Other Site of Care)

848

0.25

357,008

367,608

10,600

n/a

n/a

Screening for Metabolic Disorders

848

0.25

357,008

367,608

10,600

2860

n/a

Thirty-day all-cause unplanned readmission following Psychiatric hospitalization in an Inpatient Psychiatric Facility*

0

0

0*

0

0

TOTAL

848

0.25

2,856,064

2,940,864

84,800

*CMS will collect this data using Medicare Part A and Part B; therefore, these measures will not require facilities to submit data on any cases.

**212 hr/facility x 1,684 facilities = 357,008 hr

***212 hr/facility x 1,734 facilities = 367,608 hr



Non-Measure Data Collection and Reporting


We propose to remove the non-measure reporting requirement that IPFs must report sample size counts for measures for which sampling is performed.


Our currently approved iteration estimates that the five elements of non-measure data collection (Medicare patient population counts, non-Medicare patient population counts, population counts by diagnostic group, population counts by age, and sample size counts) would require 2.5 hours of information collection burden per IPF. Because we are proposing to remove one of the five data elements, we estimate this will reduce the burden by 20% (i.e., one-fifth). Therefore, we estimate the following burden reduction associated with this proposal:


Non-Measure Data

Hourly Burden Reduction Per IPF

Total Hourly Burden Reduction

Cost Burden Reduction per IPF

Total Cost Burden Reduction

Sample size counts

0.5 hours

(2.5 hr x 0.20)

(842 hr)

(0.5 hr x 1,684 IPFs)

$16.42

(0.5 hr x $32.84/hr)

($27,651)

(842 hr x $32.84/hr)


In line with our adjustment to the number of IPF facilities, we adjust the remaining 80 % or 2.0 hours of non-measure reporting burden as follows:


Non-measure Data Collection and Submission

IPFs

Hours per IPF

Total Hours for All IPFs

Current

1,684

2.0

3,368

Proposed

1,734

2.0

3,468

Difference

+86

n/a

+172


Summary of Burden Changes


We estimate that the proposals in the FY 2019 IPF PPS proposed rule for the IPFQR Program result in a total burden reduction as depicted in the following table:

Changes: Time (hr)

Changes: Cost ($)

Measure Data Collection and Reporting

Removal of eight measures

(1,801,880)

(65,912,770.4)

Burden adjustment for currently approved measures (based on number +50 facilities)

84,800

3,101,984

Non-Measure Data Collection and Reporting

Removal of sample size counts reporting requirement

(842)

(30,800)

Burden adjustment (based on number +50 facilities)

100

3,658

Total Burden Reduction

(1,717,822)

(62,837,928)


  1. Publication/Tabulation Dates


IPFs will submit their measures through a Web-based Measures Tool on the QualityNet website. After IPFs have previewed their data, CMS will publicly display the measure rates on the CMS website. The following is the planned schedule of activities to reach these objectives.


The following table shows the timeline for measures for the FY 2020 payment determination and subsequent years.


Date

Scheduled Activity

4/15/2018

Proposed Rule Published (approximate date)

8/1/2018

Final Rule Published (approximate date)

1/1/2018

Start of Reporting Period

12/31/2018

End of Reporting Period

7/1/2019

Begin Data Submission*

8/15/2019

End Submission Deadline*

8/15/2019

Deadline to Complete Data Accuracy and Completeness Acknowledgement (DACA) *

FY 2020

Public Display of data on Hospital Compare*

*Specific dates to be announced via subregulatory guidance


  1. Expiration Date


We will display the expiration date on associated forms.


18. Certification Statement


There are no exceptions to the certification statement.


B. Collections of Information Employing Statistical Methods


CMS will not be employing any sampling techniques or statistical methods. However, CMS will allow IPFs to report data for certain measure using sampling.

Because CMS is not employing any sampling techniques or statistical methods, this section is not applicable to this collection.


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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleFY 2019 IPFQR Program Supporting Statements: Procedural Requirements
File Modified0000-00-00
File Created2021-01-21
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