Supporting Statement—Part A
Quality
Measures and Administrative Procedures for the Hospital-Acquired
Condition Reduction Program for the FY 2024 IPPS Program Year
(CMS-10668)
The Centers for Medicare & Medicaid Services (CMS) is committed to promoting higher quality healthcare and improving outcomes for Medicare beneficiaries. The Hospital-Acquired Condition (HAC) Reduction Program is established by section 1886(p) of the Act, as added by Section 3008 of the Affordable Care Act (Pub. L. 111-148), and requires the Secretary to reduce payments to hospitals in the worst-performing quartile of all subsection (d) hospitals by 1 percent effective beginning on October 1, 2014 and subsequent years.
To administer its requirements, the HAC Reduction Program relies on data collection and validation processes established through the Centers for Disease Control and Prevention’s (CDC) OMB control number, 0920-0666, and the Hospital Inpatient Quality Reporting (IQR) Program’s OMB control number, 0938-1022. However, in the Fiscal Year (FY) 2019 Inpatient Prospective Payment System (IPPS)/Long-Term Care Hospital (LTCH) PPS final rule, the Hospital IQR Program finalized the removal of National Healthcare Safety Network (NHSN) Healthcare-associated Infection (HAI) measures and NHSN HAI validation processes beginning on January 1, 2020. Removing the NHSN HAI measures from the Hospital IQR Program and ceasing collection and validation of these measures under the Hospital IQR Program will affect how the HAC Reduction Program administers its NHSN HAI data collection and validation in subsequent years. To continue effective administration of the HAC Reduction Program, the Program adopted validation templates similar to the ones retired by Hospital IQR Program to continue the HAC Reduction Program’s use and validation of NHSN HAI data for discharges beginning in Q3 2020.
The HAC Reduction Program identifies the worst-performing quartile of hospitals by calculating a Total HAC Score derived from the CMS PSI 90 and NHSN HAI measures, which require that we collect claims-based and chart-abstracted measures data, respectively. As stated above, validation of NHSN HAI measures was previously performed by the Hospital IQR Program. Because the Hospital IQR Program finalized its proposal to remove and cease validation for NHSN HAI measures, the HAC Reduction Program adopted policies to validate NHSN HAI data reported by subsection (d) hospitals to ensure that hospitals report correct NHSH HAI measure data, and the Total HAC Score is calculated using accurate data. The HAC Reduction Program also finalized a policy to penalize any hospitals that fail validation by assigning the maximum Winsorized z-score for the set of measures, which fail validation, for use in the Total HAC Score calculation. The collection of information for validation is necessary to ensure that the HAC Reduction Program and Total HAC Score are administered fairly.
The HAC Reduction Program will continue to receive NHSN HAI data for hospitals from CDC. Because the burden associated with submitting data for the NHSN HAI measures is captured under a separate OMB control number, 0920-0666, we do not provide an independent estimate of the burden associated with these measures for the Hospital IQR Program.
We note that in the FY 2021 Inpatient Prospective Payment System (IPPS)/Long-Term Care Hospital (LTCH) PPS proposed rule, we did not propose the addition or removal of any measures for the FY 2024 program year or subsequent years. The HAC Reduction Program currently has adopted six measures, which were finalized in previous rulemaking. The program uses five CDC NHSN measures of healthcare-associated infections: Catheter-Associated Urinary Tract Infection (CAUTI), NHSN Facility-wide Inpatient Hospital-onset Clostridium difficile Infection (CDI), NHSN Central Line-Associated Bloodstream Infection (CLABSI), American College of Surgeons – Centers for Disease Control and Prevention Harmonized Procedure Specific Surgical Site Infection for Colon and Abdominal Hysterectomy Procedures (SSI), and NHSN Facility-wide Inpatient Hospital-onset Methicillin-resistant Staphylococcus aureus Bacteremia (MRSA). The Program also uses Patient Safety and Adverse Events Composite (CMS PSI 90) as its sixth measure.
To facilitate the HAC Reduction Program, validation templates to ensure data accuracy are necessary. There are 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).
The validation templates are dependent upon a hospital’s selection for validation and may not be required by any particular hospital in any given year.
All the information to collect the templates listed above have been previously used in the Hospital IQR Program. To adopt these templates in the HAC Reduction Program, the only changes to these templates were to update the program name to reflect the HAC Reduction Program on the forms. Annual updates are made to the validation templates for the CLABSI, CAUTI, MRSA, and CDI measures 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.
Additionally, we note that the burden associated with completing and submitting the following forms is already accounted for under OMB Control Number 0938-1022
Hospital IQR Program Data Accuracy and Completeness Acknowledgement (DACA)
CMS IPPS Quality Reporting Programs Measure Exception Form for PC, ED, and HAI Data Submission
Hospital IQR Program Validation Educational Review Form, and
CMS Quality Reporting Program Extraordinary Circumstances Exceptions (ECE) Request Form
Only the DACA form must be completed by all hospitals 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 or one time only forms, and hospitals may not need to complete any of these forms in any given year.
Annually, subsection (d) hospitals covered under Section 5001(b) of the DRA must complete a 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 an acknowledgement that the data a hospital has submitted are complete and accurate. The burden associated with the DACA form is accounted for under the Hospital IQR Program’s OMB control number, 0938-1022.
In addition to the DACA form, the HAC Reduction Program has adopted a number of ad hoc processes for situations that may impact specific hospitals. These processes include an Extraordinary Circumstances policy, an NHSN HAI exception policy for hospitals with certain data considerations, and an Educational Review Process for hospitals that have questions regarding the validation process or its results. In order for hospitals to engage these processes, hospitals must submit forms that are currently and will be subsequently associated with the Hospital IQR Program’s PRA Package. The burden associated with each of the forms used to avail themselves to the appropriate process is accounted for under the Hospital IQR Program’s OMB control number, 0938-1022.
The HAC Reduction Program is a payment program that assesses hospital performance with respect to healthcare-associated infections of all subsection (d) hospitals using claims-based and NHSN HAI measures. While all claims-based data is submitted through claims processing systems that have validation methods to accept accurate Medicare claims into the claims database, the NHSN HAI data is not validated through other CMS processes. For the HAC Reduction Program to assess hospitals fairly, it must be able to ensure the accuracy of the data it collects. Validation is necessary to ensure the data used by the program is both correct and useful.
Because the Hospital IQR Program removed the NHSN HAI measures and the accompanying validation processes, the HAC Reduction Program adopted analogous processes to continue validation. To validate NHSN HAI data, CMS performs a random selection of up to 600 subsection (d) hospitals in the HAC Reduction Program on an annual basis for validation of chart-abstracted measures. In the FY 2021 IPPS/LTCH PPS proposed rule, CMS is proposing to reduce this to a group of up to 400 hospitals beginning with CY 2020 and subsequent years. Each hospital selected for validation is to produce a list of patients/lab results associated with the 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 be required to produce the CLABSI and CAUTI templates and the other 300 hospitals would be required to produce only the MRSA and CDI templates. If the update to select up to 400 is finalized, approximately 200 hospitals would be required to produce the CLABSI and CAUTI templates and the other approximately 200 hospitals would be required to produce only the MRSA and CDI templates.
Hospitals that do not treat these conditions or do not have treatment locations defined for the NHSN HAI measures used in the Hospital IQR Program (CLABSI, CAUTI, and SSI) 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 submit a CMS IPPS Quality Reporting Programs Measure Exception Form for NHSN HAI Data Submission. This form is accounted for under OMB Control Number 0938-1022.
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. Likewise, the HAC Reduction Program will continue to update the templates annually. 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)).
Hospitals may use the educational review process to correct disputed chart-abstracted HAI measure validation results for all quarters of validation. To submit a formal request, hospitals can utilize the Educational Review Request Form. This form is accounted for under OMB Control Number 0938-1022.
In the event of extraordinary circumstances not within the control of the hospital, a hospital can request an exemption or extension for meeting program requirements. For the hospital to receive consideration for an extension or exemption, an CMS Quality Reporting ECE Request Form must be submitted within 90 calendar days of an extraordinary circumstance event. This form is accounted for under OMB Control Number 0938-1022.
CMS will use the information collected for the HAC Reduction Program to determine whether a hospital is within the worst-performing quartile of subsection (d) hospitals. As stated above, the HAC Reduction Program applies a 1-percent payment reduction to Medicare fee-for-service claims for hospitals in the worst-performing quartile of all subsection (d) hospitals. To determine which hospitals are in the worst-performing quartile, the HAC Reduction Program uses CMS PSI 90 data and NHSN HAI measure data. The Program must collect chart-abstracted information to validate NHSN HAI data reported by subsection (d) hospitals to ensure that hospitals report correct NHSH HAI measure data, and the Total HAC Score is calculated using accurate data. The information will be made available to hospitals for their use in internal quality improvement initiatives. This information 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.
To assist hospitals in standardizing data collection initiatives across the industry, CMS continues to improve data collection tools to make data submission easier for hospitals (including the collection of data from paper medical records for chart-abstracted measures) and increase the utility of the data provided by the hospitals. The NHSN HAI measures are collected through National Healthcare Safety Network, a federal registry. Chart-abstracted information may be submitted electronically, but for many hospitals there still is a manual component.
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.
The information to be collected is not duplicative of similar information collected by CMS. As required by statute, CMS maintains a set of quality measures which a hospital must report to be scored in the HAC Reduction Program.
Information collection requirements were designed to allow maximum flexibility specifically to small hospitals having 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 HAC Reduction Program includes 1,188 small hospitals in the FY 2020 program year. An additional 15 hospitals have not reported bed size data; this could bring the "small hospital" total to as high as 1,203. We do not expect this number to change significantly by the FY 2024 program year.
No special processes or procedures are available to small hospitals to make the information collection less burdensome. We anticipate that subsection (d) hospitals, including small subsection (d) hospitals, will experience little to no change as the Hospital IQR Program ceases its validation process and the HAC Reduction Program begins its validation process. We are finalizing policies to make the processes under the HAC Reduction Program as similar as possible to the current Hospital IQR Program processes and anticipate that small hospitals participating in the Hospital IQR Program will continue to be familiar with the information collection request required for validation.
We have designed the collection of quality measure data to be as minimally burdensome as possible while collecting the information necessary for data validation and for calculation of summary figures to be used as reliable estimates of hospital performance. Data validation is expected to occur quarterly, but as noted above, if the proposals in the FY 2021 IPPS/LTCH PPS proposed rule are finalized, only up to 400 hospitals will be selected for validation. Neither less frequent collection of data nor validation of fewer cases is practicable at this time. Less frequent data collection would strain the ability for CMS to validate the submitted validation template and associated NHSN HAI infection cases in a timely manner. Under the current process, Clinical Data Abstraction Center (CDAC) abstractors are able to review and validate hospital submissions as those submissions are made each quarter. If the hospitals submitted data less frequently, CDAC abstractors would not have time to complete the necessary reviews of each submission before the Total HAC Score is calculated. Similarly, if the HAC Reduction Program proposed to validate fewer cases, the statistical analysis would be altered, and the Program would be less likely to generate meaningful results from validation.
There are no special circumstances.
The FY 2021 IPPS/LTCH PPS proposed rule, published on May 29, 2020 (85 FR 32460) serves as the 60-day Federal Register notice.
CMS is supported in this initiative by the CDC. The CDC collaborates with CMS on an ongoing basis, providing technical assistance in developing and/or identifying quality measures.
There will be no gifts given for participation.
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.
There are no sensitive questions.
Under Section 1886(p) of the Social Security Act, we are required to rank hospitals with respect to the national average in hospital-acquired conditions and reduce payment by 1 percent to the worst-performing quartile. In the FY 2021 IPPS/LTCH PPS proposed rule, we are not finalizing any new measures for the HAC Reduction Program. However, we are proposing to update the number of hospitals selected for validation from up to 600 hospitals to up to 400 hospitals, effective beginning with the FY 2024 program year. This package excludes burden associated with the NHSN HAI data collection, which is captured under a separate OMB control number: 0920-0666.
For the purposes of burden estimation, we assume all activities associated with the HAC Reduction Program for 3,300 IPPS hospitals, of which up to 400 will be selected for validation of the data submitted for the NHSN measures associated with the HAC Reduction Program, 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 HAC Reduction Program. The labor performed can be accomplished by these staff with a median hourly wage in general medical and surgical hospitals of $19.40 per hour1; 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 “overhead” costs, as opposed to direct costs or employee wages, are subject to some interpretation at the organization 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 $38.80 ($19.40 base salary + $19.40 fringe).
We estimate a total burden 28,800 hours associated with our proposed policy changes for FY 2024. Taken with our estimated wage rate of $38.80, we estimate a total cost of approximately $1,117,440 across all participating hospitals. The estimated total burden was calculated as follows:
Consistent with previous estimates, we have estimated a reporting burden of 80 hours (20 hours x 1 record per hospital per quarter x 4 quarters) per hospital selected for validation per year to submit the CLABSI and CAUTI templates, and 64 hours (16 hours x 1 record per hospital per quarter x 4 quarters) per hospital selected for validation per year to submit the MRSA and CDI templates. We estimate a total burden of 28,800 hours [(80 hours per hospital to submit CLABSI and CAUTI templates + 64 hours per hospital to submit MRSA and CDI templates) x 200 hospitals selected for validation] and approximately $1.1 million (28,800 hours x $38.80 per hour).
Table 1. Burden Calculations for the HAC Reduction Program Validation Program
Validation for up to 400 IPPS Hospitals
Measure Set |
Number of hospitals reporting |
Annual burden (hours) per hospital |
Calculation for FY 2021 for all subsection (d) hospitals selected for validation |
Cost per Hour |
Total Cost |
HAI Validation Templates (CLABSI, CAUTI) |
200 |
80 |
16,000 hours |
$38.80 |
$620,800 |
HAI
Validation Templates |
200 |
64 |
12,800 hours |
$38.80 |
$496,640 |
Total |
|
|
28,800 hours |
|
$1,117,440 |
There are no capital costs associated with the HAC Reduction Program’s proposed policies.
The cost to the Federal Government includes costs associated with the collection and validation of the data. The cost is estimated at $7,500,000 annually for the validation contract. Additionally, this program takes one and one-half (1.5) CMS staff at a GS-13 level to operate. GS-13 Step 5 approximate annual salary is $116,353 (DC, M D, VA, WV, PA local) for an additional cost of $174,530. The total annual cost to the Federal Government is $7,674,530.
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.
Table 2, below depicts the calculations used in the HAC Reduction Program’s previously approved PRA package.
Table 2. Previously Approved Burden Calculations for the HAC Reduction Program Validation Program
Measure Set |
Number of hospitals reporting |
Annual burden (hours) per hospital |
Calculation for FY 2021 for all subsection (d) hospitals selected for validation |
Cost per Hour |
Total Cost |
HAI Validation Templates (CLABSI, CAUTI) |
300 |
80 |
24,000 hours |
$36.58 |
$877,920 |
HAI
Validation Templates |
300 |
64 |
19,200 hours |
$36.58 |
$702,336 |
Total |
|
|
43,200 hours |
|
$1,580,256 |
In the FY 2021 IPPS/LTCH PPS proposed rule, we are proposing two changes that will affect the information collection burden associated with the HAC Reduction Program. First, we are proposing to reduce the number of hospitals selected for validation from up to 600 to up to 400. This equates to a reduction of 100 hospitals submitting HAI validation templates for CLABSI and CAUTI, and 100 hospitals submitting HAI validation templates for MRSA and CDI. The effects of this change are depicted in Table 3, below.
Table 3. Reduction in Hours Associated with Proposed Changes
Measure Set |
Number of Hospitals No Longer Reporting |
Annual burden (hours) per hospital |
Reduced number of Hours |
HAI Validation Templates (CLABSI, CAUTI) |
100 |
80 |
8,000 hours |
HAI
Validation Templates |
100 |
64 |
6,400 hours |
Total |
|
|
14,400 hours |
Reducing the previously approved 43,200 hours by 14,400 yields the 28,800 hours described in Section 12, above. At the previously approved wage rate of $36.58 per hour, this is a reduction of $526,752, which would equate to a total cost of $1,053,504 ($1,580,156 - $526,752). However, the second change in the FY 2021 IPPS/LTCH PPS proposed rule that affects the HAC Reduction Program is a change in wage rate from $36.58 per hour to $38.80 per hour, which is a difference of $2.22 per hour. Over the remaining 28,800 hours, this equates to an increase of $63,936, for a total cost burden of $1,117,440, as described in Section 12, above.
The goal of the data collection is to validate NHSN HAI data. We will continue to display quality information for public viewing on the Hospital Compare website or its successor website as required for the HAC Reduction Program by Section 1886(p)(6) of the Social Security Act. 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. Hospital quality data on Hospital Compare are updated on a quarterly basis. One of the goals of the HAC Reduction 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.
We will display this expiration date on each of the forms listed above in section A.1.c, which would become available on the QualityNet website’s HAC Reduction Program page. We will display the approved expiration date prominently on our QualityNet website’s HAC Reduction Program pages used to document our measure specifications and reporting guidance.
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.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | HACRP PRA Supporting Statement - Part A |
| File Modified | 0000-00-00 |
| File Created | 2021-01-14 |