CMS-10210 - FY2024 Final Rule (HIQR)_Supporting Statement B

Supporting Statement - Part B

Submission of Information for the Hospital Inpatient Quality Reporting Program

Collection of Information Employing Statistical Methods

1. Describe potential respondent universe.

All hospitals receiving reimbursement under the Inpatient Prospective Payment System (IPPS) in the United States constitute the potential respondent universe, approximately 3,150 IPPS hospitals, and 1,350 non-IPPS hospitals participating in information collection on a voluntary basis.

2. Describe procedures for collecting information.

Data are submitted via a secure website. Patient-level data are submitted directly to CMS, while summary or aggregate data are submitted directly to CMS or to the Centers for Disease Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN) via web-based tools.

3. Describe methods to maximize response rates.

The Hospital Inpatient Quality Reporting (IQR) Program is a quality reporting program with the goal of driving quality improvement through measurement and transparency. Hospitals participate by submitting data to CMS on measures of inpatient quality of care and meeting other program requirements outlined in rulemaking. CMS encourages hospital participation by subjecting hospitals that do not participate, or participate but fail to meet program requirements, to a one-fourth reduction of the applicable percentage increase in their Annual Payment Update (APU) under the IPPS for the applicable fiscal year. In addition, CMS removes barriers to responding by providing abstraction and submission tools, educational resources and presentations, outreach and communications about program requirements and deadline reminders, and technical assistance to any hospitals requiring assistance with program requirements.

4. Describe any tests of procedures or methods.

Sampling for Chart-Abstracted Data for the Hospital IQR Program

Under the Hospital IQR Program, hospitals are required to submit to CMS quarterly aggregate population and sample size data for those measures that a hospital submits as chart-abstracted measures (80 FR 49709 through 49710). Hospitals may also submit measure data for the entire applicable patient population in lieu of sampling. For more detailed information regarding the history and updates on sampling and case thresholds, we refer readers to the FY 2011 IPPS/LTCH PPS final rule (75 FR 50221), the FY 2012 IPPS/LTCH PPS final rule (76 FR 51641), the FY 2013 IPPS/LTCH PPS final rule (77 FR 53537), the FY 2014 IPPS/LTCH PPS final rule (78 FR 50819), and the FY 2016 IPPS/LTCH PPS final rule (80 FR 49709). 

Background History on Validation Policy for Chart-Abstracted Data for the Hospital IQR Program

The Hospital IQR Program adopted validation requirements in the FY 2013 IPPS/LTCH PPS final rule (77 FR 53539 through 53553). For more detailed information on validation processes for chart-abstracted measures and electronic clinical quality measures (eCQMs), and previous updates to these processes for the Hospital IQR Program, we refer readers to the FY 2014 IPPS/LTCH PPS final rule (78 FR 50822 through 50835), the FY 2015 IPPS/LTCH PPS final rule (79 FR 50262 through 50273), the FY 2016 IPPS/LTCH PPS final rule (80 FR 49710 through 49712), the FY 2017 IPPS/LTCH PPS final rule (81 FR 57173 through 57181), the FY 2018 IPPS/LTCH PPS final rule (82 FR 38398 through 38403), the FY 2019 IPPS/LTCH PPS final rule (83 FR 41607 through 41608), and the FY 2021 IPPS/LTCH PPS final rule (85 FR 58946 through 58947).

Validation for chart-abstracted measures has been updated over recent years as the number of chart-abstracted measures has been reduced from the Hospital IQR Program. In the FY 2019 IPPS/LTCH PPS final rule (83 FR 41562 through 41567), we removed four clinical process of care measures, and noted that for the CY 2021 reporting period/FY 2023 payment determination and subsequent years, only one clinical process of care measure (Sepsis measure) remains in the program for chart-abstracted validation (83 FR 41608).

We adopted the process for validating eCQM data in the FY 2017 IPPS/LTCH PPS final rule (81 FR 57173 through 57181). Validation of eCQM data was finalized for the FY 2020 payment determination and subsequent years (starting with the validation of CY 2017 eCQM data that would impact FY 2020 payment determinations). We refer readers to the FY 2018 IPPS/LTCH PPS final rule (82 FR 38398 through 38403), in which we finalized several updates to the processes and procedures for validation of CY 2017 eCQM data for the FY 2020 payment determination, validation of CY 2018 eCQM data for the FY 2021 payment determination, and eCQM data validation for subsequent years. In the FY 2023 IPPS/LTCH PPS final rule, we finalized an increase in the reporting of medical record requests from 75 percent of records to 100 percent of records, beginning with the validation of CY 2022 eCQM data affecting the FY 2025 payment determination and for subsequent years (87 FR 49308 through 49310).

Validation Policy for the Hospital IQR Program

As finalized in the FY 2021 IPPS/LTCH PPS final rule, the Hospital IQR Program will select up to 400 hospitals for validation, of which up to 200 will be selected randomly, and up to 200 will be selected using the targeting criteria described in the rule (85 FR 58946 through 58947). To be eligible for random selection for validation, a hospital will have to be a subsection (d) hospital. To be eligible for targeted selection for validation, the hospital will have to be a subsection (d) hospital and meet one or more of the targeting criteria.

If selected for validation, hospitals have to submit eight randomly selected medical records on a quarterly basis. For chart-abstracted cases, that would result in a total of 32 records per year. For eCQM cases, hospitals are required to report eCQM data results in a total of 16 requested cases from 2 calendar quarters of data affecting the FY 2024 payment determination, 24 requested cases from 3 quarters of data affecting the FY 2025 payment determination, and 32 requested cases over 4 quarters of data affecting the FY 2026 payment determination and for subsequent years.  In the FY 2024 IPPS/LTCH PPS final rule, we added the validation targeting criterion to include any hospital with a two-tailed confidence interval that is less than 75 percent and which submitted less than four quarters of data due to receiving an extraordinary circumstances exception (ECE) for one or more quarters, beginning with the FY 2027 payment determination.

In the FY 2015 IPPS/LTCH PPS final rule (79 FR 50260), we established an educational review process for validation of chart-abstracted measures. The process was subsequently updated in the FY 2018 IPPS/LTCH PPS final rule (82 FR 38402 through 38403). In this process, hospitals may request an educational review if they believe they have been scored incorrectly or if they have questions about their validation results. In the FY 2021 IPPS/LTCH PPS final rule, we extended this educational review process to include both chart-abstracted and eCQM measures, rather than just chart-abstracted measures (85 FR 58953). In the FY 2022 IPPS/LTCH PPS final rule, we finalized an extension to the availability of educational reviews for 4th quarter data such that if an error is identified during the education review process for 4th quarter data, we will use the corrected quarterly score to compute the final confidence interval used for payment determination.

Validation Response Rates for the Hospital IQR Program

For the Hospital IQR Program, we provide one combined validation score starting with validation affecting the FY 2024 payment determination and for subsequent years. Specifically, this single score reflects a weighted combination of a hospital’s validation performance for chart-abstracted measures and eCQMs. Since eCQMs are not currently validated for accuracy, the eCQM portion of the combined agreement rate will be multiplied by a weight of zero percent and chart-abstracted measure agreement rate will be weighted at 100 percent for validation affecting the FY 2024 payment determination and subsequent years (that is, starting with the CY 2021 discharge data submitted for FY 2023 payment determination and validation affecting the FY 2024 payment determination) (85 FR 58950 through 58952).

CMS uses these validation efforts to provide assurance of the accuracy of data submitted by hospitals for use in the Hospital IQR Program. Hospital IQR Program data for selected time periods becomes publicly displayed as required by Section 1886(b)(3)(B)(viii)(VII) of the Social Security Act. This section of the Social Security Act requires the Secretary to report quality measures of process, structure, outcome, patients’ perspectives on care, efficiency, and costs of care that relate to services furnished in inpatient settings in hospitals on the Internet website of CMS. The section also requires that the Secretary establish procedures for making information regarding measures available to the public after ensuring that a hospital has the opportunity to review its data before they are made public. Our current policy, as outlined in the FY 2014 IPPS/LTCH PPS final rule (78 FR 50776), is to report data from the Hospital IQR Program as soon as it is feasible on CMS websites such as the Compare tool hosted by HHS, available at: https://www.medicare.gov/care-compare, and/or its successor website after a 30-day preview period.

5. Provide name and telephone number of individuals consulted on statistical aspects.

Julia Venanzi Grace Snyder

410-786-1471 410-786-0700

Mihir Patel

410-786-2815