Response to Comments (Proposed)

Response to Comments on the Burden Estimates for the FY 2025 IRF QRP Proposals*

The FY 2025 IRF PPS Notice of Proposed Rulemaking (89 FR 22246) was published on March 29, 2024. In response to the NPRM, CMS received four comments related to the proposed burden estimate. CMS responded to those comments in the FY 2025 IRF PPS Final Rule that was published on August 6, 2024. The IRF PPS Final Rule is available here: https://www.federalregister.gov/documents/2024/08/06/2024-16911/medicare-program-inpatient-rehabilitation-facility-prospective-payment-system-for-federal-fiscal. Please see the response to comments document.

Comment: Three commenters urged CMS to update its estimate of the change in burden resulting from these new IRF QRP changes to account for the costs associated with training and education, time required to administer and reconcile patient assessments, and costs associated with software development and other required technical updates. One of these commenters specifically noted they do not believe the estimate accurately reflects the time to conduct patient interviews and reconcile information from the patient nor does it account for the costs associated with software development and other technology that will make the collection of this information easier and timelier for IRFs and other providers.

Response: We acknowledge that the net effect of our policies finalized in this final rule is an increase of $338.03 per IRF per year.

The burden estimate for the proposed SDOH items is based on past IRF burden calculations and represents the time it takes to encode the IRF-PAI. As the commenter pointed out in their example, the patient must be assessed and information gathered. After the patient assessment is completed, the IRF-PAI is coded with the information and submitted to the internet Quality Improvement and Evaluation System (iQIES), and it is these steps (after the patient assessment) that the estimated burden and cost captures. This method is consistent with past collection of information estimates.¹

We also note that some IRFs will incur a higher cost than was estimated due to their size and volume of admissions, and some IRFs will incur a lower cost. Regarding the comments about IRFs’ costs associated with training and education, time required to administer and reconcile patient assessments, and costs associated with software development and other required technical updates, CMS continually looks for opportunities to minimize burden associated with collection and submission of the IRF-PAI for information users through strategies that simplify collection and submission requirements. This includes standardizing instructions, providing a help desk, hosting a dedicated webpage, communication strategies, free data specifications, and free on-demand reports. We describe each of those below and how they will potentially reduce new burden on IRFs collecting and submitting these new and modified SDOH assessment items.

First, we will standardize the collection instructions for the new and modified SDOH assessment items across all IRFs, ensuring that all instructions and notices are written in plain language, and by providing step-by-step examples for completing the IRF-PAI. Second, CMS provides a dedicated help desk to support users and respond to questions about the data collection, and IRFs can utilize this help desk when they have questions about the new and modified SDOH assessment items. Third, a dedicated IRF QRP web page houses multiple modes of tools, such as instructional videos, case studies, user manuals, and frequently asked questions. We plan to update this webpage with new resources to support IRFs’ understanding of the new SDOH assessment items and the modified assessment item as soon as technically feasible, and these resources will be available to all users of the IRF-PAI. Fourth, CMS utilizes a listserv to facilitate outreach to users, such as communicating timely and important new material(s), and we will use those outreach resources when providing training and information about the new and modified SDOH assessment items. Fifth, CMS creates data collection and submission specifications for IRF electronic health record (EHR) software available free of charge to all IRFs and their technology partners, and these will be updated to incorporate the new and modified SDOH assessment items. Finally, CMS provides IRFs with a free internet-based system through which users can access on-demand reports for feedback about the IRFs’ compliance with collection and submission of the new and modified SDOH assessment items associated with their facility.

Comment: One commenter urged CMS to recognize that administrative requirements are already overburdening the IRF workforce and incorporating these new standardized patient assessment data elements would further decrease resources from patient care. This commenter reported that it currently takes an average of 45 minutes per patient to pull information and scores and enter them into the IRF-PAI. This commenter noted that the 45 minutes of time does not include the time it takes their staff to complete their assessments that contribute to the IRF-PAI, and completing assessments for patients with cognitive deficits takes even longer.

Response: As the commenter pointed out in their example, the patient must be assessed, and information gathered. We disagree that this policy, if finalized, will take time away from patient care. The new assessment items (Living Situation, Food, and Utilities) are all important pieces of information to developing and administering a comprehensive plan of care in accordance with §412.606. Rather than taking time away from patient care, providers will be documenting information they are likely already collecting through the course of providing care to the patients.

After the patient assessment is completed, the IRF-PAI is coded with the information and submitted to the CMS system, and it is these steps (after the patient assessment) that the estimated burden and cost captures. As we stated in section IX.A. of this final rule, our assumptions for staff type were based on the categories generally necessary to perform an assessment, and subsequently encode it, which is consistent with past collection of information estimates.² While we acknowledge that some IRFs may train and utilize other personnel, our estimates are based on the categories of personnel necessary to complete the IRF-PAI.

We also note that the commenter’s estimate of the time it takes its members to code the IRF-PAI (45 minutes) is consistent with the total time we report in our Paperwork Reduction Act (PRA) package (0938-0842). We estimate the next version of the IRF-PAI will take an average of 1 hour and 47 minutes per IRF-PAI assessment which includes the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.

1 FY 2016 IRF PPS proposed rule https://www.federalregister.gov/citation/80-FR-23390 (80 FR 23390)

2 FY 2016 IRF PPS proposed rule (80 FR 23390).

*Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2025 and Updates to the IRF Quality Reporting Program. 89 FR 64330 through 64332. https://www.federalregister.gov/d/2024-16911/p-505.