CMS-10431 PCHQR FY 2025 Supporting Statement A_8-28-24

Supporting Statement – Part A

Submission of Information for the PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program: FY 2025 IPPS/LTCH PPS Final Rule

(OMB# 0938-1175; CMS-10431)

1. Background

This is a revision of the currently approved information collection request. The Centers for Medicare & Medicaid Services’ (CMS’) quality reporting programs promote higher quality, more efficient healthcare for Medicare beneficiaries by collecting and reporting on quality-of-care metrics. This information is made available to consumers, both to empower Medicare beneficiaries and inform decision-making, as well as to incentivize healthcare facilities to make continued improvements.

Specifically, CMS has implemented quality measure reporting programs for multiple settings, including for the PPS-exempt cancer hospital (PCH) setting, to achieve its overarching priorities and initiatives, including the National Quality Strategy and the Meaningful Measure 2.0 Framework. In particular, Meaningful Measures 2.0 promotes innovation and modernization of all aspects of quality to better address health care priorities and gaps, emphasize digital quality measurement, and promote patient perspectives by supporting five interrelated goals: (1) empower consumers to make good health care choices through patient-directed quality measures and public transparency, (2) leverage quality measures to promote health equity and close gaps in care, (3) streamline quality measurement, (4) leverage measures to drive outcome improvement through public reporting and payment programs, and (5) improve quality measure efficiency by transitioning to digital measures and using advanced data analytics.

The information collection requirements through the FY 2027 program year are currently approved under OMB control number 0938-1175 (expiration date January 31, 2027). This request covers data collection requirements for the FY 2027 program year and subsequent years. This revised information collection request includes the updated measure set for the FY 2027 program year as well as updated wage rates.

B. Justification

1. Need and Legal Basis

Pursuant to section 1866(k)(1) of the Social Security Act, starting in FY 2014 and for subsequent fiscal years, PCHs, as described in section 1886(d)(1)(B)(v) of the Social Security Act, shall submit pre-defined quality measures to the CMS. Such data shall be submitted in a form and manner and at a time specified by the Secretary. We continue to require PCHs to meet the procedures previously set forth for making public the data/measure rates submitted under the PCHQR Program. As CMS’s aim is to facilitate high quality of care in a meaningful and effective manner while simultaneously remaining mindful of the reporting burden on the PCHs, CMS intends to reduce duplicative reporting efforts whenever possible by leveraging existing infrastructure.

1. PCHQR Program Quality Measures

The PCHQR Program seeks to collect and publicly report data on quality-of-care metrics for the PCH setting. Measure data are submitted via one of three modes: (1) web-based, (2) claims-based; (3) and survey-based, as seen in Table 1.

For measure data submitted as “web-based” via the Centers for Disease Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN), measures are calculated using data submitted to the NHSN under OMB control number 0920-1317 (expiration date March 31, 2026) for the COVID–19 Vaccination Coverage Among Healthcare Personnel (HCP) measure and under OMB control number 0920-0666 (expiration date December 31, 2026) for all other NHSN measures. We note that the CDC currently has a PRA waiver for the collection and reporting of vaccination data under section 321 of the National Childhood Vaccine Injury Act of 1986 (enacted on November 14, 1986) (NCVIA).¹ For Patient Engagement/Experience of Care, structural, and process measures, PCHs are required to submit measure data via CMS’ Hospital Quality Reporting (HQR) system with the exception of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey. For the HCAHPS Survey, PCHs are required to administer the survey and submit the survey data to CMS. These survey administration burdens are captured under OMB control number 0938-0981, which expires January 31, 2025.

For measure data submitted as “claims-based”, information is derived through analysis of administrative Medicare Fee-for-Service (FFS) claims and beneficiary enrollment data and do not require additional effort or burden from hospitals.

Table 1. Currently Approved PCHQR Program Measures for the FY 2026 Program Year

Measure Type and Name	CBE No.
Safety and Healthcare-Associated Infection Measures
Central Line-Associated Bloodstream Infection Outcome Measure (CLABSI)*	0139
Catheter-Associated Urinary Tract Infection Outcome Measure (CAUTI)*	0138
Harmonized Procedure Specific Surgical Site Infection (SSI) Outcome Measure (currently includes SSIs following Colon Surgery and Abdominal Hysterectomy Surgery)*	0753
Facility-wide Inpatient Hospital-onset Clostridium difficile Infection (CDI) Outcome Measure*	1717
Facility-wide Inpatient Hospital-onset Methicillin-resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure*	1716
Influenza Vaccination Coverage Among Healthcare Personnel (HCP)*	0431
COVID-19 Healthcare Personnel (HCP) Vaccination**	N/A
Clinical Process/Oncology Care Measures
Proportion of Patients Who Died from Cancer Receiving Chemotherapy in the Last 14 Days of Life (EOL-Chemo)	0210
Proportion of Patients Who Died from Cancer Not Admitted to Hospice (EOL-Hospice)	0215
Intermediate Clinical Outcome Measures
Proportion of Patients Who Died from Cancer Admitted to the Intensive Care Unit (ICU) in the Last 30 Days of Life (EOL-ICU)	0213
Proportion of Patients Who Died from Cancer Admitted to Hospice for Less Than Three Days (EOL-3DH)	0216
Claims-Based Outcome Measures
Admissions and Emergency Department (ED) Visits for Patients Receiving Outpatient Chemotherapy	N/A
30-Day Unplanned Readmissions for Cancer Patients	3188
Surgical Treatment Complications for Localized Prostate Cancer	N/A
Patient Engagement/Experience of Care Measures
Documentation of Goals of Care Discussions Among Cancer Patients	N/A
HCAHPS Survey***
Health Equity Measures
Hospital Commitment to Health Equity	N/A
Screening for Social Drivers of Health	N/A
Screen Positive Rate for Social Drivers of Health	N/A

*Burden for these measures are accounted for under OMB control number 0920-0666.

**Burden for this measure is accounted for under OMB control number 0920-1317.

***Burden for this measure is accounted for under OMB control number 0938-0981.

In the FY 2025 IPPS/LTCH PPS final rule, we are adopting the Patient Safety Structural measure into the PCHQR Program measure set beginning with the CY 2025 reporting period/FY 2027 program year. For this measure, PCHs will be required to submit measure data via CDC’s NHSN. We are also modifying the HCAHPS Survey beginning with the CY 2025 reporting period/FY 2027 program year. We note that as stated below in section 12, estimates for the PCHQR Program under OMB control number 0938-1175 exclude burden associated with NHSN measures which are submitted separately under OMB control numbers 0920-0666 and 0920-1317, and the HCAHPS Survey which is submitted separately under OMB control number 0938-0981. As a result, we are not estimating a change in burden under OMB control number 0938-1175 due to the policies in the FY 2025 IPPS/LTCH PPS final rule.

2. PCHQR Program Administrative Forms

CMS has implemented procedural requirements that align the current quality reporting programs, including the PCHQR, Hospital Inpatient Quality Reporting (IQR), Hospital Readmissions Reduction, Hospital Outpatient Quality Reporting, Hospital-Acquired Condition (HAC), and Hospital Value-Based Purchasing (VBP) Programs. These procedural requirements involve submission of forms to comply with the PCHQR Program requirements. Unlike other existing quality reporting programs, however, the PCHQR Program is not linked to any payment penalties if quality measures are not submitted.

The PCHQR Program uses four administrative forms: (1) Notice of Participation Form; (2) Data Accuracy and Completeness Acknowledgement (DACA) Form; (3) Measures Exception Form; and (4) Extraordinary Circumstances Exception (ECE) Form. These forms are used across ten quality programs (Hospital IQR Program, Hospital Outpatient Quality Reporting Program, Inpatient Psychiatric Facility Quality Reporting Program, PCHQR Program, Ambulatory Surgical Center Quality Reporting Program, Hospital VBP Program, Hospital-Acquired Condition Reduction Program, Hospital Readmissions Reduction Program, End Stage Renal Disease Quality Incentive Program, and Rural Emergency Hospital Quality Reporting Program), therefore we have included the burden associated with these forms under OMB control number 0938-1022 (Hospital IQR Program). Most of these forms are not completed on an annual basis, but on a need-to-use, exception basis, and most PCHs will not need to complete any of these forms in any given year. Thus, the burden for providers associated with forms utilized in the PCHQR Program is nominal, if any.

1. Notice of Participation Form

To begin participation in the PCHQR Program, PCHs must complete a Notice of Participation. The Notice of Participation explains the participation and reporting requirements for the program. PCHs that previously indicated their intent to participate will be considered active PCHQR Program participants until they submit a withdrawal to CMS. PCHs that no longer wish to participate in the PCHQR Program or those that no longer wish to submit data for publishing on the Compare tool hosted by HHS or its successor website(s) can notify CMS of their decision using the same form discussed above.

2. DACA Form

Annually, PCHs participating in quality reporting use the Hospital Quality Reporting DACA form after 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, completed annually, is an acknowledgement that the data a hospital has submitted are complete and accurate.

3. Measures Exception Form

PCHs that performed a combined total of 9 or fewer colon surgeries and abdominal hysterectomies in the calendar year prior to the reporting year are eligible to submit the Measure Exception Form to reduce the burden of reporting the SSI measure.

4. ECE Request Form

CMS offers a process for PCHs to request exceptions to the reporting of required quality data when a PCH experiences an extraordinary circumstance not within the control of the PCH, such as a natural disaster.

2. Information Users

PCHs use the feedback reports provided to CMS to examine their individual PCH-specific care domains and types of patients so they can compare present performance to past performance as well as to national performance norms including other PCHs; to evaluate the effectiveness of care provided to specific types of patients and, in the context of investigating processes of care, to individual patients; to monitor quality improvement outcomes continuously over time and assess their own strengths and weaknesses in the clinical services they provide objectively; and to inform the respective PCH of the care-related areas, activities, and/or behaviors that result in effective patient care, and alert them to needed improvements. Such information is essential to PCHs in initiating quality improvement strategies and can also be used to improve PCHs’ resource planning.

The availability of peer performance enables state agencies and CMS to identify opportunities for improvement in the PCH, and to evaluate more effectively the PCH’s own quality assessment and performance improvement program.

National accrediting organizations such as The Joint Commission (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.

In November 2014, the PCHQR Program began publicly reporting quality measures on the Hospital Compare website, now called Care Compare, available to consumers on www.Medicare.gov. On December 1, 2020, CMS relocated PCH data to the Provider Data Catalog (PDC). The PDC site can be accessed at https://data.cms.gov/provider-data/. The website provides information for consumers and their families about the quality of care provided by an individual hospital, allowing them to see how well patients of one facility fare compared to those in other facilities and to state and national averages. Modeled after the Hospital IQR Program, the PCHQR Program uses quality measures to assist consumers in making informed decisions when choosing a PCH; to monitor the care the PCH is providing; and to stimulate the PCH to further improve quality and identify optimal practice.

Under section 3014 of the Patient Protection and Affordable Care Act of 2010 (ACA), CMS is required to evaluate the impact and efficiency of CMS measures in quality reporting programs and to post the report every three years. Following the compilation of data from the Hospital IQR Program and other CMS programs, CMS’ findings were formally written into the latest triennial National Impact Assessment Report, which was released in CY 2024.²

3. Use of Information Technology

To assist PCHs in participating in standardized data collection initiatives across the industry, CMS continues to improve data collection tools with the goal of making data submission easier (e.g., the automated collection of electronic patient data in EHRs for electronic clinical quality measures (eCQMs) and the collection of data from federal registries like the NHSN), and to increase the utility of the data provided by the PCHs.

As reflected by the collection and reporting of claims-based quality measures, efforts are made to reduce burden by limiting the adoption of measures requiring the submission of patient-level information that must be acquired through chart-abstraction and to employ existing data and data collection systems. The complete list of measures and data collection forms are organized by type of data collected and data collection mechanism in Table 1.

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

4. Duplication of Efforts

The information to be collected is not duplicative of similar information collected by CMS or other efforts to collect quality of care data for PCH care. Where possible, we have selected measures that are currently reported through a common mechanism for all hospitals to conduct uniform measure reporting across settings. For example, we leverage data reported to the CDC through the NHSN so as not to require duplicate reporting.

5. Small Business

Information collection requirements were designed to allow maximum flexibility specifically for small PCH providers participating in the PCHQR Program. This effort assists small PCH providers in gathering information for their own quality improvement efforts. We define a “small hospital” as one with 1-99 inpatient beds; 4 of the 11 PCHs that report data for the PCHQR Program meet this definition. 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) function.

6. Less Frequent Collection

CMS has designed the collection of quality-of-care data to be the minimum necessary for reporting of data on measures that are meaningful indicators of cancer patient care, and for calculation of summary figures to be used as reliable estimates of PCH performance. Claims-based measures are calculated from Medicare FFS claims data; hospitals submit claims for reimbursement or payment per claims processing timeliness requirements. To collect the information less frequently would compromise the timeliness of any calculated estimates. In addition, the NHSN web-based COVID-19 HCP Vaccination measure collected by the CDC is submitted for at least one self-selected week during each month of the reporting quarter. To collect these measure data less frequently would compromise the timeliness of any calculated estimates.

7. Special Circumstances

There are no special circumstances.

8. Federal Register Notice/Outside Consultation

The 60-day Federal Register notice of the FY 2025 IPPS/LTCH PPS proposed rule (RIN 0938-AV34, CMS-1808-P) was published on May 2, 2024 (89 FR 35934). No comments were received regarding the burden estimates included in this PRA package. The FY 2025 IPPS/LTCH PPS final rule (RIN 0938-AV34, CMS-1808-F) was published on August 28, 2024 (89 FR 68986).

Measures adopted for the PCHQR Program are required by statute to undergo a recognized consensus process. Section 3014 of the ACA modified section 1890(b) of the Act to require CMS to develop quality and efficiency measures through a “consensus-based entity.” To fulfill this requirement, the Measure Applications Partnership (MAP) was formed to review measures consistent with this provision of the Act and renamed the Partnership for Quality Measurement (PQM) in CY 2023. The PQM provides input on the Measures under Consideration (MUC) list as part of the Pre-Rulemaking Measure Review (PRMR). We refer readers to https://p4qm.org/PRMR-MSR for more information on the PRMR process. Prior and in addition to the ACA and the formation of the PQM, CMS has utilized consensus processes consistent with the authorizing statute for selecting and adopting quality measures for the PCHQR Program.

CMS is additionally supported in this program’s efforts by the CDC, Health Resources and Services Administration, and the Agency for Healthcare Research and Quality. These organizations consult with CMS on an ongoing basis, providing technical assistance in developing and/or identifying quality measures, and assisting in making collected information accessible, understandable, and relevant to the public. CMS also regularly engages interested parties (e.g. solicitation of comments).

9. Payments/Gifts to Respondent

Section 1866(k) of the Act applies to hospitals described in section 1886(d)(1)(B)(v) of the Act and requires PCHs to report data in accordance with the requirements of the PCHQR Program for purposes of measuring and making publicly available information on the quality of care furnished by PCHs, however, there is no reduction in payment to a PCH that does not report data. No payments or gifts will be given to PCHs for participation.

10. Confidentiality

We pledge privacy to the extent provided by law. As a matter of policy, CMS will prevent the disclosure of personally identifiable information contained in the data submitted. All information collected under the PCHQR Program will be maintained in strict accordance with statutes and regulations governing confidentiality requirements for CMS data, including the Privacy Act of 1974 (5 U.S.C. 552a), the Health Insurance Portability and Accountability Act (HIPAA), and the Quality Improvement Organizations confidentiality requirements, which can be found at 42 C.F.R. Part 480. In addition, the tools used for transmission of data are considered confidential forms of communication, and there are safeguards in place in accordance with HIPAA Privacy and Security Rules to protect the submission of patient information, at 45 CFR Part 160 and 164, Subparts A, C, and E. Only PCH-specific data will be made publicly available as mandated by statute.

Data related to the PCHQR Program is housed in the HQR application group. CMS’ HQR is a General Support System (GSS) housing protected health information (PHI). Users who access CMS’ HQR system are identity-managed to permit access to the system and have role-based restrictions (including log-in and password) to the data they can see. The System of Records Notice (SORN) in use for the quality programs including the PCHQR Program is MBD 09-70-0536, as modified on February 14, 2018 (83 FR 6591).

11. Sensitive Questions

There are no questions of a sensitive nature associated with the forms. 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 case-specific data. Case-specific data will not be released to the public and are not releasable by requests under the Freedom of Information Act. Only PCH-specific data will be released to the public after PCHs have had an opportunity to review the data that are to be made public, as mandated by statute. 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)

1. Background

For the PCHQR Program, the burden associated with meeting program requirements includes the time and effort associated with completing administrative requirements and collecting and submitting data on the required measures for the 11 PCHs participating in the PCHQR Program.

In the FY 2025 IPPS/LTCH PPS final rule, we are not adopting any new measures, removing any existing measures, or changing existing reporting requirements that affect burden under OMB control number 0938-1175. We discuss the policies in the FY 2025 IPPS/LTCH PPS final rule that will not affect information collection in section B.1.a.

2. Burden for the FY 2027 Payment Determination

Our currently approved burden estimates are based on an assumption of 11 PCHs. For the purposes of burden estimation, we assume all activities associated with the PCHQR Program will be completed by Medical Records Specialists, with the exception of survey completion which will be completed by patients. These staff are qualified to complete the tasks associated with the submission of data to clinical registries and the completion of any of the other applicable forms associated with activities related to the PCHQR Program.

OMB has currently approved 35 hours at a cost of $895 for the FY 2026 program year and 109 hours at a cost of $2,452 for the FY 2027 program year under OMB control number 0938-1175, accounting for information collection burden experienced by 11 PCHs. As shown in Table 3, we estimate a baseline burden of 34 hours at a cost of $985 for the FY 2026 program year. We note the reduction in burden for the FY 2026 program year due to incorrectly estimating a burden of 2 hours for the Screening for Social Drivers of Health measure previously, instead of the correct burden of 1 hour.

We reiterate that our estimates exclude burden associated with the previously approved NHSN measures, which are submitted separately under OMB control number 0920-0666. These estimates also exclude the burden associated with the HCAHPS Survey which is submitted separately under OMB control number 0938-0981, as well as the burden associated with the COVID-19 HCP Vaccination measure, for which data are submitted under OMB control number 0920-1317. Finally, we do not include burden associated with claims-based measures as these measures are calculated using claims data submitted by the PCHs as part of their reimbursement process and are calculated by CMS without additional information collection, not by the PCHs.

Table 2. Currently Approved Burden Estimates for the PCHQR Program for the FY 2026 Program Year

Measure Set	Estimated time per record (minutes) - FY 2026 Program Year	Number reporting quarters per year - FY 2026 Program Year		Number of respondents		Average number records per PCH per quarter		Annual burden (hours) per PCH	Total Burden Hours for FY 2026 Program Year
PATIENT ENGAGEMENT/EXPERIENCE OF CARE MEASURES
Documentation of Goals of Care Measure	10	1		11		1		0.167	2
STRUCTURAL MEASURES
Hospital Commitment to Health Equity Measure	10	1			11	1		0.167	2
PROCESS MEASURES
Screening for Social Drivers of Health Measure (Survey)	0.033	1	828				1	205.1	28
Screening for Social Drivers of Health Measure (Reporting)	10	1	6				1	0.167	1
Screen Positive Rate for Social Drivers of Health Measure	10	1	6				1	0.167	1
Total Burden Hours									34
Total Burden for Surveys @ Average Individual Labor rate (28 hours x $24.04/hr)									$673
Total Burden @ Medical Records Specialist labor rate (7 hours x $52.12/hr)									$312
Total Burden									$985

3. Updated Hourly Wage Rate

While the most recent data from the BLS reflects a median hourly wage of $22.69 per hour for all medical records specialists, $26.06 is the mean hourly wage for “general medical and surgical hospitals,” which is an industry within medical records specialists (we note that BLS does not provide median occupation wage rates for individual industries).³ We believe the industry of “general medical and surgical hospitals” is more specific to our settings for use in our calculations than other industries that fall under medical records specialists, such as “office of physicians” or “nursing care facilities.” We calculate the cost of overhead, including fringe benefits, at 100 percent of the mean hourly wage, consistent with previous years. This is necessarily a rough adjustment, both because fringe benefits and overhead costs vary significantly by employer and methods of estimating these costs vary widely in the literature. Nonetheless, we believe that doubling the hourly wage rate ($26.06 × 2 = $52.12) to estimate total cost is a reasonably accurate estimation method. Accordingly, we calculate cost burden to hospitals using a wage plus benefits estimate of $52.12 per hour for the PCHQR Program.

4. Patient Engagement/Experience of Care Reporting and Submission Burden

For the Documentation of Goals of Care Discussions Among Cancer Patients measure, PCHs will report data through CMS’ HQR System on an annual basis during the submission period. We estimate a burden of no more than 10 minutes per PCH per year, as each PCH will only be required to report one aggregate numerator and denominator for all patients. Using the estimate of 10 minutes (or 0.167 hours) per PCH per year, we estimate a total annual burden for the FY 2027 program year and subsequent years of approximately 2 hours across all PCHs (0.167 hours × 11 PCHs) at a cost of $104 (2 hours × $52.12).

5. Process Measure Reporting and Submission Burden

For each of the two Health Equity measures (Screening for Social Drivers of Health and Screen Positive Rate for Social Drivers of Health), PCHs will report data through CMS’ HQR System on an annual basis during the submission period.

In the FY 2024 IPPS/LTCH PPS final rule, the Screening for Social Drivers of Health and Screen Positive Rate for Social Drivers of Health measures were adopted with voluntary reporting in the CY 2024 reporting period/FY 2026 program year followed by mandatory reporting on an annual basis beginning with the CY 2025 reporting period/FY 2027 program year. For the FY 2027 program year and subsequent years, we estimate a total burden for data submission of 4 hours (0.167 hours x 11 PCHs x 2 measures) at a cost of $208 (4 hours x $52.12).

For the Screening for Social Drivers of Health measure, PCHs are required to report on patient screening of five health-related social needs: food insecurity, housing instability, transportation problems, utility difficulties, and interpersonal safety. PCHs will be able to collect data and report the measure via multiple methods. We believe that most PCHs will likely collect data through a screening tool incorporated into their electronic health record (EHR) or other patient intake process. We estimate a burden of 2 minutes (0.033 hours) per patient to conduct this screening.

For patients completing the survey, we believe that the cost for beneficiaries undertaking administrative and other tasks on their own time is a ​​post-tax wage of $24.04/hr.  The Valuing Time in U.S. Department of Health and Human Services Regulatory Impact Analyses: Conceptual Framework and Best Practices identifies the approach for valuing time when individuals undertake activities on their own time.⁴  To derive the costs for patients, a measurement of the usual weekly earnings of wage and salary workers of $1,118, divided by 40 hours to calculate an hourly pre-tax wage rate of $27.95/hr.⁵  This rate is adjusted downwards by an estimate of the effective tax rate for median income households of about 14 percent calculated by comparing pre- and post-tax income,⁶ resulting in the post-tax hourly wage rate of $24.04/hr.  Unlike our State and private sector wage adjustments, we are not adjusting beneficiary wages for fringe benefits and other indirect costs since the individuals’ activities, if any, would occur outside the scope of their employment. 

Based on the most recent patient data from PCHs, approximately 275 patients will be screened annually in each PCH for this measure, for a total of 3,025 patients across all 11 PCHs. For the FY 2027 program year and subsequent years, we estimate a total annual burden for patient screening of 101 hours (3,025 respondents x 0.033 hours) at a cost of $2,428 (101 hours x $24.04) across all PCHs.

For the FY 2027 program year and subsequent years, we estimate an annual burden of 105 hours (4 hours + 101 hours) at a cost of $2,636 ($208 + $2,428) for both process measures.

6. Structural Measure Reporting and Submission Burden

For structural measures, PCHs will report data through CMS’ HQR System on an annual basis during the submission period. For the Hospital Commitment to Health Equity measure, using a burden estimate of 10 minutes (or 0.167 hours) per PCH per year, we estimate a total annual burden for data submission for the FY 2027 program year and subsequent years of approximately 2 hours across all PCHs (0.167 hours × 11 PCHs) at a cost of $104 (2 hours × $52.12) across all PCHs.

7. Claims-Based Measure Reporting and Submission Burden

Claims-based measures are derived through analysis of administrative claims data and do not require additional effort or burden on hospitals. As a result, the PCHQR Program’s claims-based measures (see Table 1) do not influence our burden calculations.

8. Survey Measure Reporting and Submission Burden

The information collection requirements associated with the HCAHPS survey-based measure are currently approved under OMB control number 0938-0981, which expires January 31, 2025.  As a result, the policy to require data collection for these measures does not influence our burden calculations under OMB control number 0938-1175.

9. Burden Estimate Summary

As shown in Table 3, in summary under OMB control number 0938-1175, we estimate a total burden of 109 hours at a cost of $2,844 across the 11 PCHs for data collection and submission for the FY 2027 program year. With the exception of updated wage rates, we are not revising our burden estimates associated with the policies in the FY 2025 IPPS/LTCH PPS final rule.

Table 3. Summary of Burden Estimates for the FY 2026 and FY 2027 Program Years

Information Collection	FY 2026 Program Year	Difference from Currently Approved	FY 2027 and Subsequent Program Years	Difference from Currently Approved
Patient Engagement/Experience of Care Measures	2	0	2	0
Process Measures	30	-1	105	0
Structural Measures	2	0	2	0
Claims-Based Measures	N/A	0	N/A	0
Survey-Based Measures	N/A	0	N/A	0
Total Burden Hour Estimate	34	-1	109	0
Total Burden Cost Estimate	$985	+$90	$2,844	+$392

13. Capital Costs (Maintenance of Capital Costs)

Regarding the Hospital Commitment to Health Equity and Patient Safety Structural measures, in order for PCHs to receive a point for each of the domains in the measure, PCHs are required to affirmatively attest to each of the statements within that domain. We estimate that a PCH that is unable to earn points for one or more domains may opt to incur additional costs associated with activities which could include updating hospital policies, protocols, or processes; engaging senior leadership, participating in new quality improvement activities; conducting required analyses; and training staff. The extent of these costs would vary from PCH to PCH depending on what policies the PCH already has in place, what activities the PCH is already performing, facility size, and the individual choices each PCH makes in order to meet the criteria necessary to attest affirmatively.

Regarding the Screening for Social Drivers of Health, for PCHs that are not currently administering some screening mechanism and elect to begin doing so as a result of this policy, there would be some non-recurring costs associated with changes in workflow and information systems to collect the data. The extent of these costs is difficult to quantify as different PCHs may utilize different modes of data collection (for example, paper-based, electronically patient-directed, clinician-facilitated, etc.). In addition, depending on the method of data collection utilized, the time required to complete the survey may add a negligible amount of time to patient visits.

14. Cost to Federal Government

The cost to the Federal Government for maintaining program activities is for supporting data system architecture, data storage, maintenance and updating of information technology infrastructure on the HQR system secure portal, providing ongoing technical assistance to hospital and data vendors, calculation of claims-based measures and validation, measure development and maintenance, the provision of hospitals with feedback and preview reports, as well as costs associated with public reporting. These costs are estimated at $10,050,000 annually for the validation and quality reporting contracts. Additionally, this program requires one CMS staff at a GS-13 Step 5 level to operate. GS-13 Step 5 approximate annual salary is $133,692 plus benefits (30%) of $40,108 for a total cost of $173,800. The total annual cost to the Federal Government is $10,223,800.

For most of 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 PCHs for claims-based measures.

15. Program or Burden Changes

We are updating the wage rate from Medical Reports Specialists from $44.86/hour to $52.12/hour based on more recent BLS wage data, as previously discussed. We are also updating the wage rate for beneficiaries from $20.71/hour to $24.04, as previously discussed. These updates result in a total increase in burden of $392 from our currently approved estimate of $2,452 for the FY 2027 program year. We estimate no other changes to information collection burden.

16. Publication/Tabulation Dates

The goal of the data collection is to tabulate and publish PCH-specific data. We will continue to display PCH quality information for public viewing as required by Social Security Act section 1866(k)(4) for the PCHQR Program. PCH data from this initiative is currently used to populate the Provider Data Catalog, available at: https://data.cms.gov/provider-data. Data are presented on the Provider Data Catalog in a format mainly aimed towards consumers, patients, and the general public, providing access to PCH-specific quality measure performance rates along with state and national performance rates. For certain quality measures, data are presented on the Provider Data Catalog in performance categories of Better, No Different, or Worse than the National Rate. More detailed measure data, including the data used for the Provider Data Catalog, are also available to the public as downloadable files at https://data.cms.gov/provider-data. PCH quality data on the Provider Data Catalog are currently updated on a quarterly and annual basis. One of the goals of the PCHQR 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.

17. Expiration Date

We will display the approved expiration date on each of the forms included as appendices to this PRA, which would become available on the QualityNet website (https://qualitynet.cms.gov). We will also display the approved expiration date prominently on the QualityNet website’s PCHQR 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.

2. Collection of Information Employing Statistical Methods

The use of statistical methods does not apply to this form.

1 Pub. L. 99-660.

2 The latest 2024 Impact Assessment Report, as well as earlier reports from 2012, 2015, 2018, and 2021 may be found at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/National-Impact-Assessment-of-the-Centers-for-Medicare-and-Medicaid-Services-CMS-Quality-Measures-Reports.

3 U.S. Bureau of Labor Statistics. Occupational Outlook Handbook, Medical Records Specialists. Accessed on February 13, 2024. Available at https://www.bls.gov/oes/current/oes292072.htm

4 https://aspe.hhs.gov/reports/valuing-time-us-department-health-human-services-regulatory-impact-analyses-conceptual-framework.

5 https://www.bls.gov/news.release/pdf/wkyeng.pdf. Accessed January 1, 2024.

6 https://www.census.gov/library/stories/2023/09/median-household-income.html. Accessed January 2, 2024.

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