CMS-10210 HIQR FY 2025 FR Supporting Statement B_clean

Supporting Statement - Part B

Submission of Information for the Hospital Inpatient Quality Reporting (IQR) Program

Collection of Information Employing Statistical Methods

1. Describe potential respondent universe.

All subsection (d) hospitals receiving reimbursement under the Inpatient Prospective Payment System (IPPS) in the United States (approximately 3,050 IPPS hospitals) and 1,500 non-IPPS hospitals participating in information collection on a voluntary basis constitute the potential respondent universe.

2. Describe procedures for collecting information.

Data are submitted via a secure web portal to the Hospital Quality Reporting (HQR) system. Data may be patient-level submitted directly to CMS or summary or aggregate data 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 IQR Program as a pay-for-reporting program strives to have a streamlined measure set that provides meaningful measurement that also serves to differentiate facilities by quality of care while limiting burden to the fullest extent possible. 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. To further incentivize hospitals, CMS also provides confidential feedback reports that hospitals may use to assess their performance and operationalize quality improvement activities throughout the quality reporting period. In addition, CMS removes barriers by providing data collection tools in order to make data submission easier (e.g., the automated collection of electronic patient data in electronic health records (EHRs) for electronic clinical quality measures (eCQMs) and hybrid measures, the free CMS Abstraction and Reporting Tool (CART) for use in collecting data from paper or electronic medical records for chart-abstracted measures, or the collection of data from federal registries like the NHSN), as well as to increase the utility of the data provided by the hospitals. Lastly, CMS has engaged a national support contractor to provide technical assistance with the data collection tool, other program requirements, and to provide education to support program participants.

4. Describe any tests of procedures or methods.

1. 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.

2. Validation Policy for Chart-Abstracted Data and eCQMs for the Hospital IQR Program

For the Hospital IQR Program, CMS performs a random selection of up to 200 subsection (d) hospitals and an additional 200 hospitals using targeting criteria on an annual basis for validation. To be eligible for targeted selection for validation, the hospital must be a subsection (d) hospital and meet one or more of the following targeting criteria:

• any hospital with abnormal or conflicting data patterns;

• any hospital with rapidly changing data patterns;

• any hospital that submits data to NHSN after the Hospital IQR Program data submission deadline has passed;

• any hospital that joined the Hospital IQR Program within the previous 3 years, and which has not been previously validated;

• any hospital that has not been randomly selected for validation in the past 3 years;

• any hospital that passed validation in the previous year, but had a two-tailed confidence interval that included 75 percent;

• any hospital with a two-tailed confidence interval that is less than 75 percent, and that had less than four quarters of data due to receiving an extraordinary circumstances exception for one or more quarters; or

• any hospital which failed to report to NHSN at least half of actual healthcare-associated infection events detected as determined during the previous year’s validation effort.

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 32 requested cases over 4 quarters of data affecting the FY 2027 payment determination and for subsequent years.  In the FY 2025 IPPS/LTCH PPS final rule, we are removing the requirement that hospitals must submit 100 percent of eCQM records to pass validation beginning with CY 2025 eCQM data affecting the FY 2028 payment determination.

Hospitals may request an educational review if they believe they have been scored incorrectly or if they have questions about their validation results for chart-abstracted measures or eCQMs. 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.

3. 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).

In the FY 2025 IPPS/LTCH PPS final rule, we are implementing eCQM validation scoring based on the accuracy of eCQM data beginning with CY 2025 eCQM data affecting the FY 2028 payment determination. Specifically, we are finalizing that eCQM validation scores will be determined using the same methodology that is currently used to score chart-abstracted measure validation.  Hospitals’ eCQM data will be used to compute an agreement rate and its associated confidence interval.  The upper bound of the two-tailed 90 percent confidence interval will be used as the final eCQM validation score for the selected hospital and a minimum score of 75 percent accuracy will be required for the hospital to pass the eCQM validation requirement.

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 and are posted by the corresponding hospital CMS Certification Number (CCN) on Care Compare or its successor website.¹ 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. Data are publicly reported on Care Compare or its successor website to help consumers make better informed decisions and to assist hospitals in their quality improvement initiatives by providing hospitals an opportunity to view how they are performing in comparison to other hospitals. CMS makes chart-abstracted patient-level data submitted by hospitals to the Hospital IQR Program publicly available on Care Compare or its successor website whether or not the data have been validated for payment purposes.

Our current policy 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

1 Quality measure data that does not reach a certain case minimum is not reported on Care Compare or its successor website.