CMS-10250.HOQR CY 2025 Supporting Statement Part A_final

Supporting Statement – Part A

Submission of Information for the Hospital Outpatient Quality Reporting (OQR) Program: CY 2025 OPPS/ASC Proposed Rule

(OMB# 0938-1109; CMS-10250)

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 the hospital outpatient setting, as authorized by statute, and seeks to achieve overarching priorities and initiatives promoting quality healthcare, as detailed in the National Quality Strategy¹ and the Meaningful Measures 2.0 Framework.² 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 calendar year (CY) 2029 payment determination are currently approved under OMB control number 0938-1109 (expiration date February 28, 2025). This request covers data collection requirements for the CY 2027 payment determination and subsequent years. This revised information collection request includes burden for the proposed adoption of the Hospital Commitment to Health Equity (HCHE) measure, the Screening for Social Drivers of Health (SDOH) measure, the Screen Positive Rate for SDOH measure, and the Patient Understanding of Key Information Related to Recovery After a Facility-Based Outpatient Procedure or Surgery Patient-Reported Outcomes-Based Performance Measure (PRO-PM).

B. Justification

1. Need and Legal Basis

The Hospital OQR Program was established under section 1833(t) of the Social Security Act (the Act). The Medicare Improvements and Extension Act of the Tax Relief and Health Care Act of 2006³ section 109(a) amended section 1833(t) of the Act by adding a new subsection (17) that affects the payment rate update applicable to Outpatient Prospective Payment System (OPPS) payments for services furnished by hospitals in outpatient settings on or after January 1, 2009.

Section 1833(t)(17)(A) of the Act, which applies to hospitals as defined under section 1886(d)(1)(B) of the Act, states that hospitals that fail to report data required for quality measures selected by the Secretary in the form and manner required by the Secretary under section 1833(t)(17)(B) of the Act will incur a reduction in their annual payment update (APU) factor to the Outpatient Department fee schedule of 2.0 percentage points.

Section 1833(t)(17)(C)(i) of the Act requires the Secretary to develop measures appropriate for the measurement of the quality of care (including medication errors) furnished by hospitals in outpatient settings, that these measures reflect consensus among affected parties and, to the extent feasible and practicable, that these measures include those set forth by one or more national consensus-building entities. Section 1833(t)(17)(C)(ii) of the Act allows the Secretary to select measures that are the same as (or a subset of) the measures for which data are required to be submitted under the Hospital Inpatient Quality Reporting (IQR) Program.

Section 1833(t)(17)(D) of the Act gives the Secretary the authority to replace measures or indicators as appropriate, such as where all hospitals are effectively in compliance, or the measures or indicators have been subsequently shown not to represent the best clinical practice. Section 1833(t)(17)(E) of the Act requires the Secretary to establish procedures for making data submitted under the program developed for hospital outpatient settings available to the public. Such procedures include providing facilities with the opportunity to review their data prior to public release.

Continued expansion and refinement of the quality measure set is consistent with the letter and spirit of the authorizing legislation to collect and make publicly available hospital-reported information on the quality-of-care delivered in the hospital outpatient setting.

1. Hospital OQR Program Quality Measures

Hospital OQR Program payment determinations are based on the reporting of data and submission of applicable forms by hospital outpatient departments (HOPDs) on measures derived from various data sources, including: patient medical records, electronic health records (EHRs) and health information technology (HIT) systems, Medicare fee-for-service (FFS) claims, beneficiary and enrollment data, web submission forms, and patient surveys, as well as data validation for selected HOPDs. In an effort to reduce burden, a variety of data collection mechanisms are employed, with every consideration taken to employ data and data collection systems already in place.

Measures for the Hospital OQR Program data are submitted via one of six modes: (1) chart-abstracted; (2) claims-based; (3) web-based; (4) digital; (5) survey-based; and (6) Patient-Reported Outcomes-Based Performance Measures (PRO-PM), as seen in Table 1.

For measure data submitted as “chart-abstracted,” information is derived through analysis of a patient’s medical record. Chart-abstracted data involves manual data entry effort and requires some burden from HOPDs.

For measure data submitted as “digital,” such as electronic clinical quality measures (eCQMs), information is electronically extracted from electronic health records (EHRs) and/or health information technology (HIT) systems. Because patient data are already entered into EHRs and HITs as part of clinical practice, only the time associated with electronically submitting data to CMS is accounted for in our burden estimates.

For “web-based” measures, measure data are submitted differently depending on the measure. The COVID–19 Vaccination Coverage Among Healthcare Personnel (HCP) measure is calculated using data submitted via the Centers for Disease Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN) under OMB control number 0920-1317 (expiration date March 31, 2026). 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).⁴ For any structural and process measures reported directly to CMS, HOPDs are required to submit measure data via CMS’ Hospital Quality Reporting (HQR) system.

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

For measure data submitted as “survey-based,” information is derived through analysis of responses to the Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) Survey and requires HOPDs to administer the survey and submit the survey data to CMS. These survey administration burdens are captured under OMB control number 0938-1240, which expires November 30, 2026.

The Hospital-Level Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) PRO-PM uses four sources of data for the calculation of the measure: (1) PRO data; (2) claims data; (3) Medicare enrollment and beneficiary data; and (4) U.S. Census Bureau survey data. We estimate no additional burden associated with claims data, Medicare enrollment and beneficiary data, and U.S. Census Bureau survey data as these data are already collected via other mechanisms. Once HOPDs collect the PRO data, it is submitted electronically via the CMS HQR system.

Table 1. Previously Finalized Hospital OQR Program Measures for the CY 2026 Payment Determination and Subsequent Years

Measure Data Submission Mode and Name	CBE No.
Chart-Abstracted Measures
Median Time for Discharged Emergency Department (ED) Patients (formally referred to as Median Time from ED Arrival to ED Departure for Discharged ED Patients)	N/A†
Head Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) Scan Results for Acute Ischemic Stroke or Hemorrhagic Stroke Patients Who Received Head CT or MRI Scan Interpretation Within 45 minutes of Emergency Department Arrival	0661
Claims-Based Measures
MRI Lumbar Spine for Low Back Pain	N/A†
Abdomen - Use of Contrast Material	N/A
Cardiac Imaging for Preoperative Risk Assessment for Non-Cardiac Low-Risk Surgery	N/A†
Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy	2539
Admissions and Emergency Department Visits for Patients Receiving Outpatient Chemotherapy	3490
Hospital Visits after Hospital Outpatient Surgery (formally referred to as Risk-Standardized Hospital Visits Within 7 Days After Hospital Outpatient Surgery)	2687
Breast Cancer Screening Recall Rates	N/A
Web-Based Measures
Patient Left Without Being Seen	N/A†
Colonoscopy Follow-Up Interval (formally referred to as Appropriate Follow-up Interval for Normal Colonoscopy in Average Risk Patients)	0658
Cataracts Visual Function (formally referred to as Cataracts - Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery)	N/A†
COVID-19 Vaccination Coverage Among HCP*	3636
eCQMs
ST-Segment Elevation Myocardial Infarction (STEMI)	N/A
Excessive Radiation eCQM (formally Excessive Radiation Dose or Inadequate Image Quality for Diagnostic CT in Adults)	3663e
Patient-Reported Outcomes-Based Performance Measures
Risk-Standardized PRO–PM Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) in the Hospital Outpatient Setting (THA/TKA PRO-PM)	N/A
Survey-Based Measures
OAS CAHPS Survey	N/A

†Measure is no longer endorsed by the Consensus Based Entity (CBE) but was endorsed previously.

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

2. Summary of Proposed Hospital OQR Program Changes

In the CY 2025 OPPS/ASC proposed rule, we proposed to adopt three web-based measures that would impact previously approved burden estimates: (1) the HCHE measure, beginning with the CY 2025 reporting period/CY 2027 payment determination; (2) the Screening for SDOH measure, beginning with voluntary reporting for the CY 2025 reporting period followed by mandatory reporting beginning with the CY 2026 reporting period/CY 2028 payment determination; (3) the Screen Positive Rate for SDOH measure, beginning with voluntary reporting for the CY 2025 reporting period and mandatory reporting beginning with the CY 2026 reporting period/CY 2028 payment determination. We also proposed to adopt the Patient Understanding of Key Information Related to Recovery After a Facility-Based Outpatient Procedure or Surgery Patient Reported Outcome-Based Performance Measure (Information Transfer PRO-PM), beginning with voluntary reporting for the CY 2026 reporting period and mandatory reporting beginning with the CY 2027 reporting period/CY 2029 payment determination.

We also proposed changes to the Hospital OQR Program that would not impact previously approved burden estimates. We proposed to remove two claims-based measures beginning with the CY 2025 reporting period/CY 2027 payment determination: (1) MRI Lumbar Spine for Low Back Pain measure; and (2) Cardiac Imaging for Preoperative Risk Assessment for Non-Cardiac, Low-Risk Surgery measure. Because these measures are calculated using Medicare FFS claims that are already reported to the Medicare program for payment purposes, removing these measures would not result in a change in burden. We further proposed to modify the public reporting of data for the Median Time from ED Arrival to ED Departure for Discharged ED Patients (Median Time for Discharged ED Patients) measure – Psychiatric/Mental Health Patients stratification so that it may be published on Care Compare in addition to the data.cms.gov downloadable files beginning in CY 2025. Because we are not proposing to require HOPDs to collect or submit any additional data for purposes of this public reporting, this proposal would not result in a change in burden. Lastly, we proposed to require EHR technology to be certified to all eCQMs available to report beginning with the CY 2025 reporting period/CY 2027 payment determination. We do not expect HOPDs would experience an increase in information collection burden associated with this proposal because the use of EHR technology that is certified to all available eCQMs is already required for the Promoting Interoperability Program (83 FR 41672) and the Hospital IQR Program (84 FR 42604).

3. Hospital OQR Program Administrative Forms

CMS has implemented procedural requirements that align the hospital and ASC quality reporting programs, which involve submission of certain forms to comply with program requirements. As a result, many of the forms are used for multiple programs but are included under OMB control number 0938-1022 to reduce administrative burden and the potential for errors when updates are necessary.

The Hospital OQR Program uses five administrative forms: (1) Extraordinary Circumstances Exception (ECE) Request; (2) Reconsideration Request; (3) Validation Review; (4) Withdrawal of Participation Form; and (5) Request Form for Withholding/Footnoting Data From Public Reporting. None of these forms are completed on an annual basis; all are on a need-to-use, exception basis and most HOPDs will not need to complete any of these forms in any given year. Thus, the burden for providers associated with forms utilized in the Hospital OQR Program is nominal, if any.

1. ECE Request Form

CMS offers a process for HOPDs to request an exception to the reporting of required quality data and data validation when an HOPD experiences an extraordinary circumstance not within the control of the HOPD, such as a natural disaster. 

2. Reconsideration Request Form

When CMS determines that an HOPD has not met program requirements and would receive a 2.0 percentage point reduction in their APU, HOPDs may submit a Reconsideration Request to CMS no later than the first business day⁵ on or after March 17 of the affected payment year. CMS provides this form online and facilities may submit the form online or by fax.

3. Validation Review Form

CMS performs a random and targeted selection of HOPDs reporting under the Hospital OQR Program on an annual basis. The selection includes up to 500 HOPDs — up to 450 randomly selected HOPDs and up to 50 targeted HOPDs. In the event that CMS determines an HOPD did not meet the Hospital OQR Program validation requirement due to a confidence interval validation score of less than 75 percent, the HOPD may complete and submit the Validation Review Form online.

(4) Withdrawal of Participation Form

Once an HOPD submits quality measure data (e.g., using the web-based data collection tool), and the submission is accepted, it will continue to be considered a participant of the Hospital OQR Program, regardless of whether it continues to submit quality measure data, until it formally withdraws from the program. To withdraw from the program after submitting quality measure data, an HOPD must complete and submit an online withdrawal form by August 31^st for the applicable CY.

5. Request Form for Withholding/Footnoting Data From Public Reporting

Hospitals that voluntarily participate in quality reporting but are not paid under the IPPS may elect to have those data withheld from public reporting by completing the Request Form for Withholding/Footnoting Data from Public Reporting.  Once the form is submitted, data can be withheld for the quarter in which the form is submitted.  However, the data will be released on the Compare tool hosted by HHS or its successor website(s) for subsequent releases unless the hospital submits a new Request Form for Withholding/Footnoting Data from Public Reporting indicating the measure(s) the hospital would like to withhold from public reporting for the period.

2. Information Users

The Hospital OQR Program, as a pay-for-reporting program, strives to have a streamlined measure set that serves to meaningfully differentiate facilities by quality of care while limiting burden to the fullest extent possible. CMS provides confidential feedback reports that HOPDs may use to assess their performance and operationalize quality improvement activities throughout the quality reporting period. These reports include data that CMS has collected from the HOPD and the HOPD’s claims, as well as information about how the HOPD’s data compare to the performance of other HOPDs. For example, the Facility, State and National (FSN) Report allows hospitals to compare their performance on a specific measure during a specific timeframe to the average performance of other HOPDs at the state and national levels.

Additionally, Quality Improvement Organizations (QIOs) use Hospital OQR Program data to improve quality of care through education, outreach, and sharing best practices.  Furthermore, data collected for the Median Time for Discharge ED Patients and Patient Left Without Being Seen measures are included in the Medicare Beneficiary Quality Improvement Project (MBQIP), a quality improvement activity under the Medicare Rural Hospital Flexibility (Flex) grant program of the Health Resources and Services Administration’s (HRSA) Federal Office of Rural Health Policy (FORHP). The goal of MBQIP is to improve the quality of care provided in critical access hospitals (CAHs) by increasing quality data reporting by CAHs and then driving quality improvement activities based on the data. The MBQIP provides an opportunity for individual hospitals to look at their own data, measure their outcomes against other CAHs, and partner with other HOPDs in the state around quality improvement initiatives to improve outcomes and provide the highest quality care to every one of their patients.⁶

This information is also available to Medicare beneficiaries, as well as to the general public, by providing hospital information on the Compare tool hosted by HHS, available at: https://www.medicare.gov/care-compare/, or its successor website(s) and on data.cms.gov to assist them in making decisions about their healthcare. CMS sometimes conducts focus groups or market testing prior to publicly reporting hospital quality data on the Compare tool hosted by HHS or its successor website(s) to get feedback on ways to make the website more user-friendly. Feedback from these focus groups has helped CMS understand how beneficiaries and consumers use the Compare tool hosted by HHS or its successor website(s). Under emergency circumstances, consumers choose hospitals based on proximity, reputation, prior experience, or their doctor’s recommendation. For childbirth or elective hospital admissions, when patients and their family members may have the time and motivation to consider options and engage in informed decision making, they have expressed interest in information such as the provider’s track record in treating their condition, safety and infection rates, and a hospital’s recognized areas of expertise, as well as to take into consideration their doctor’s recommendation.

Under section 1890A(a)(6) of the Social Security Act, 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 OQR Program and other CMS quality programs, CMS’ findings were formally written into the latest triennial National Impact Assessment Report, which was released in 2024.⁷

3. Use of Information Technology

To assist HOPDs 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 eCQMs, 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), and to increase the utility of the data provided by the HOPDs. CMS also provides a secure data warehouse via the HQR system for storage and transmittal of data as well as data validation and aggregation services prior to the release of data to the CMS website. HOPDs have the option of using authorized vendors to transmit the data. 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.

As reflected by the collection and reporting of claims-based quality measures, quality measures collected via the HQR system, and measures which are digitally-derived (e.g. eCQMs), 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 are organized by the type of data collected and data collection mechanism in Table 1.

For the claims-based measures or measures which collect data from claims and other administrative data in part, this section is not applicable, because these measures can be or partially 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 to collect these data 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 hospital outpatient care. CMS requires HOPDs to submit quality measure data for services provided in the outpatient setting. We prioritize efforts to reduce reporting burden for the collection of quality-of-care information by utilizing electronic data that HOPDs already collect for reporting to The Joint Commission for accreditation.

5. Small Business

Information collection requirements are designed to allow maximum flexibility, specifically to small HOPDs participating in the Hospital OQR Program. We define a “small HOPD” as one with 1-99 beds. The Hospital OQR Program included approximately 1,533 participating small HOPDs for the CY 2025 payment determination.

The HRSA’s Medicare Rural Hospital Flexibility Program (Flex) and MBQIP, as well as CMS’ QIOs, provide technical assistance to small hospitals to reduce burden and improve healthcare quality. CMS also provides a help-desk hotline for troubleshooting purposes and 24/7 free information available on the QualityNet website through a Questions and Answers function. These activities will assist small HOPDs in gathering information for their own quality improvement efforts and for meeting Hospital OQR Program information collection requirements.

6. Less Frequent Collection

CMS has designed the collection of quality-of-care data to be the minimum necessary for data validation and calculation of summary figures to be reliable estimates of HOPD performance. Under the Hospital OQR Program, HOPDs are required to submit CMS web-, PRO-PM, claims-and digital-based measure data on an annual basis relevant to their reporting period to make payment determinations. Frequency of data collection may vary (monthly, quarterly, annually, etc.) based on how a quality measure is specified. The following table (Table 2) details the frequency of data submission to CMS by measure type for the Hospital OQR Program.

Table 2. Frequency of Data Submission Under the Hospital OQR Program by Measure Type

Measure Type	Frequency of Data Submission
Chart-abstracted	Quarterly
Web-based	Annually
Survey-based	Quarterly
eCQMs	Annually
NHSN	Quarterly*
THA/TKA PRO-PM	Annually
Information Transfer PRO-PM**	Annually

*One of the two NHSN this web-based measure type measures is collected by the CDC and is submitted for at least one self-selected week during each month of the reporting quarter, but is aggregated quarterly for applicable CMS quality reporting programs.

**Measure is proposed in the CY 2025 OPPS/ASC proposed rule.

Claims-based measures are calculated from Medicare FFS claims data and MA encounter data; HOPDs submit claims for reimbursement or payment per claims processing timeliness requirements. 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

A 60-day Federal Register notice for this data collection was published on July 22, 2024

(89 FR 59437).

Measures adopted for the Hospital OQR Program are required by statute to undergo a recognized consensus process. Section 1890A of the Act requires CMS to consider input on the selection of quality and efficiency measures from a multi-stakeholder group convened by the “consensus-based entity.” To fulfill this requirement, the Partnership for Quality Measurement 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/About for more information on the PRMR process.

CMS is additionally supported in this program’s efforts by The Joint Commission, CDC, HRSA, 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

HOPDs are required to submit these data in order to receive the full APU. No other payments or gifts will be given to HOPDs 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 Hospital OQR 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 HOPD-specific data will be made publicly available as mandated by statute.

Data related to the Hospital OQR 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 Hospital OQR 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 these 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 hospital-specific data will be released to the public after hospitals have had an opportunity to review the data that are to be made public with respect to the hospital, 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

In the CY 2025 OPPS/ASC proposed rule, we proposed to adopt three web-based measures that would impact previously approved burden estimates: (1) the HCHE measure, beginning with the CY 2025 reporting period/CY 2027 payment determination; (2) the Screening for SDOH measure, beginning with voluntary reporting for the CY 2025 reporting period followed by mandatory reporting beginning with the CY 2026 reporting period/CY 2028 payment determination; and (3) the Screen Positive Rate for SDOH measure, beginning with voluntary reporting for the CY 2025 reporting period and mandatory reporting beginning with the CY 2026 reporting period/CY 2028 payment determination. We also proposed to adopt one patient reported outcome-based performance measure that would impact previously approved burden estimates: (1) the Patient Understanding of Key Information Related to Recovery After a Facility-Based Outpatient Procedure or Surgery, Patient Reported Outcome-Based Performance Measure (Information Transfer PRO-PM), beginning with voluntary reporting for the CY 2026 reporting period and mandatory reporting beginning with the CY 2027 reporting period/CY 2029 payment determination.

We discuss other program updates proposed in the CY 2025 OPPS/ASC proposed rule which would not affect information collection burden under OMB control number 0938-1109 in section B.1.a.

2. Burden for the CY 2026 Payment Determination

Our currently approved burden estimates were based on an assumption that approximately 3,350 HOPDs would report data to the Hospital OQR Program. Based on the most recent available data from the CY 2024 Hospital OQR Program payment determination, we estimate that 3,200 HOPDs will report data to the Hospital OQR Program for the CY 2026 payment determination. For the purposes of burden estimation, we assume all activities associated with the Hospital OQR 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 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 Hospital OQR Program.

OMB has currently approved 262,537 hours at a cost of approximately $13.7 million under OMB control number 0938-1109, accounting for information collection burden experienced by approximately 3,350 HOPDs for the CY 2026 payment determination. As shown in Table 3, using our updated assumption of 3,200 HOPDs and updated wage rates, we estimate a revised baseline burden of 251,050 hours at a cost of $13,903,149 for the CY 2026 payment determination. As previously stated, our burden estimates exclude burden associated with the COVID-19 Vaccination Coverage Among HCP measure under OMB control number 0920-1317 (expiration date March 31, 2026), the OAS CAHPS Survey measure under OMB control number 0938-1240 (expiration date November 30, 2026), and claims-based quality measures, which do not require additional effort or burden from HOPDs. We also note that any burden related to claims more generally is accounted for under the Health Insurance Common Claims Form and Supporting Regulations under OMB control number 0938-1197 (expiration date December 31, 2024).

Table 3. Currently Approved Burden Estimates for the Hospital OQR Program Measure Set and Other Activities for the CY 2026 Payment Determination

Measure Set	Estimated time per record (minutes) - CY 2026 payment determination	Number reporting quarters per year - CY 2026 payment determination	Number of respondents		Average number records per HOPD per quarter	Annual burden (hours) per HOPD	Total Burden Hours for CY 2026 payment determination
Administrative Activities	2,520	1	3,200		1	42	134,400
Chart-Abstracted Measures
Median Time for Discharged ED Patients	2.9	1	3,200		289	14.2	45,440
Head CT or MRI Scan Results for Acute Ischemic Stroke or Hemorrhagic Stroke Patients Who Received Head CT or MRI Scan Interpretation Within 45 minutes of Emergency Department Arrival	2.9	1	3,200		289	14.2	45,440
Chart-Abstracted Measure Subtotal							90,880
Web-Based Measures
Patient Left Without Being Seen	10	1	3,200		1	0.167	533
Colonoscopy Follow-Up Interval (Reporting)	10	1	3,200		1	0.167	533
Colonoscopy Follow-Up Interval (Chart Abstraction)	2.9	1	3,200		96	4.7	15,053
Cataracts Visual Function (Reporting)	10	1	640		1	0.167	107
Cataracts Visual Function (Chart Abstraction)	2.9	1	640		96		3,011
Web-Based Measures Subtotal							19,237
eCQM Measures
STEMI	10	1		3,200	1	0.167	533
Excessive Radiation*	10	0		0	0	0	0
eCQM Measures Subtotal							533
PRO-PM
THA/TKA (Patient Survey)*	7.25	0		0	0	0	0
THA/TKA (Reporting)*	10	0		0	0	0	0
PRO-PM Subtotal							0
Validation	15	1		500	48	12	6,000
Total Burden Hours							251,050
Total Burden @ Medical Records Specialist labor rate ($55.38/hr)							$13,903,149

*These measures do not begin voluntary reporting until the CY 2025 reporting period.

Changes to currently approved burden estimates due to proposals in the CY 2025 OPPS/ASC proposed rule are discussed below.

3. Updated Hourly Wage Rate

The most recent data from the Bureau of Labor Statistics May 2023 National Occupational Employment and Wage Estimates reflects a mean hourly wage of $27.69 per hour for medical records specialists working in “general medical and surgical hospitals”⁸ We calculated the cost of overhead, including fringe benefits, at 100 percent of the mean hourly wage, consistent with previous years. This is 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 to estimate the total cost is a reasonably accurate estimation method and allows for a conservative estimate of hourly costs. Accordingly, unless otherwise specified, we will calculate cost burden to hospitals using a wage plus benefits estimate of $55.38 per hour throughout the discussion in this section of this rule for the Hospital OQR Program.

4. Administrative Burden

Administrative burden involves the time and effort associated with completing program and system requirements and managing facility operations (78 FR 75171), and includes duties such as ensuring staffing, identifying and maintaining an active HQR system Security Administrator/Official, and filling out forms and other paperwork.

As previously noted in Section B(3), the Hospital OQR Program utilizes four forms in its administrative activities: (1) Extraordinary Circumstances Exception (ECE) Request; (2) Reconsideration Request; (3) Validation Review; and (4) Withdrawal from Participation. None of these forms are completed on an annual basis; all are on a need-to-use, exception basis and most HOPDs will not need to complete any of these forms in any given year. Thus, the burden associated with forms utilized in the Hospital OQR Program is nominal, if any.

The burden associated with submitting an ECE Request is accounted for in OMB control number 0938-1022 (expiration date January 31, 2026) and is therefore excluded from this burden estimate. Moreover, consistent with regulations under the Paperwork Reduction Act of 1995, 5 C.F.R. § 1320.4, the burden associated with filing a Reconsideration Request, Validation Review, or a Withdrawal from Participation Form is excluded from this package because this collection occurs during the conduct of an administrative action.

In the CY 2025 OPPS/ASC proposed rule, we did not propose any changes to the administrative burden for the CY 2027 payment determination. Thus, our estimates for administrative burden remain the same as those previously approved under this OMB control number. Specifically, we previously estimated, in the CY 2014 OPPS/ASC final rule with comment period (78 FR 75171), that the burden associated with completing administrative requirements is 42 hours per HOPD. Therefore, for all program-eligible HOPDs, we estimate a total annual administrative burden of 134,400 hours (42 hours per HOPD x 3,200 HOPDs) at a cost of $7,443,072 (134,400 hours x $55.38 per hour).

5. Chart-Abstraction Burden

For the CY 2025 reporting period/CY 2027 payment determination, the chart-abstracted measure set for the Hospital OQR Program is comprised of the Median Time for Discharged ED Patients and the Head CT or MRI Scan Results for Acute Ischemic Stroke or Hemorrhagic Stroke Patients Who Received Head CT or MRI Scan Interpretation Within 45 minutes of ED Arrival measures.

For chart-abstracted measures where patient-level data are submitted directly to CMS, we previously estimated it would take 2.9 minutes, or 0.049 hours per case per measure to collect and submit the data for each submitted case (80 FR 70582). Additionally, we estimate that an average of 289 cases are reported per HOPD for chart-abstracted measures. We therefore estimate that it will take approximately 14.2 hours (0.049 hours x 289 cases) at a cost of approximately $786 per HOPD (14.2 hours x $55.38/hour) to collect and report data for each chart-abstracted measure. Therefore, for all participating HOPDs, we estimate an annual chart-abstraction burden of 45,440 hours (14.2 hours per HOPD x 3,200 HOPDs) at a cost of $2,516,467 per measure (45,440 hours x $55.38/hour). For the CY 2027 payment determination and subsequent years, the total annual burden for all HOPDs to submit both measures are estimated to be 90,880 hours (45,440 hours/measure x 2 measures) at a cost $5,032,934 (90,880 hours x $55.38/hour).

5. Web-Based Measures Burden

There are four web-based measures in the Hospital OQR Program for the CY 2025 reporting period/CY 2027 payment determination and subsequent years: Patient Left Without Being Seen, Colonoscopy Follow-Up Interval, Cataracts Visual Function, and COVID-19 Vaccination Coverage Among HCP. The Cataracts Visual Function measure is voluntary; we estimate that approximately 20 percent of hospitals will report on this measure.

We previously estimated in the CY 2016 OPPS/ASC final rule with comment period (80 FR 70582), that HOPDs spend approximately 10 minutes, or 0.167 hours, per measure to report web-based measures. For the CY 2027 payment determination and subsequent years, we estimate a web-based burden of 1,173 hours [(0.167 hours/HOPD x 3,200 HOPDs x 2 measures) + (0.167 hours/hospital x 3,200 hospitals x 20 percent x 1 measure)] at a cost of $64,961 (1,173 hours x $55.38/hour) for all three CMS measures. The COVID-19 Vaccination Coverage Among HCP measure, collected by CDC, is not covered here, as noted previously.

There are two web-based measures in the Hospital OQR Program measure set that also require chart-abstraction: (1) Colonoscopy Follow-Up Interval, and (2) Cataracts Visual Function. We previously estimated that chart abstraction for a web-based measure requires 2.9 minutes, or 0.049 hours, per case per measure as finalized in the CY 2016 OPPS/ASC final rule (80 FR 70582). Based on the current Hospital OQR Program Specifications Manual, the sample size requirement for HOPDs with populations of 900 patients or less is 63 cases annually and the requirements for HOPDs with populations of greater than 900 patients is 96 cases annually.⁹ To be conservative, we base our burden estimates on an estimate of 96 cases per HOPD annually. For the CY 2027 payment determination and subsequent years, we estimate a chart-abstraction burden of 18,063 hours [(0.049 hours/case x 96 cases/measure x 3,200 HOPDs x 1 measure) + (0.049 hours/case x 96 cases/measure x 3,200 HOPDs x 20 percent x 1 measure)] at a cost of $1,000,329 (18,063 hours x $55.38/hour) for both measures.

In the CY 2025 OPPS/ASC proposed rule, we proposed to adopt the HCHE measure beginning with the CY 2025 reporting period/CY 2027 payment determination. For this measure, HOPDs would be required to report on attestations of “yes” or “no” to a set of five domains related to organizational efforts towards health equity once annually using a CMS-designated information system. We estimate the reporting burden associated with this measure to be, on average across all 3,200 HOPDs, no more than 10 minutes per HOPD per year, as we believe the burden for HOPDs to report this measure would be very similar to the burden for hospital inpatient departments to report the same measure once annually under the Hospital IQR Program as approved under OMB control number 0938-1022 (expiration date January 31, 2026). Using an estimate of 10 minutes (or 0.167 hours) per HOPD per year, we estimate a total annual burden increase of 533 hours (0.167 hours × 3,200 HOPDs) at a cost of $29,518 (533 hours × $55.38/hour) across program-eligible HOPDs.

In the CY 2025 OPPS/ASC proposed rule, we propose to adopt the Screening for SDOH measure beginning with voluntary reporting for the CY 2025 reporting period followed by mandatory reporting beginning with the CY 2026 reporting period/CY 2028 payment determination. For this measure, HOPDs would be required to report whether they screened patients for five health-related social needs (HRSN).

HOPDs would be able to collect data for the measure using a self-selected screening tool. We expect that most HOPDs would likely collect data through a screening tool incorporated into their EHR or other patient intake process. We estimate the information collection burden related to conducting patient screening associated with this measure to be 2 minutes (0.033 hours) per patient. This is based on the currently approved burden estimate for the Hospital IQR Program under OMB control number 0938-1022 (expiration date January 31, 2026) for the same measure with patient screening for the same HRSN domains and the same frequency of data reporting.

To provide an estimate of patient volume for the purposes of calculating the information collection burden associated with this measure, we utilized data derived from the American Hospital Association which estimates 2,399 outpatient visits per 1,000 population in CY 2022¹⁰ and multiplied this by the estimated total U.S. population in CY 2022¹¹ to estimate the total number of outpatient visits across all U.S. community hospitals. Then, in order to derive an estimate for only the 3,200 program-eligible HOPDs in the Hospital OQR Program, we multiplied the total number of outpatient visits by a ratio of program-eligible HOPDs to all U.S. community hospitals. Therefore, we estimate that each year 498,843,518 patients ((2,399 outpatient visits per 1,000 population in CY 2022 × 333,287,557 total U.S population in 2022) × (3,200 HOPDs ÷ 5,129 U.S community hospitals¹²)) would be screened when reporting on the measure becomes mandatory. As submission rates among facilities may vary, we conservatively estimate that for voluntary reporting for the CY 2025 reporting period, 50 percent of HOPDs would survey 50 percent of patients, and beginning with the first mandatory reporting period, 100 percent of HOPDs would survey 100 percent of patients.

We determine the cost for patients (or their representative) undertaking administrative and other tasks, such as filling out a survey or intake form, using a post-tax wage of $24.49/hr based on the report “Valuing Time in U.S. Department of Health and Human Services Regulatory Impact Analyses: Conceptual Framework and Best Practices,” which identifies the approach for valuing time when individuals undertake activities on their own time.¹³ To derive the costs for patients (or their representatives), a measurement of the usual weekly earnings of wage and salary workers of $1,139 is divided by 40 hours to calculate an hourly pre-tax wage rate of $28.48/hr.¹⁴ 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,¹⁵ resulting in the post-tax hourly wage rate of $24.49/hr. Unlike our state and private sector wage adjustments, we are not adjusting patient wages for fringe benefits and other indirect costs since the individuals’ activities, if any, would occur outside the scope of their employment.

For the CY 2025 voluntary reporting period, we estimate a total burden increase for patients of 4,115,459 hours (498,843,518 patients × 50 percent response rate × 50 percent of HOPDs × 0.033 hours per patient) at a cost of $100,787,591 (4,115,459 hours × $24.49/hour). Beginning with the CY 2026 mandatory reporting period, we estimate an annual total burden increase for patients of 16,461,836 hours (498,843,518 patients × 0.033 hours per patient) at a cost of $403,150,364 (16,461,836 hours × $24.49/hour).

Also in the CY 2025 OPPS/ASC proposed rule, we proposed to adopt the Screen Positive Rate for SDOH measure beginning with voluntary reporting for the CY 2025 reporting period followed by mandatory reporting beginning with the CY 2026 reporting period/CY 2028 payment determination. If a hospital participates in both the Hospital OQR and Hospital IQR Programs, the hospital would need to submit data on this measure separately under each program. As such, we are estimating the burden separately under each program.

For this measure, HOPDs would be required to report on the number of patients who screened positive for one or more of the five domains (reported as five separate rates to reflect each of the five HRSN domains) divided by the total number of patients screened. We include the collection burden associated with screening patients in our discussion of the Screening for SDOH measure. Thus, for the Screen Positive Rate for SDOH measure, we estimate only the additional burden for HOPD reporting via the HQR system since patients would not need to provide, and HOPDs would not need to collect, any additional information for this measure. We continue to estimate that, for voluntary reporting for the CY 2025 reporting period, 50 percent of HOPDs would submit data, and beginning with the first mandatory reporting period, 100 percent of HOPDs would submit data.

For both the Screening for SDOH and Screen Positive Rate for SDOH measures, measure data will be aggregated to the HOPD level as a numerator and a denominator and would be submitted via the HQR system annually. Similar to the currently approved burden estimate for other web-based measures, as well as the same measure with the same frequency of data reporting for the Hospital IQR Program under OMB control number 0938-1022, we estimate a burden of 10 minutes (0.167 hours) per measure per HOPD to report the measure data. With regard to reporting for the CY 2025 voluntary reporting period, we estimate a total collection and reporting burden increase for program-eligible HOPDs of 267 hours (3,200 HOPDs × 50 percent of HOPDs × 0.167 hours per HOPD) at a cost of $14,786 (267 hours × $55.38/hour) for each measure. Beginning with the CY 2026 mandatory reporting period, we estimate a total collection and reporting burden increase for program-eligible HOPDs of 533 hours (3,200 HOPDs × 0.167 hours per HOPD) at a cost of $29,518 (533 hours × $55.38/hour) for each measure.

Table 4. Estimated Burden for the Web-Based Measure Reporting and Submission Requirements for the CY 2027 through CY 2028 Payment Determination Years

Web-Based Measure Reporting		Estimated time per record (minutes)	Number reporting quarters per year	Number of Respondents	Average number records per Respondent per quarter	Annual burden (hours) per Respondent	Total Annual hours for all Respondents
CY 2027 Payment Determination
Patient Left Without Being Seen		10	1	3,200	1	0.167	533
Colonoscopy Follow-Up Interval (Reporting)		10	1	3,200	1	0.167	533
Colonoscopy Follow-Up Interval (Chart Abstraction)		2.9	1	3,200	96	4.7	15,053
Cataracts Visual Function (Voluntary Reporting)		10	1	640	1	0.167	107
Cataracts Visual Function (Voluntary Chart Abstraction)		2.9	1	640	96	4.7	3,010
Hospital Commitment to Health Equity		10	1	3,200	1	0.167	533
Screening for SDOH (Voluntary Patient Surveys)		2	1	124,710,880	1	0.033	4,115,459
Screening for SDOH (Voluntary Reporting)		10	1	1,600	1	0.167	267
Screen Positive Rate for SDOH (Voluntary Reporting)		10	1	1,600	1	0.167	267
Total Burden Hours							4,135,762
Total Burden @ Individual labor rate ($24.49/hr)							$100,787,591
Total Burden @ Medical Records Specialist labor rate ($55.38/hr)							$1,124,380
CY 2028 Payment Determination
Patient Left Without Being Seen	10		1	3,200	1	0.167	533
Colonoscopy Follow-Up Interval (Reporting)	10		1	3,200	1	0.167	533
Colonoscopy Follow-Up Interval (Chart Abstraction)	2.9		1	3,200	96	4.7	15,053
Cataracts Visual Function (Voluntary Reporting)	10		1	640	1	0.167	107
Cataracts Visual Function (Voluntary Chart Abstraction)	2.9		1	640	96	4.7	3,010
Hospital Commitment to Health Equity	10		1	3,200	1	0.167	533
Screening for SDOH (Mandatory Patient Surveys)	2		1	498,843,518	1	0.033	16,461,836
Screening for SDOH (Mandatory Reporting)	10		1	3,200	1	0.167	533
Screen Positive Rate for SDOH (Mandatory Reporting)	10		1	3,200	1	0.167	533
Total Burden Hours							16,482,672
Total Burden @ Individual labor rate ($24.49/hr)							$403,150,364
Total Burden @ Medical Records Specialist labor rate ($55.38/hr)							$1,153,844

5. Claims-Based Measures Burden

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

5. Survey Measures Burden

The information collection requirements associated with the OAS CAHPS survey-based measure is currently approved under OMB control number 0938-1240, which expires November 30, 2026.  As a result, the policy to require data collection for the measure does not influence our burden calculations under OMB control number 0938-1109.

5. eCQM Measures Burden

There are two eCQMs in the Hospital OQR Program for the CY 2025 reporting period/CY 2027 payment determination and subsequent years: the STEMI eCQM and the Excessive Radiation Dose or Inadequate Image Quality for Diagnostic CT in Adults eCQM.

For the CY 2025 reporting period/CY 2027 payment determination, HOPDs are required to report the STEMI eCQM for two self-selected quarters, followed by three self-selected quarters for the CY 2026 reporting period/CY 2028 payment determination, and four quarters for the CY 2027 reporting period/CY 2029 payment determination and for subsequent years. Based on experience with reporting of eCQMs in the Hospital IQR Program, we are aligning our estimate of the time required for a Medical Records Specialist to submit the data required for the measure to be 10 minutes (0.167 hours) per quarter for each HOPD.  For the CY 2025 reporting period/CY 2027 payment determination, we estimate the annual burden for all HOPDs to be 1,067 hours (3,200 HOPDs x 0.167 hours x 2 quarters) at a cost of $59,090 (1,067 hours x $55.38/hour). For the CY 2026 reporting period/CY 2028 payment determination, we estimate the annual burden for all HOPDs to be 1,600 hours (3,200 HOPDs x 0.167 hours x 3 quarters) at a cost of $88,608 (1,600 hours x $55.38/hour). For the CY 2027 reporting period/CY 2029 payment determination and subsequent years, we estimate the annual burden for all HOPDs to be 2,133 hours (3,200 HOPDs x 0.167 hours x 4 quarters) at a cost of $118,126 (2,133 hours x $55.38/hour).

In the CY 2024 OPPS/ASC final rule, we finalized adopting the Excessive Radiation Dose or Inadequate Image Quality for Diagnostic CT in Adults eCQM, beginning with the voluntary CY 2025 reporting period, followed by mandatory reporting beginning with the CY 2027 reporting period/CY 2029 payment determination. For the CY 2025 and CY 2026 voluntary reporting periods, HOPDs will be able to voluntarily report the measure for one or more quarters during the year. For subsequent years, we finalized to gradually increase the number of quarters of data HOPDs will be required to report on the measure starting with two self-selected quarters for the CY 2027 reporting period/CY 2029 payment determination, and all four quarters for the CY 2028 reporting period/CY 2030 payment determination. For the voluntary reporting periods in CY 2025 and CY 2026, we estimate 20 percent of HOPDs will voluntarily report at least one quarter of data for the measure with 100 percent of HOPDs reporting the measure as required in subsequent years. Similar to the STEMI eCQM, we assume a Medical Records Specialist will require 10 minutes to submit the data required per quarter for each HOPD. For the CY 2025 and CY 2026 voluntary reporting periods, we estimate an annual burden for voluntarily participating HOPDs of 107 hours (3,200 HOPDs × 20 percent × 0.167 hours × 1 quarter) at a cost of $5,926 (107 hours × $55.38/hour). For the CY 2027 reporting period/CY 2029 payment determination, we estimate the annual burden for all HOPDs to be 1,067 hours (3,200 HOPDs × 0.167 hours × 2 quarters) at a cost of $59,090 (1,067 hours × $55.38/hour). For the CY 2028 reporting period/CY 2030 payment determination, we estimate the annual burden for all HOPDs to be 2,133 hours (3,200 HOPDs × 0.167 hours × 4 quarters) at a cost of $118,126 (2,133 hours × $55.38/hour).

For the Excessive Radiation eCQM, HOPDs would log in through the measure developer’s secure portal and run the free Alara Imaging Software for CMS Measure Compliance (or similar software) inside their firewall. The software runs automatically to create the three intermediate data elements needed for the measure. Once the software finishes creating these intermediate variables, HOPDs can send the data to its EHR for measure calculation and reporting. The software allows additional options such as the ability to send the data to other business associates of the HOPD if needed. No manual data entry is required. We continue to estimate that each HOPD will spend approximately 15 minutes (0.25 hours) annually to conduct these activities prior to data submission. For the CYs 2025 and 2026 voluntary reporting periods, we estimate a total burden in CY 2025 and CY 2026 of 160 hours (0.25 hours x 3,200 HOPDs × 20 percent) at a cost of $8,861 (160 hours x $55.38/hour). For the CY 2027 reporting period and subsequent years, we estimate an annual burden of 800 hours (0.25 hours x 3,200 HOPDs) at a cost of $44,304 (800 hours x $55.38/hour) for all HOPDs.

Table 5. Estimated Burden for the eCQM Reporting and Submission Requirements for the CY 2027 through CY 2030 Payment Determination Years

eCQM Measure Reporting			Estimated time per record (minutes)	Number reporting quarters per year			Number of HOPDs reporting				Average number records per HOPD per quarter		Annual burden (hours) per HOPD	Total Annual hours for all HOPDs
CY 2027 Payment Determination
STEMI eCQM			10			2			3,200		1		0.33	1,067
Excessive Radiation eCQM (Voluntary)			10			1			640		1		0.167	107
Login and Run Software for Excessive Radiation eCQM(Voluntary)			15			1			640		1		0.25	160
Total Burden Hours														1,334
Total Burden @ Medical Records Specialist labor rate ($55.38/hr)														$73,877
CY 2028 Payment Determination
STEMI eCQM		10				3			3,200		1		0.50	1,600
Excessive Radiation eCQM (Voluntary)		10				1			640		1		0.167	107
Login and Run Software for Excessive Radiation eCQM (Voluntary)		15				1			640		1		0.25	160
Total Burden Hours														1,867
Total Burden @ Medical Records Specialist labor rate ($55.38/hr)														$103,395
CY 2029 Payment Determination
STEMI eCQM	10				4			3,200		1		0.67		2,133
Excessive Radiation eCQM	10				2			3,200		1		0.33		1,067
Login and Run Software for Excessive Radiation eCQM	15				1			3,200		1		0.25		800
Total Burden Hours														4,000
Total Burden @ Medical Records Specialist labor rate ($55.38/hr)														$221,520
CY 2030 Payment Determination and Subsequent Years
STEMI eCQM	10				4			3,200		1		0.67		2,133
Excessive Radiation eCQM	10				4			3,200		1		0.67		2,133
Login and Run Software for Excessive Radiation eCQM	15				1			3,200		1		0.25		800
Total Burden Hours														5,067
Total Burden @ Medical Records Specialist labor rate ($55.38/hr)														$280,556

5. Patient-Reported Outcome Measures

In the CY 2024 OPPS/ASC final rule, we finalized adopting the THA/TKA PRO-PM with voluntary reporting beginning with the CY 2025 reporting period through the CY 2027 reporting period, followed by mandatory reporting beginning with the CY 2028 reporting period/CY 2031 payment determination. This measure was previously adopted for the Hospital IQR Program in the FY 2023 IPPS/LTCH PPS final rule with an estimated burden of 7.25 minutes (0.120833 hours) per patient to complete both the pre-operative and post-operative surveys and 10 minutes (0.167 hours) per hospital per response to collect and submit the measure data via the HQR system (87 FR 49386 through 49387). We believe the estimated burden for both patient surveys and data submission will be the same for the Hospital OQR Program.

The THA/TKA PRO–PM uses four sources of data for the calculation of the measure: (1) PRO data; (2) claims data; (3) Medicare enrollment and beneficiary data; and (4) U.S. Census Bureau survey data. We estimate no additional burden associated with claims data, Medicare enrollment and beneficiary data, and U.S. Census Bureau survey data as these data are already collected via other mechanisms such as Medicare enrollment forms, CMS Form 1500, and U.S. Census Informational Questionnaires. Many HOPDs have already incorporated PRO data collection into their workflows. While we did not specify how HOPDs collect PRO data for this measure, HOPDs new to collecting PRO data will have multiple options for when and how they will collect these data so they can best determine the mode and timing of collection that works best for their patient population.

The possible patient touchpoints for pre-operative PRO data collection include the doctor’s office, pre-surgical steps such as education classes, or medical evaluations that can occur in an office or at the HOPD. The modes of PRO data collection can include completion of the pre-operative surveys using electronic devices (such as an iPad or tablet), pen and paper, mail, telephone, or through a patient portal. Post-operative PRO data collection modes are similar to pre-operative modes. The possible patient touchpoints for post-operative data collection can occur before the follow-up appointment, at the doctor’s office, or after the follow-up appointment. The potential modes of PRO data collection for post-operative data are the same as for pre-operative data. If the patient does not or cannot attend a follow-up appointment, the modes of collection can include completion of the post-operative survey using email, mail, telephone, or through a patient portal. Similar to other surveys, like the OAS CAHPS, we believe the use of multiple modes will maximize response rates as it allows for different patient preferences.

For the THA/TKA PRO–PM data, HOPDs will be able to submit data during three voluntary periods. The first voluntary reporting period will begin in CY 2025 for eligible procedures occurring between January 1, 2025, through December 31, 2025; the second voluntary reporting period will begin with CY 2026 for eligible procedures occurring between January 1, 2026, through December 31, 2026; and the third voluntary reporting period will begin in CY 2027 for eligible procedures occurring between January 1, 2027 through December 31, 2027. Voluntary reporting will be followed by mandatory reporting for eligible elective procedures beginning with the CY 2028 reporting period (occurring January 1, 2028, through December 31, 2028), impacting the CY 2031 payment determination. HOPDs will need to submit data twice (pre-operative data and post-operative data) for each reporting period.

For the purposes of calculating burden, similar to assumptions used for the Hospital IQR Program in the FY 2023 IPPS/LTCH PPS final rule (87 FR 49386 through 49387), we estimate that during the voluntary periods, 50 percent of HOPDs that perform at least one THA/TKA procedure will submit data for 50 percent of THA/TKA patients. For purposes of calculating burden, we estimate that, during the mandatory period, 100 percent of HOPDs will submit for 100 percent of patients. While we finalized a requirement for HOPDs to submit, at minimum, 50 percent of eligible, complete pre-operative data with matching eligible, complete post-operative data, we are conservative in our estimate for the mandatory period in case HOPDs exceed this threshold.

For burden estimating purposes for this measure, we assume that most HOPDs will likely undertake PRO data collection through a screening tool incorporated into their EHR or other patient intake process. We estimate that approximately 526,793 THA/TKA procedures occur in the outpatient setting each year, and that many patients can complete both the pre-operative and post-operative questionnaires. However, from our experience with using this measure in the Comprehensive Joint Replacement model, we are also aware that not all patients who complete the pre-operative questionnaire will complete the post-operative questionnaire. For CYs 2025, 2026, and 2027 voluntary reporting periods, we assume 50 percent of patients from 50 percent of the hospitals, or 131,698 patients, will complete the survey (526,793 patients × 0.50 × 0.50 of hospitals) for a total of 15,914 hours annually (131,698 respondents × 0.120833 hours) at a cost of $389,734 (15,914 hours × $24.49/hour). Beginning with mandatory reporting in the CY 2028 reporting period, we estimate a total of 63,654 hours (526,793 patients × 0.120833 hours) at a cost of $1,558,886 (63,654 hours × $24.49/hour) across all HOPDs.

Regarding HOPDs’ burden related to submitting data for this measure, which will be reported via the HQR system, we estimate a burden of 10 minutes per response. HOPDs will submit data associated with pre-operative surveys by March 31 of the CY following the CY in which the eligible procedures took place and will submit data associated with post-operative surveys by March 31 of the CY following the CY in which pre-operative data were submitted. Therefore, for the first voluntary reporting period for eligible procedures occurring in CY 2025, pre-operative survey data submission will occur in the first quarter of the CY 2026 reporting period and post-operative survey data submission will occur in the first quarter of the CY 2027 reporting period. For each reporting period, we estimate that each HOPD will spend 20 minutes (0.33 hours) annually (10 minutes × 2 surveys) to collect and submit the data. For the CY 2026 reporting period, we estimate a burden for 50 percent of voluntarily participating HOPDs of 267 hours (0.167 hours × 3,200 HOPDs × 50 percent) at a cost of $14,786 (267 hours × $55.38/hour). For the CY 2027 and CY 2028 reporting periods, we estimate a burden for 50 percent of voluntarily participating HOPDs of 533 hours (0.33 hours × 3,200 HOPDs × 50 percent) at a cost of $29,518 (533 hours × $55.38/hour). For the mandatory CY 2029 reporting period, we estimate a burden for all HOPDs of 800 hours [(0.167 hours × 3,200 HOPDs × 50 percent) + (0.167 hours x 3,200 HOPDs)] at a cost of $44,304 (800 hours × $55.38/hour). For the mandatory CY 2030 reporting period and subsequent years, we estimate a total of 1,067 hours (0.33 hours × 3,200 HOPDs) at a cost of $59,090 (1,067 hours × $55.38/hour).

In the CY 2025 OPPS/ASC proposed rule, we proposed to adopt the Information Transfer PRO-PM beginning with voluntary reporting for the CY 2026 reporting period and mandatory reporting beginning with the CY 2027 reporting period/CY 2029 payment determination. The Information Transfer PRO–PM would use PRO data regarding recovery instructions, collected by HOPDs through a nine-item survey instrument administered to patients post-operatively. The modes of PRO data collection can include completion of the post-operative surveys electronically. We have also proposed to allow HOPDs to report a minimum random sample of at least 300 completed patient surveys, or all surveys responses if an HOPD is unable to collect at least 300.

To provide an estimate of patient volume for the purposes of calculating the information collection burden associated with this measure, we utilized data derived from the American Hospital Association related to hospital outpatient visits to estimate that each year 498,843,518 patients ((2,399 outpatient visits per 1,000 population in CY 2022¹⁶ × 333,287,557 total U.S population in 2022¹⁷) × (3,200 HOPDs ÷ 5,129 U.S community hospitals¹⁸)) would be screened if the measure became mandatory. As submission rates among facilities may vary, we conservatively estimate that for voluntary reporting for the CY 2025 reporting period, 50 percent of HOPDs would survey 50 percent of patients, and beginning with the first mandatory reporting period, 100 percent of HOPDs would survey 100 percent of patients. While we proposed to allow HOPDs to report a minimum random sample if they are able to collect at least 300 completed patient surveys, we also proposed to require all patients to be surveyed for this measure once mandatory reporting begins.

We estimate each patient would require an average of 6 minutes (0.1 hours) to complete the survey.¹⁹ For the CY 2025 voluntary reporting period, we estimate a total burden for patients of 12,471,088 hours (498,843,518 patients × 50 percent response rate × 50 percent of HOPDs × 0.1 hours per patient surveyed) at a cost of $305,416,945 (12,471,088 hours × $24.49/hour). Beginning with the CY 2026 mandatory reporting period, we estimate an annual total burden for patients of 49,884,352 hours (498,843,518 patients × 0.1 hours per patient) at a cost of $1,221,667,780 (49,884,352 hours × $24.49/hour).

Measure data would be submitted via the HQR system annually. Similar to the currently approved burden estimate for other web-based measures reported via the HQR system for the Hospital OQR Program, we estimate a burden of 10 minutes (0.167 hours) per HOPD to report measure data. For the CY 2025 voluntary reporting period, we estimate a total collection and reporting burden for program-eligible HOPDs of 267 hours (3,200 HOPDs × 50 percent of HOPDs × 0.167 hours per HOPDs) at a cost of $14,786 (267 hours × $55.38/hour). Beginning with the CY 2026 mandatory reporting period, we estimate a total collection and reporting burden for program-eligible HOPDs of 533 hours (3,200 HOPDs × 0.167 hours per HOPD) at a cost of $29,518 (533 hours × $55.38/hour).

Table 6. Estimated Burden for the PRO-PM Reporting and Submission Requirements for the CY 2027 through CY 2032 Payment Determination Years

PRO-PM Measure Reporting			Estimated time per record (minutes)	Number reporting quarters per year	Number of Respondents	Average number records per Respondent per quarter		Annual burden (hours) per Respondent	Total Annual hours for all Respondents
CY 2027 Payment Determination
THA/TKA (Voluntary Patient Surveys)			7.25	2	131,698	1		0.12083	15,914
Information Transfer (Voluntary Patient Surveys)			6	1	124,710,880	1		0.1	12,471,088
Information Transfer (Voluntary Reporting)			10	1	1,600	1		0.167	267
Total Burden Hours									12,487,269
Total Burden @ Individual labor rate ($24.49/hr)									$305,416,945
Total Burden @ Medical Records Specialist labor rate ($55.38/hr)									$14,786
CY 2028 Payment Determination
THA/TKA (Voluntary Patient Surveys)		7.25		2	131,698	1		0.12083	15,914
THA/TKA (Voluntary Measure Reporting)		10		1	1,600	1		0.167	267
Information Transfer (Mandatory Patient Surveys)		6		1	498,843,518	1		0.1	49,884,352
Information Transfer (Mandatory Reporting)		10		1	3,200	1		0.167	533
Total Burden Hours									49,901,066
Total Burden @ Individual labor rate ($24.49/hr)									$1,222,057,514
Total Burden @ Medical Records Specialist labor rate ($55.38/hr)									$44,304
CY 2029 Payment Determination
THA/TKA (Voluntary Patient Surveys)	7.25			2	131,698	1	0.12083		15,914
THA/TKA (Voluntary Measure Reporting)	10			2	1,600	1	0.33		533
Information Transfer (Mandatory Patient Surveys)	6			1	498,843,518	1	0.1		49,884,352
Information Transfer (Mandatory Reporting)	10			1	3,200	1	0.167		533
Total Burden Hours									49,901,333
Total Burden @ Individual labor rate ($24.49/hr)									$1,222,057,514
Total Burden @ Medical Records Specialist labor rate ($55.38/hr)									$59,036
CY 2030 Payment Determination
THA/TKA (Mandatory Patient Surveys)	7.25			2	526,793	1	0.12083		63,654
THA/TKA (Voluntary Measure Reporting)	10			2	1,600	1	0.33		533
Information Transfer (Mandatory Patient Surveys)	6			1	498,843,518	1	0.1		49,884,352
Information Transfer (Mandatory Reporting)	10			1	3,200	1	0.167		533
Total Burden Hours									49,949,073
Total Burden @ Individual labor rate ($24.49/hr)									$1,223,226,666
Total Burden @ Medical Records Specialist labor rate ($55.38/hr)									$59,036
CY 2031 Payment Determination
THA/TKA (Mandatory Patient Surveys)	7.25			2	526,793	1	0.12083		63,654
THA/TKA (Voluntary Measure Reporting)	10			1	1,600	1	0.167		267
THA/TKA (Mandatory Measure Reporting)	10			1	3,200	1	0.167		533
Information Transfer (Mandatory Patient Surveys)	6			1	498,843,518	1	0.1		49,884,352
Information Transfer (Mandatory Reporting)	10			1	3,200	1	0.167		533
Total Burden Hours									49,949,339
Total Burden @ Individual labor rate ($24.49/hr)									$1,223,226,666
Total Burden @ Medical Records Specialist labor rate ($55.38/hr)									$73,822
CY 2032 Payment Determination and Subsequent Years
THA/TKA (Mandatory Patient Surveys)	7.25			2	526,793	1	0.12083		63,654
THA/TKA (Mandatory Measure Reporting)	10			2	3,200	1	0.33		1,067
Information Transfer (Mandatory Patient Surveys)	6			1	498,843,518	1	0.1		49,884,352
Information Transfer (Mandatory Reporting)	10			1	3,200	1	0.167		533
Total Burden Hours									49,949,606
Total Burden @ Individual labor rate ($24.49/hr)									$1,223,226,666
Total Burden @ Medical Records Specialist labor rate ($55.38/hr)									$88,608

5. Validation Burden

The burden associated with the validation procedures is the time and effort necessary to submit supporting medical record documentation for validation. We previously estimated that it would take each of the 500 selected HOPDs approximately 12 hours to comply with these data submission requirements (76 FR 74553 and 74577). To comply with the requirements, we also estimated that each HOPD would submit up to 48 cases for the affected year for review (76 FR 74553).

Because all selected HOPDs must comply with these requirements each year, we continue to estimate a total submission of up to 24,000 charts by the selected HOPDs (500 HOPDs ´ 48 cases per HOPD) (76 FR 74553). Therefore, for the selected HOPDs, we continue to estimate a total annual validation burden, for four quarters of data, of 6,000 hours (500 HOPDs x 12 hours per hospital), and a total financial burden of approximately $332,280 (6,000 hours x $55.38/hour).

HOPDs with less than four quarters of data subject to validation due to receiving an ECE for one or more quarters and with a two-tailed confidence interval that is less than 75 percent will be targeted for validation in the subsequent validation year. However, these HOPDs will not be penalized for payment. HOPDs will still be subject to both payment penalization and targeting for the subsequent year if they either (a) have less than four quarters of data but do not have an ECE or waiver for one or more quarters and do not meet the 75 percent threshold; or (b) have four quarters of data subject to validation and do not meet the 75 percent threshold. This policy does not increase reporting burden, because it changes neither the total number of HOPDs required to submit data nor the amount of data HOPDs selected for validation would be required to submit.

12. Total Burden for the CY 2027 through CY 2030 Payment Determinations

As shown in Tables 7 and 8, in summary, under OMB control number 0938-1109, we estimate a total annual information collection burden increase for 3,200 HOPDs of 66,336,597 hours associated with our proposed policies and updated burden estimates described above and a total cost increase related to this information collection of $1,624,286,808 (which also reflects use of updated hourly wage rates as previously discussed), from the CY 2025 reporting period/CY 2027 payment determination through the CY 2028 reporting period/CY 2030 payment determination, compared to our currently approved information collection burden estimates. The tables below summarize the total burden changes for each respective CY payment determination compared to our currently approved information collection burden estimates (the columns in each table for the CY 2030 payment determination reflects the cumulative burden changes).

Table 7. Total Burden Hours for the CY 2027 through CY 2030 Payment Determinations

Information Collection	CY 2027	Difference from Currently Approved	CY 2028	Difference from Currently Approved	CY 2029	Difference from Currently Approved	CY 2030	Difference from Currently Approved
Administrative Activities	134,400	-6,300	134,400	-6,300	134,400	-6,300	134,400	-6,300
Chart-Abstracted Measures	90,880	-4,260	90,880	-4,260	90,880	-4,260	90,880	-4,260
Web-Based Measures	4,135,762	4,115,623	16,482,672	16,462,533	16,482,672	16,462,533	16,482,672	16,462,533
Claims-Based Measures	N/A	0	N/A	0	N/A	0	N/A	0
Survey-Based Measures	N/A	0	N/A	0	N/A	0	N/A	0
eCQM Measures	1,334	-62	1,867	-87	4,000	-188	5,067	-237
PRO-PM	12,487,269	12,471,355	49,901,066	49,884,873	49,901,333	49,884,861	49,949,073	49,884,861
Validation	6,000	0	6,000	0	6,000	0	6,000	0
TOTAL	16,855,645	16,576,356	66,616,885	66,336,759	66,619,285	66,336,646	66,668,092	66,336,597

Table 8. Total Burden Dollars for the CY 2027 through CY 2030 Payment Determinations*

Information Collection	CY 2027	Difference from Currently Approved	CY 2028	Difference from Currently Approved	CY 2029	Difference from Currently Approved	CY 2030	Difference from Currently Approved
Administrative Activities	$7,443,072	-$348,894	$7,443,072	-$348,894	$7,443,072	-$348,894	$7,443,072	-$348,894
Chart-Abstracted Measures	$5,032,934	-$235,919	$5,032,934	-$235,919	$5,032,934	-$235,919	$5,032,934	-$235,919
Web-Based Measures	$101,911,971	$100,796,673	$404,304,208	$403,188,910	$404,304,208	$403,188,910	$404,304,208	$403,188,910
Claims-Based Measures	N/A	$0	N/A	$0	N/A	$0	N/A	$0
Survey-Based Measures	N/A	$0	N/A	$0	N/A	$0	N/A	$0
eCQM Measures	$73,877	-$3,428	$103,395	-$4,542	$221,520	-$10,384	$280,556	-$13,186
PRO-PM	$305,431,731	$305,041,997	$1,222,101,818	$1,221,696,622	$1,222,116,550	$1,221,695,897	$1,223,285,702	$1,221,695,897
Validation	$332,280	$0	$332,280	$0	$332,280	$0	$332,280	$0
TOTAL	$420,225,865	$405,250,429	$1,639,317,707	$1,624,296,177	$1,639,450,564	$1,624,289,610	$1,640,678,752	$1,624,286,808

* Cost estimates are based on updated wage rates. Differences from currently approved burden account for updating estimates of currently approved hours to the new wage rates.

13. Capital Costs (Maintenance of Capital Costs)

For HOPDs that are not currently collecting data for one or both of the THA/TKA or Information Transfer PRO-PMs, there will be some non-recurring costs associated with changes in workflow and information systems to collect these data. The extent of these costs is difficult to quantify as different HOPDs may utilize different modes of data collection (for example paper-based, electronically patient-directed, clinician-facilitated, etc.). While we assume the majority of HOPDs will report data for this measure directly to CMS, we assume some HOPDs may elect to submit measure data via a third-party survey vendor, for which there are associated costs. Under OMB control number 0938-1240 for the OAS CAHPS Survey measure (expiration date November 30, 2026), an estimate of approximately $4,000 per hospital is used to account for these costs.

While we do not expect HOPDs would experience an increase in information collection burden associated with the proposal to require EHR technology to be certified to all eCQMs available to report, we expect some costs to be incurred by HOPDs to have the option to report the eCQMs. However, due to the differences in the build of respective CEHRT deployed in HOPDs, the mapping required to capture required data for measure calculation, and the range of HOPD participation in the development, implementation, and testing of new CEHRT functionality, an estimated cost impact of the proposal is not quantifiable as it will vary by CEHRT and HOPD.

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 takes one CMS staff at a GS-13 Step 6 level to operate. GS-13 Step 6 approximate annual salary is $137,624 plus benefits (30 percent) of $41,287 for a total cost of $178,911. The total annual cost to the Federal Government is $10,228,911.

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.

15. Program or Burden Changes

We previously requested and received approval for total annual burden estimates under this OMB control number for the CY 2025 reporting period/CY 2027 payment determination of 279,289 hours at a cost of $14,056,647 as a result of policies finalized in the CY 2024 OPPS/ASC final rule. Accounting for updated wage rates, the total cost of $14,056,647 increases to $14,975,402. For the CY 2025 reporting period/CY 2027 payment determination, based on the policy proposals in the CY 2025 OPPS/ASC proposed rule, we estimate a total burden of 16,855,645 hours at a cost of $420,225,865 (an increase of 16,576,356 and $406,169,218 from our estimate in the CY 2024 OPPS/ASC final rule). This burden estimate also represents an increase of 16,593,108 and $406,542,452 from the currently approved burden estimate of 262,537 hours and $13,683,413 for the CY 2024 reporting period/CY 2026 payment determination.

The proposed adoption of the HCHE measure would result in a total estimated burden increase of 533 hours at a cost of $29,518 beginning with the CY 2027 payment determination. The proposed adoption of the Screening for SDOH and Screen Positive Rate for SDOH measures would result in a total estimated burden increase of 16,462,369 hours at a cost of $403,179,882 and 533 hours at a cost of $29,518, respectively, when mandatory reporting begins for the CY 2028 payment determination. The proposed adoption of the Information Transfer PRO-PM would result in a total estimated burden increase of 49,884,885 hours at a cost of $1,221,697,298 when mandatory reporting begins for the CY 2028 payment determination.

Accounting for the impact of the proposals in the CY 2025 OPPS/ASC proposed rule, our updated estimate of the number of HOPDs results in an annual burden decrease of 11,723 hours and $649,408 beginning with the CY 2027 payment determination. The aggregate increase due to these policies and adjustments as reflected in our burden estimates for the CY 2030 payment determination is 66,336,597 hours (-11,723 + 533 + 16,462,369 + 533 + 49,884,885) and $1,624,286,808 (-649,408 + $29,518 + $403,179,882 + $29,518 + $1,221,697,298) as shown in Tables 7 and 8.

16. Publication

As required by authorizing statute, quality measure data have been made publicly available after providing HOPDs the opportunity to review their data. The goal of the data collection is to tabulate and publish HOPD-specific data. Hospital data from these initiatives are currently used to populate data.cms.gov and the Compare tool. Data are presented on the Compare tool 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. For certain outcome and cost measures, data are presented on the Compare tool in performance categories of Better, No Different, or Worse than the National Rate. More detailed measure data, including the data used for the Compare tool, are also available to the public as downloadable files at https://data.cms.gov/provider-data/. Hospital quality data on the Compare tool are currently updated on a quarterly basis. 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 Hospital OQR 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.

19. Collections of Information Employing Statistical Methods

This information collection does not require the use of statistical methods. However, to reduce burden, facilities may sample using either the simple random sampling or systematic random sampling method applied consistently within a quarter to reduce the number of cases for which to submit data for certain measures.

1 https://www.cms.gov/medicare/quality/meaningful-measures-initiative/cms-quality-strategy

2 https://www.cms.gov/medicare/quality/meaningful-measures-initiative/meaningful-measures-20

3 Pub. L. 109-432

4 Pub. L. 99-660.

5 42 CFR § 416.310(f) All deadlines occurring on a Saturday, Sunday, or legal holiday, or on any other day all or part of which is declared to be a nonwork day for Federal employees by statute or Executive order are extended to the first day thereafter which is not a Saturday, Sunday, or legal holiday or any other day all or part of which is declared to be a nonwork day for Federal employees by statute or Executive order.

6 For additional details about the MBQIP project, please visit: www.ruralcenter.org/tasc/mbqip.

7 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.

8 U.S. Bureau of Labor Statistics. Occupational Outlook Handbook, Medical Records Specialists. Accessed April 29, 2024. Available at: https://www.bls.gov/oes/current/oes292072.htm.

9 https://qualitynet.cms.gov/outpatient/specifications-manuals

10 Kaiser Family Foundation, Hospital Outpatient Visits per 1,000 Population by Ownership Type. Available at https://www.kff.org/other/state-indicator/outpatient-visits-by-ownership/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D

11 Growth in U.S. Population Shows Early Indication of Recovery Amid COVID-19 Pandemic, December 22, 2022. Available at https://www.census.gov/newsroom/press-releases/2022/2022-population-estimates.html

12 American Hospital Association, Fast Facts on U.S. Hospitals. Available at https://www.aha.org/statistics/fast-facts-us-hospitals

13 Office of the Assistant Secretary for Planning and Evaluation, Valuing Time in U.S. Department of Health and Human Services Regulatory Impact Analyses: Conceptual Framework and Best Practices, September 17, 2017. Available at https://aspe.hhs.gov/reports/valuing-time-us-department-health-human-services-regulatory-impact-analyses-conceptual-framework.

14 Bureau of Labor and Statistics, Usual Weekly Earnings of Wage and Salary Workers, First Quarter 2024. Available at https://www.bls.gov/news.release/pdf/wkyeng.pdf. Accessed April 16, 2024

15 U.S. Census Bureau, End of Pandemic-Era Expanded Federal Tax Programs Results in Lower Income, Higher Poverty, September 12, 2023. Available at https://www.census.gov/library/stories/2023/09/median-household-income.html. Accessed April 16, 2024.

16 ibid

17 ibid

18 ibid

19 Yale New Haven Health Services Corporation - Center for Outcomes Research & Evaluation, Methodology Report For Public Comment: Patient Understanding of Key Information Related to Recovery From an Outpatient Surgery or Procedure. Available at https://www.cms.gov/medicare/quality/initiatives/hospital-quality-initiative/measure-methodologyhttps://mmshub.cms.gov/sites/default/files/Patient-Receipt-Key-Info-Public-Comment-03082022.pdf.

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