CMS-10870_REHQR CY 2026 Supporting Statement Part B

Supporting Statement - Part B

Submission of Information for the Rural Emergency Hospital Quality Reporting (REHQR) Program

Collection of Information Employing Statistical Methods

1. Describe potential respondent universe.

Based on the actual number of acute care and critical access hospital conversions to REH status as of April 11, 2025, we estimate that 38 REHs would report data to the REHQR Program during the CY 2026 reporting period. While the exact number of REHs required to submit data may vary due to status changes to and from an REH, REHs are required by statute to submit quality data.

2. Describe procedures for collecting information.

Data may be patient-level, summary, or aggregate data submitted directly to CMS via a secure web portal (currently, the Hospital Quality Reporting system) by either the facility or their authorized vendor(s), as specified.

3. Describe methods to maximize response rates.

To reduce burden and thereby maximize response rates, REHs can sample for the Median Time from Emergency Department (ED) Arrival to ED Departure for Discharged ED Patients measure as it requires direct data entry. Sample size requirements per quarter per REH for this measure are based on an REH’s denominator population. REHs can utilize sampling techniques of their choosing. Additionally, in the CY 2026 OPPS/ASC proposed rule, we are proposing to adopt the Emergency Care Access & Timeliness electronic clinical quality measure (eCQM) beginning with the CY 2027 reporting period/CY 2029 program determination as an alternative to reporting the Median Time from ED Arrival to ED Departure for Discharged ED Patients measure to meet program requirements.

4. Describe any tests of procedures or methods.

Sampling for Chart-Abstracted Data for the REHQR Program

For one measure under the REHQR Program, to reduce burden REHs may submit data for sample case sizes of their population; for case populations of less than 63, data for all cases would be submitted, for a population size between 63 and 900, data for a minimum of 63 cases would be submitted, and for case population sizes of greater than 900, data for 96 cases would be submitted. REHs that choose to sample should ensure that the sampled data represents their outpatient population by using either the simple random sampling or systematic random sampling and that the sampling techniques are applied consistently. REHs may also submit measure data for the entire applicable patient population in lieu of sampling.

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

Anita Bhatia, PhD, MPH

410-786-7236

Grace Snyder, JD, MPH

410-786-0700