Supporting Statement A
Requirements for the
Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program
CMS-10432, OMB 0938-1171
The Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program was established under section 1886(s)(4) of the Social Security Act, as amended by sections 3401 and 10322 of the Patient Protection and Affordable Care Act (ACA) and further amended by section 4125(c) of the Consolidated Appropriations Act, 2023. Under the IPFQR Program, starting in fiscal year (FY) 2014, Inpatient Psychiatric Facilities (IPFs) shall submit pre-defined quality measures to the Centers for Medicare & Medicaid Services (CMS). IPFs that fail to report on the selected quality measures and comply with other administrative requirements will have their IPF prospective payment system (PPS) payment updates reduced by 2.0 percentage points. To comply with the statutory mandate, we are updating the IPFQR Program requirements.
This updated collection of information request reflects changes to the IPFQR Program in association with our FY 2024 Inpatient Psychiatric Facility Prospective Payment System (IPF PPS) final rule (CMS-1783-F, RIN 0938-AV06) as well as burden adjustments based on the availability of more recent wage figures, facility estimates, and case estimates. The rule-related changes to program requirements reflect adoption of four new measures, removal of two measures, modification of one measure, adoption of a data validation pilot, and codification of administrative policies. Overall, we project that all of the changes, including measure set changes, and updates in the number of participating IPFs (a reduction of 38 IPFs), case numbers, and wage rate, will reduce total reporting burden by approximately 381,000 hours and reduce the total cost by approximately $8.1 million. Details are provided in sections 12 and 15, below.
Section 1886(s)(4)(C) of the Act requires that, for FY 2014 (October 1, 2013 through September 30, 2014) and each subsequent FY, each psychiatric hospital and psychiatric unit paid under the IPF PPS shall submit to the Secretary data on quality measures as specified by the Secretary (42 CFR 412.404(b)). Such data shall be submitted in a form and manner, and at a time, specified by the Secretary.
Information about previously adopted measures for the IPFQR Program is available on the QualityNet website, https://qualitynet.cms.gov/ipf/measures.
In the FY 2024 IPF PPS final rule, we are finalizing the following measure related policies:
Adopt the Facility Commitment to Health Equity measure beginning with the FY 2026 payment determination;
Adopt the Screening for Social Drivers of Health measure beginning with voluntary reporting of CY 2024 data followed by mandatory reporting of CY 2025 data for the FY 2027 payment determination;
Adopt the Screen Positive Rate for Social Drivers of Health measure beginning with voluntary reporting of CY 2024 data followed by mandatory reporting of CY 2025 data for the FY 2027 payment determination;
Adopt the Psychiatric Inpatient Experience (PIX) survey to measure patient experience of care in the IPF setting beginning with voluntary reporting of CY 2025 data followed by mandatory reporting of CY 2026 data for the FY 2028 payment determination;
Modify the COVID-19 Vaccination Coverage Among Health Care Personnel (HCP) measure beginning with fourth quarter CY 2023 data for the FY 2025 payment determination and, following this first single-quarter reporting period, reporting of full calendar year data beginning with CY 2024 for the FY 2026 payment determination;
Remove the Patients Discharged on Multiple Antipsychotic Medications with Appropriate Justification (HBIPS-5) measure beginning with the FY 2025 payment determination; and
Remove the Tobacco Use Brief Intervention Provided or Offered and Tobacco Use Brief Intervention Provided (TOB-2/2a) measure beginning with the FY 2025 payment determination.
Additionally, in the FY 2024 IPF PPS final rule, we have two non-measure related policies. Specifically, we are adopting a data validation pilot and we are codifying certain administrative requirements for the IPFQR Program. For the validation pilot we will randomly select 100 facilities and request 8 charts per quarter (a total of 32 charts per year) from each facility that chooses to participate. We are reimbursing IPFs that participate in the data validation pilot at a rate of $3.00/chart. We do not anticipate that these proposals will have an impact on provider or patient information collection burden.
Section 1886(s)(4)(E) of the Act requires the Secretary to establish procedures for making public the data submitted by IPFs under the IPFQR Program. For CMS to publish the measure rates, IPFs are required to submit the Notice of Participation (NOP) form. By such submission, IPFs indicate their agreement to participate in the IPFQR Program and submit the required data pertaining to applicable quality measures for each fiscal year’s payment determination. In addition, IPFs give their consent to publicly report their measure rates on a CMS website. CMS recognizes that IPFs may choose not to participate or may choose to withdraw from the IPFQR Program. To this end, our procedures include the necessary steps that IPFs must take to indicate their intent to participate or withdraw.
As part of our procedural requirements, we require that IPFs acknowledge the accuracy and completeness of submitted data. We seek to collect information on valid, reliable, and relevant measures of quality, and to share this information with the public; therefore, IPFs must submit the Data Accuracy and Completeness Acknowledgement (DACA) form.
We recognize that some IPFs may choose to have a vendor transmit quality data on the IPF’s behalf. To ensure that the IPF has authorized the vendor and the vendor has agreed that it will collect and transmit data in accordance with HIPAA regulatory requirements regarding security and privacy, we require IPFs to complete a vendor authorization form approving the vendor to transmit the facility’s quality of care data.
In our effort to foster alignment across quality reporting programs, we now include the Extraordinary Circumstances Exception form and the Reconsideration Request form as part of the Hospital Inpatient Quality Reporting (IQR) Program’s PRA package (OMB control number 0938-1022; CMS-10210). While IPFs may also need to complete and submit these forms, the associated burden is addressed in the Hospital IQR Program PRA package.
IPFs: The primary ways an IPF will use the information are: to examine the individual IPF’s specific care domains and types of patients; to compare present performance to past performance and to national performance norms; to use quality measures to evaluate the effectiveness of care provided to specific types of patients; to monitor quality improvement outcomes over time; to assess their own strengths and weaknesses in the clinical services that they provide; to address care-related areas, activities, or behaviors that result in effective patient care; and to alert themselves to needed improvements. Such information is essential to IPFs in initiating quality improvement strategies. This information can also be used to improve an IPF’s financial planning and marketing strategies.
State Agencies/CMS: Agencies will use the data to compare an IPF’s results with its peer performance. The availability of peer performance enables state agencies and CMS to identify opportunities for improvement in the IPF and to improve evaluation of the IPF’s own quality assessment and performance improvement program.
Accrediting Bodies: National accrediting organizations, such as The Joint Commission (TJC), or state accreditation agencies may wish to use the information to target potential or identified problems during the organization’s accreditation review of that facility.
Beneficiaries/Consumers: The IPFQR Program publicly reports data through a CMS website. These data provide information for consumers and their families on the quality of care provided by individual facilities, allowing them to compare patient outcomes between facilities and against the state and national average. The website provides information in consumer-friendly language and offers a tool to assist consumers with selecting an IPF.
IPFs can utilize electronic means to submit/transmit their forms (such as through submission of XML files in the Hospital Quality Reporting system) and data via a CMS-provided secure web-based tool, which is available through the secure portal in the Hospital Quality Reporting system. IPF users are required to open an account to set up secure logins and then will be able to complete all the necessary forms/applications that are applicable to their specific needs (e.g., NOP or DACA).
A web-based measure online tool is used for data entry in the secure portal in the Hospital Quality Reporting system. Data are stored to support retrieving reports for IPFs to view their measure rates/results. Facilities can access a preview report via the secure portal within the Hospital Quality Reporting system prior to release of data on the CMS website for public viewing.
Facilities that currently collect and report data on TJC measures can use the same information to report to CMS on TJC measures in the IPFQR Program, which avoids duplication of efforts and reduces burden to the IPFs. As for collection of the FAPH, Thirty-day All-cause Readmission Following Hospitalization in an IPF, and Medication Continuation following Discharge from an IPF measures, CMS will collect such data using Medicare Part A, Part B, and Part D claims; therefore, these measures will pose no additional information collection burden on IPFs.
Information collection requirements are designed to allow maximum flexibility specifically to small IPF providers participating in the IPFQR Program. This effort assists small IPF providers in gathering information for their own quality improvement efforts. For example, we provide a help-desk hotline for troubleshooting purposes and 24/7 free information available on the QualityNet website and through a Questions and Answers (Q&A) functionality. Further, we will support submission of patient-level data through the publicly available CMS Abstraction & Reporting Tool (CART).
We have designed the collection of quality of care data to be the minimum necessary for reporting of data on measures considered to be meaningful indicators of psychiatric patient care. To this end, we only require a single, annual report of measure data from facilities for data covered by this PRA package.
With respect to the information collection covered in this package, there are no special circumstances that would require an information collection to be conducted in a manner that requires respondents to:
• Report information to the agency more often than quarterly;
• Prepare a written response to a collection of information in fewer than 30 days after receipt of it;
• Submit more than an original and two copies of any document;
• Retain records, other than health, medical, government contract, grant-in-aid, or tax records for more than three years;
• Collect data in connection with a statistical survey that is not designed to produce valid and reliable results that can be generalized to the universe of study;
• Use a statistical data classification that has not been reviewed and approved by OMB;
• Include a pledge of confidentiality that is not supported by authority established in statute or regulation that is not supported by disclosure and data security policies that are consistent with the pledge, or which unnecessarily impedes sharing of data with other agencies for compatible confidential use; or
• Submit proprietary trade secret, or other confidential information unless the agency can demonstrate that it has instituted procedures to protect the information's confidentiality to the extent permitted by law.
Serving as the 60-day notice, the FY 2024 IPF Prospective Payment System (PPS) proposed rule (CMS-1783-P, RIN 0938-AV06) published in the Federal Register on April 10, 2023 (88 FR 21238). Comments were received; a summary of the comments and our response are attached to this collection of information request.
The final rule (CMS-1783-F; RIN 0938-AV06) published in the Federal Register on August 2, 2023 (88 FR 51054).
Outside Consultation
CMS is supported in this initiative by TJC and the Centers for Disease Control and Prevention (CDC). These organizations, in conjunction with CMS, will provide technical assistance in developing or identifying quality measures, and assist in making the information accessible, understandable, and relevant to the public.
Although participation in the IPFQR Program is voluntary (i.e., not required by Medicare Conditions of Participation), all eligible IPFs must submit their data to receive the full market basket update for a given FY. If data are not submitted to CMS, the IPF receives a reduction of 2 percentage points from its Annual Payment Update (APU) unless CMS grants an exception.
As noted in the FY 2024 IPF PPS final rule (88 FR 51143), we reimburse hospitals directly for expenses associated with submission of charts for measure data validation – we reimburse hospitals at a rate of $3.00 per record submitted.
All information collected under this initiative is maintained in strict accordance with statutes and regulations governing confidentiality requirements, which can be found at 42 CFR part 480. In addition, the tools used for transmission of data are considered confidential forms of communication and are Health Insurance Portability and Accountability Act (HIPAA)- compliant.
The PIX survey asks patients to respond to questions about their age, gender, sexual orientation, race/ethnicity, religious/faith tradition, and disability status. The questions are optional and are provided to collect additional information to stratify the results of the survey by at a population level, in order to determine whether patient experience at inpatient psychiatric facilities significantly differs by any of these patient factors.
Otherwise, there are no sensitive questions included in the information request. Specifically, the collection does not solicit questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private.
The following burden estimates include the time required for data collection and submission through the Hospital Quality Reporting system.
We estimate that there are approximately 1,596 facilities eligible to participate in the IPFQR Program (based on the most recent eligibility data, submitted in CY 2022). Because historical data indicates that almost all facilities participate, and because we wish to be conservative in our estimates, we estimated that all eligible facilities will participate in the IPFQR Program.
We also estimate that the average facility will submit measure data on 609 cases per year for all measures that allow sampling, and measure data on 1,261 cases for measures that require data submission on all discharges. Furthermore, the Follow-up After Psychiatric Hospitalization, the Thirty-Day All-Cause Unplanned Readmission Following Psychiatric Hospitalization in an IPF, and the Medication Continuation Following Discharge from an IPF measures will not require facilities to submit data on any cases since CMS will collect the data under Medicare Part A, Part B, and Part D claims. We also note that data collected for the COVID-19 Vaccination Coverage Among HCP measure is being collected by the CDC under the CDC’s OMB control number 0920-1317.
The collection of quality of care data is designed to be the minimum necessary for reporting of data on measures considered to be meaningful indicators of psychiatric patient care. To this end, we only require a single, annual report of measure data for the measures discussed in this PRA package from facilities.
In the FY 2022 IPF PPS final rule (86 FR 42662), we estimated that the labor performed could be accomplished by Medical Records and Health Information Technician staff based on a median hourly wage in general medical and surgical hospitals of $20.50 per hour. We note that since then and as of the publication date of the FY 2024 IPF PPS proposed rule, this Bureau of Labor Statistics occupation category has been replaced with Medical Records Specialists and more recent wage data reflecting a median hourly wage of $22.43 per hour.
Additionally, per OMB Circular A-76, in calculating direct labor, agencies should not only include salaries and wages, but also “other entitlements” such as fringe benefits. However, obtaining data on other overhead costs is challenging. Overhead costs vary greatly across industries and firm sizes. In addition, the precise cost elements assigned as “indirect” or “overhead” costs, as opposed to direct costs or employee wages, are subject to some interpretation at the firm level. Therefore, we have chosen to calculate the cost of overhead at 100 percent of the median hourly wage. This is necessarily a rough adjustment, both because fringe benefits and overhead costs vary significantly from employer to employer and because methods of estimating these costs vary widely from study to study. We believe that doubling the hourly wage to estimate total cost is a reasonably accurate estimation method. Consequently, in calculating the labor costs, we are using an adjusted labor rate of $44.86/hour as described in Table 1.
Table 1: Wage for Medical Records Specialist
Occupation Title |
Occupation Code |
Median Hourly Wage ($/hour) |
Fringe Benefits and Overhead ($/hour) |
Adjusted Hourly Wage ($/hour) |
Medical Records Specialist |
29-2072 |
22.43 |
22.43 |
44.86 |
In the FY 2022 IPF PPS final rule, for the FY 2024 payment determination and subsequent years, we had adopted 14 measures. The FY 2024 IPF PPS final rule finalizes addition of four measures, removal of two measures, and modification of one measure. These updates will affect burden associated with the IPFQR Program with start dates beginning in CY 2024 and continuing through a start date in CY 2027. Details on the effective date of each proposal are provided in Section 15 of this document.
The burden associated with the IPFQR Program measure set is summarized in Table 2.
Table 2: Burden Associated with the IPFQR Program Measure Set
Measure ID |
Measure Description |
Cases per facility |
Effort per Case (hours) |
Effort per facility (hours) |
Cost per Facility ($) |
Total Effort (hours) |
Total Annual Cost ($) |
HBIPS-2 |
Hours of Physical Restraint Use |
1,261 |
0.25 |
315.25 |
14,142 |
503,139 |
22,570,815 |
HBIPS-3 |
Hours of Seclusion Use |
1,261 |
0.25 |
315.25 |
14,142 |
503,139 |
22,570,815 |
SUB-2 and SUB-2a |
Alcohol Use Disorder Brief Intervention Provided or Offered and Alcohol Use Disorder Brief Intervention |
609 |
0.25 |
152.25 |
6,830 |
242,991 |
10,900,576 |
SUB-3 and SUB-3a |
Alcohol and Other Drug Use Disorder Treatment Provided or Offered at Discharge and Alcohol and Other Drug Use Disorder Treatment at Discharge |
609 |
0.25 |
152.25 |
6,830 |
242,991 |
10,900,576 |
FAPH |
Follow-up After Psychiatric Hospitalization * |
0 |
0 |
0 |
0 |
0 |
0 |
TOB-3 and TOB-3a |
Tobacco Use Treatment Provided or Offered at Discharge and Tobacco Use Treatment at Discharge |
609 |
0.25 |
152.25 |
6,830 |
242,991 |
10,900,576 |
IMM-2 |
Influenza Immunization |
609 |
0.25 |
152.25 |
6,830 |
242,991 |
10,900,576 |
N/A |
Transition Record with Specified Elements Received by Discharged Patients (Discharges from an Inpatient Facility to Home/Self Care or Any Other Site of Care) |
609 |
0.25 |
152.25 |
6,830 |
242,991 |
10,900,576 |
N/A |
Screening for Metabolic Disorders |
609 |
0.25 |
152.25 |
6,830 |
242,991 |
10,900,576 |
N/A |
Thirty-day all-cause unplanned readmission following psychiatric hospitalization in an IPF |
0 |
0 |
0 |
0 |
0 |
0 |
N/A |
Medication Continuation Following Inpatient Psychiatric Discharge* |
0 |
0 |
0 |
0 |
0 |
0 |
N/A |
Modified COVID-19 Vaccination Coverage Among Health Care Personnel** |
0 |
0 |
0 |
0 |
0 |
0 |
N/A |
Facility Commitment to Health Equity |
1 |
0.167 |
0.167 |
7.5 |
267 |
11,957 |
N/A |
Screening for Social Drivers of Health |
1 |
0.167 |
0.167 |
7.5 |
267 |
11,957 |
N/A |
Screen Positive Rate for Social Drivers of Health |
1 |
0.167 |
0.167 |
7.5 |
267 |
11,957 |
PIX |
Psychiatric Inpatient Experience Survey |
300 |
0.25 |
75 |
3364.5 |
119,700 |
5,369,742 |
Total |
6,479 |
Varies |
1,620 |
72,651 |
2,584,725 |
115,950,700 |
|
*CMS will collect these data using data from Medicare Part A, Part B, and Part D claims; therefore, these measures will not require facilities to submit data on any cases.
** Data to calculate this measure is collected under the CDC’s PRA with OMB control number 0920-1317.
IPFs must submit aggregate population counts for Medicare and non-Medicare discharges by age group and diagnostic group to CMS. Our currently approved information collection request estimates that it will take each facility approximately 2.0 hours to comply with this requirement, as shown in Table 3.
Table 3: Burden Associated with Non-Measure Data Collection and Submission
Tasks |
IPFs |
Hours per IPF |
Total Hours for All IPFs |
Wage Rate |
Cost per IPF ($) |
Total Cost for All IPFs ($) |
Non-measure Data Collection and Submission |
1,596 |
2.0 |
3,192 |
44.86 |
89.72 |
143,193 |
The Notice of Participation (NOP) must be completed once per facility and the Data Accuracy and Completeness Acknowledgement (DACA) form must be filled out only once for each data submission period. The Vendor Authorization form is optional. While it is estimated that these forms should take less than five (5) minutes to complete, the time estimated for data collection and reporting for each of the measures also includes the time for completing and submitting any forms related to the measures.
Table 4 shows the total estimated burden associated with the IPFQR Program.
Table 4: Total Facility Burden
Requirement |
Respondents |
Responses |
Time (hours) |
Cost ($) |
Measure Data Collection and Reporting |
1,596 |
10,340,484 (6,479 responses per facility * 1,596 facilities) |
2,584,725 |
115,950,700 |
Non-Measure Data Collection and Reporting |
1,596 |
6,384 (4 responses per facility *1,596 facilities) |
3,192 |
143,193 |
Notice of Participation (NOP), Data Accuracy Acknowledgement, and Vendor Authorization Form* |
N/A |
N/A |
N/A |
N/A |
TOTAL |
1,596 |
10,346,868 |
2,587,917 |
*The 15 minutes per measure estimate for chart abstraction under Measure Data Collection and Reporting also includes the time for completing and submitting any forms.
In the FY 2024 IPF PPS final rule, we have adopted two measures that require collecting data from patients using standardized instruments, specifically the Screening for Social Drivers of Health (SDOH) measure and the Psychiatric Inpatient Experience (PIX) measure. To derive the costs for beneficiaries, we used a measurement of the usual weekly earnings of wage and salary workers of $998, divided by 40 hours to calculate an hourly pre-tax wage rate of $24.95/hours. This rate is adjusted downwards by an estimate of the effective tax rate for median income households of about 17 percent, resulting in the post-tax hourly wage rate of $20.71/hour. Unlike our State and private sector wage adjustments, we are not adjusting beneficiary wages for fringe benefits and other indirect costs since the individuals’ activities, if any, would occur outside the scope of their employment.
Consistent with the Hospital Inpatient Quality Reporting (IQR) Program’s estimates when adopting the same measure for acute care hospitals (see OMB control number 0938-1022; CMS-10210), we estimate the time for each patient to complete the screening for the screening for social drivers of health measure to be 2 minutes. Because the number and type of questions on the PIX survey are similar to those on the HCAHPS survey, we estimate the time required to complete this survey to be 7.25 minutes, consistent with our estimate of the time required to complete the HCAHPS survey in the Information Collection Request associated with OMB control number 0938-0981 (CMS-10102).
The PIX survey was developed by a team at the Yale University, Yale New Haven Psychiatric Hospital to address the gap in available experience of care surveys, specifically the lack of publicly available, minimally burdensome, psychometrically validated surveys specified for the IPF setting. The interdisciplinary team that developed this survey, including researchers and clinicians, conducted the following steps in developing the survey: (1) literature review; (2) patient focus groups; (3) solicitation of input from a patient and family advisory council; (4) review of content validity with an expert panel; (5) development of survey; and (6) survey testing within the Yale New Haven Psychiatric Hospital system. The survey is distributed to patients by administrative staff at a time beginning 24 hours prior to planned discharge. It can be completed prior to discharge using either a paper copy of the survey or an electronic version of the survey via tablet computer.
The total patient burden associated with completing screenings and surveys is set forth in Table 5.
Table 5: Patient Burden Associated with Screenings
Measure/ Response Description |
# Facilities |
Estimated Surveys per Facility |
Total Annual Responses |
Time per Response (hours) |
Total Annual Time |
Total Annual Cost ($) |
Screening for SDOH |
1,596 |
1,261 |
2,012,556 |
0.033 |
66,414 |
1,375,441 |
PIX |
1,596 |
300 |
478,800 |
0.121 |
57,935 |
1,199,830 |
Total |
1,596 |
1,561 |
2,491,356 |
Varies |
124,349 |
2,575,271 |
The total burden associated with the IPFQR Program is depicted in Table 6.
Table 6: Total Requested IPFQR Program Burden
Measure/ Response Description |
# Facilities |
Total Annual Responses |
Total Annual Time |
Total Annual Cost ($) |
Facility Burden |
1,596 |
10,346,868 |
2,587,917 |
116,093,893 |
Patient Burden |
1,596 |
2,491,356 |
124,349 |
2,575,271 |
Total |
1,596 |
12,838,224 |
2,712,266 |
118,669,164 |
The following documents are part of the IPFQR program:
IPFQR Program Data Entry Screen Shots (Revised to show more recent images of online data entry).
Notice of Participation (No changes).
Psychiatric Inpatient Experience (PIX) survey (newly added).
Because the Facility Commitment to Health Equity measure, Screening for Social Drivers of Health measure, and Screen Positive Rate for Social Drivers of Health measure are newly adopted, forms for these measures are not yet available.
We are adopting the Screening for Social Drivers of Health measure. For IPFs that are not currently administering some screening mechanism and elect to begin doing so as a result of this policy, there may be some non-recurring costs associated with c in workflow and information systems to collect the data. The extent of these costs is difficult to quantify as different IPFs may utilize different modes of data collection (for example, paper-based, electronically patient-directed, clinician-facilitated, etc.).
Similarly, we are adopting the Psychiatric Inpatient Experience (PIX) survey measure. There may be some non-recurring costs associated with changes in workflow and information systems to administer this survey and collect the data. The extent of these costs is difficult to quantify as different facilities currently have different practices for surveying patients to gather information on their experiences of care.
The data for the IPFQR Program measures will be reported directly to the Hospital Quality Reporting system utilizing existing system functionality. A support contractor will be utilized to provide help desk and Q&A assistance, as well as the monitoring and evaluation effort for the program. There will be minimal costs for development of the data entry tools because the development is part of an existing software development contract.
The labor cost for IPFQR Program oversight is estimated as follows:
Current year 1.0 FTE (2,080 hours) at GS-13 (step 6) salary = $ 130,683
For subsequent years 1.0 FTE (2,080 hours) at GS-13 (step 6) salary = $ 130,683
This collection of information request describes changes associated with the changes to the IPFQR Program in association with the FY 2024 Inpatient Psychiatric Facility Prospective Payment System (IPF PPS) final rule (CMS-1783-F, RIN 0938-AV06) and burden adjustments based on the availability of more recent wage figures, facility estimates, and case estimates. The final rule-related changes include adoption of four measures and removal of two other measures. These changes impact FY 2025 through FY 2028 payment determinations. For the purposes of calculating burden, we attribute the costs to the year in which the costs begin. For the policies in the FY 2024 IPF PPS final rule those are CY 2024 through CY 2027. Overall, we project that the changes would reduce information collection burden by approximately 381,000 hours and approximately $8.1 million.
In the FY 2024 IPF PPS final rule, we modified the COVID-19 Vaccination Coverage Among HCP measure. The data for this measure are covered under the CDC’s OMB control number 0920-1317 and therefore this change should have no effect on burden under the IPFQR Program’s OMB control number (0938-1171).
In the FY 2024 IPF PPS final rule, we removed two chart abstracted measures beginning with the FY 2025 payment determination. Data for these measures would have been submitted in CY 2024, so we estimate the burden reduction to occur in CY 2024. The two measures are:
Patients Discharged on Multiple Antipsychotic Medications with Appropriate Justification (HBIPS‑5); and
Tobacco Use Treatment Provided or Offered and Tobacco Use Treatment (TOB-2 and TOB-2a).
The reduction in burden associated with removing these measures (using our currently approved wage estimates, facility estimates, and case counts) is shown in Table 7.
Table 7: Updates to Burden Associated with Proposed Measure Removals
Measure ID |
# Respondents (Facilities) |
Estimated Responses per Facility |
Total Annual Responses |
Time per Response (hours) |
Time per Facility (hours) |
Total Time (hours) |
Total Cost ($) |
HBIPS-5 |
1,634 |
(609*) |
(995,106) |
0.25 |
(152.25) |
(248,776.5) |
(10,199,836) |
TOB-2/2a |
1,634 |
(609*) |
(995,106) |
0.25 |
(152.25) |
(248,776.5) |
(10,199,836) |
TOTAL |
1,634 |
(1,218) |
(1,990,212) |
0.25 |
(304.5) |
(497,553) |
(20,399,672) |
As described in Section 12, we have updated our estimated wage rate, facility counts, and case counts based on more recent data. The effects of each of these updates are described here.
We previously estimated a wage rate of $41.00/hour; we are updating that estimate to $44.86/hour, a change of $3.86/hour. The effects of this update on the remaining measures in the IPFQR Program measure set are shown in Table 8.
Table 8: Effects of Updated Wage Rate
Data collection type |
Number of measures |
Cases per measure per facility |
Total number of cases per facility |
Effort per case (hours) |
Total effort per facility (hours) |
Change in cost per facility ($) (effort * 3.86/hour wage change) |
Non-sampling measures |
2 |
1,346 |
2,692 |
0.25 |
673 |
2,597.78 |
Sampling measures |
6 |
609 |
3,654 |
0.25 |
913.5 |
3,526.11 |
Non-Measure Data |
1 |
4 |
4 |
0.5 |
2 |
7.72 |
Total Change per Facility |
6,131.61 |
|||||
For the 1,634 in our previous estimate, this totals $10,019,051 ($6,131.61/facility * 1,634 facilities).
We have previously estimated 1,346 cases for measures which do not allow sampling. Based on more recent data, we are updating our estimate for measures that do not allow sampling to 1,261 cases per IPF (a change of -85 cases for each of these 2 measures). This is equivalent to -138,890 cases across the 1,634 IPFs (-85 cases * 1,634 IPFs) in our previous estimate for each measure. We are not changing our estimated case counts for measures that allow sampling. We continue to assume an average of 0.25 hours of effort per case. Therefore, this change in cases reflects a total annual effort of -42.5 hours per facility (2 measures * -85 cases per measure * 0.25 hours per case) at a savings of $1,906.55 (-42.5 hours * $44.86/hour).
We are also estimating a change in facility counts from 1,634 to 1,596; a decrease of 38 facilities. Table 9 shows the effects of this decrease.
Table 9: Effects of Updated Facility Counts
Measure Type |
Number of Measures |
Number of Estimated Cases (per measure per facility) |
Cases per Facility |
Effort per case |
Effort per facility |
Change in Annual Effort for removing 38 facilities (hours) |
Change in Annual Effort for removing 38 facilities (dollars) |
No Sampling |
2 |
1,261 |
2,522 |
0.25 |
630.5 |
(23,959) |
(1,074,800.74) |
Sampling |
6 |
609 |
3,654 |
0.25 |
913.5 |
(34,713) |
(1,557,225.18) |
Non-Measure Data Collection |
1 |
4 |
4 |
0.5 |
2 |
(76) |
(3,409.36) |
TOTAL |
9 |
Varies |
6,180 |
Varies |
1,546 |
(58,748) |
(2,635,435.28) |
At 6,180 cases per facility; removing 38 facilties removes a total of 234,840 cases (6,180 cases per facility * 38 facilities).
Beginning with the CY 2025 data submission (reflecting care provided in CY 2024), IPFs can voluntarily report data on the Screening for Social Drivers of Health measure. Therefore, facilities that choose to voluntarily report, will need to screen patients beginning in CY 2024. Consistent with the Hospital IQR Program’s estimates in the FY 2022 IPPS/LTCH PPS final rule (87 FR 49385 through 49386) under OMB control number 0938-1022 (CMS-10210), we estimate that roughly 50 percent of IPFs would survey 50 percent of their patients. Furthermore, we estimate that it would take each patient approximately 2 minutes (0.033 hours) to respond to this survey. The estimated patient survey burden associated with this proposed screening measure is set forth in Table 10.
Table 10: Patient Survey Burden Associated with Screening for SDOH Measure
|
Total Responses |
Total Annual Time (hours) |
Total Annual Cost ($) at $20.71/hour |
Screening for SDOH |
503,139 (0.50 x 1,596 facilities * 0.50 X 1,261 patients) |
16,603.59 |
343,860.29 |
The total changes in facility information collection and reporting burden for CY 2024 are set forth in Table 11.
Table 11: Total CY 2024 Facility Information Collection Burden Changes
|
Total Responses |
Total Annual Time (hours) |
Total Annual Cost ($) |
Remove Two Measures |
(1,990,212) |
(497,553) |
(20,399,672) |
Update Wage Estimate |
N/A |
N/A |
10,019,051 |
Update Case Estimate |
(277,780) |
(69,445) |
(3,115,302.70) |
Update Facility Estimate |
(234,840) |
(58,748) |
(2,635,435.28) |
Total |
(2,502,832) |
(625,746) |
(16,131,359) |
The total change in patient survey burden for CY 2024 are shown in Table 12.
Table 12: Total CY 2024 Patient Survey Burden Changes
|
Total Responses |
Total Annual Time (hours) |
Total Annual Cost ($) |
Screening for SDOH |
503,139 |
16,603.59 |
343,860.29 |
Total |
503,139 |
16,603.59 |
343,860.29 |
The FY 2024 IPF PPS final rule describes three new measures for reporting in CY 2025, one required measure and two voluntary measures. The required measure, the Facility Commitment to Health Equity measure, is an attestation measure similar to the Hospital Commitment to Health Equity measure adopted in the Hospital IQR Program in the FY 2023 IPPS/LTCH PPS final rule (87 FR 49385). Consistent with the Hospital IQR Program’s estimates, we estimate that reporting on this measure would be completed by all IPFs and that it would take each IPF approximately 10 minutes (0.167 hours) to report on this measure.
The two voluntary measures are the Screening for Social Drivers of Health (SDOH) measure and the Screen Positive Rate for SDOH measure. These measures are both dependent on the screening for SDOH described in the Effects of Proposals on Patient Burden subsection of the Updates Affecting Burden Beginning with CY 2024 section of this document. In that section we estimated that 50 percent of facilities would collect data in CY 2024, and therefore we estimate that these 50 percent would report the data in CY 2025.
The effects of these three proposed measures on facility reporting burden are summarized in Table 13.
Table 13: Facility Information Collection Burden Changes Associated with Three Proposed Measures
Measure/ Response Description |
# Respondents (Facilities) |
Estimated Responses per Facility |
Total Annual Responses |
Time per Response (hours) |
Annual Time per Facility (hours) |
Total Annual Time (hours) |
Total Annual Cost ($) |
Facility Commitment to Health Equity |
1,596 |
1 |
1,596 |
0.167 |
0.167 |
267.53 |
11,977.62 |
Screening for Social Drivers of Health |
798 |
1 |
798 |
0.167 |
0.167 |
133.26 |
5,966.38 |
Screen Positive Rate for Social Drivers of Health |
798 |
1 |
798 |
0.167 |
0.167 |
133.26 |
5,966.38 |
Totals |
1,596 |
3 |
3,192 |
0.167 |
0.167 |
534 |
To prepare for reporting in CY 2026 the facilties that had not previously screened patients for SDOH would need to screen patients, and all facilities would need to screen 100 percent of their patients. Using the facility counts, patient counts, and average hourly earnings described previously, we estimate the burden of surveying IPF patients for health-related social needs (HRSNs) under the Screening for Social Drivers of Health and Screen Positive Rate for Social Drivers of Health measures will be 66,414.35 hours (1,596 facilities x 1,261 patients per facility x 0.033 hours) at a cost of $1,375,441.19 (66,414.35 hours x $20.71/hour). We note that 16,603.59 hours and $343,960.29 of this burden was previously accounted for in our analysis of the burden of the voluntary reporting period. Therefore, the incremental burden of switching to required reporting is 49,810.76 hours and $1,031,480.90.
Additionally, we are adopting the Psychiatric Inpatient Experience (PIX) survey measure beginning with voluntary data submission in CY 2026. To prepare for data submission in 2026, IPFs will begin administering this survey in CY 2025. We believe 50 percent of IPFs will begin collecting these data for the voluntary data submission period. We note that we allow IPFs with more than 300 eligible discharges to sample, which would require these facilities to survey 300 patients. Because the questions on the PIX survey are similar in content and response options to the questions on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, we believe that it will take patients a similar amount of time to respond to these questions. In the Information Collection Request associated with OMB control number 0938-0981 (CMS-10102), we have estimated this time to be 7.25 minutes (0.121 hours).
Therefore, we believe that the burden associated with conducting the PIX survey in CY 2025 will be 28,967.4 hours (50 percent of 1,596 facilities x 300 patients/facility x 0.121 hours) at a cost of $599,914.85 (28,967.4hours x $20.71/hour).
Our estimates for the CY 2025 total patient survey burden changes are summarized in Table 14.
Table 14: Total CY 2025 Patient Survey Burden Changes
|
Total Responses |
Total Annual Time (hours) |
Total Annual Cost ($) |
Screening for SDOH |
1,509,417 |
49,810.76 |
1,031,580.86 |
PIX |
239,400 |
28,967.40 |
599,914.85 |
Totals |
1,748,817 |
78,778.16 |
Beginning with CY 2026 data submission (affecting the FY 2027 payment determination), we estimate that 100 percent of IPFs will submit data on the Screening for Social Drivers of Health measure and Screen Positive Rate for Social Drivers of Health measure. Because we have already accounted for 50 percent of facilities submitting voluntary data on these measures, the incremental burden is the burden associated with the remaining 50 percent of facilities submitting data; that is, we estimate this burden to be 266 hours at a cost of $11,932.76. We also believe that 50 percent of facilities will submit data on the PIX measure for the voluntary reporting period in CY 2025. Because the data for this measure will require calculating an average of scores across a sample of patient surveys, we anticipate that the information collection and reporting burden for this measure will be approximately 15 minutes (0.25 hours) per patient for whom they are reporting data. The burden associated with reporting the Screening for Social Drivers of Health measure, the Screen Positive Rate for Social Drivers of Health measure, and the PIX survey measure to CMS is described in Table 15.
Table 15: Total CY 2026 Facility Information Collection Burden Changes
Measure/ Response Description |
# Respondents (Facilities) |
Responses per Facility |
Total Annual Responses |
Time per Response (hours) |
Annual Time per Facility (hours) |
Total Annual Time (hours) |
Total Annual Cost ($) |
Screening for Social Drivers of Health |
798 |
1 |
798 |
0.167 |
0.167 |
133.2 |
5,978.04 |
Screen Positive Rate for Social Drivers of Health |
798 |
1 |
798 |
0.167 |
0.167 |
133.2 |
5,978.04 |
PIX Survey |
798 |
300 |
239,400 |
0.25 |
75 |
59,850 |
|
Totals |
798 |
302 |
240,996 |
Varies |
75.33 |
60,116.4 |
2,696,827.18 |
Because reporting the PIX measure will be required for FY 2028 payment determination, the remaining 50 percent of facilities (those which did not participate in the voluntary reporting period) will begin surveying patients in CY 2026. To prepare for data submission of the PIX survey measure in CY 2027, IPFs that had not previously begun administering the PIX survey will begin administering this survey in CY 2026. The incremental burden of these 50 percent of facilities administering the survey is equivalent to the burden associated with the 50 percent of facilities that participated in the voluntary reporting in CY 2025. These estimates are summarized in Table 16.
Table 16: Total CY 2026 Patient Survey Burden Changes
|
Total Responses |
Total Annual Time (hours) |
Total Annual Cost ($) |
PIX |
239,400 |
28,967.4 |
599,914.85 |
For data submission occurring in CY 2027, submission on the PIX survey measure will be required, therefore, we believe that an additional 50 percent of facilities will report the measure (that is, the 50 percent of facilities not previously accounted for under the voluntary reporting period). Therefore, we estimate that the incremental increase in burden for IPFs associated with this requirement will be reporting by the 50 percent of facilities that had not previously reported the PIX survey measure. This burden is depicted in Table 17.
Table 17: Total CY 2027 Facility Information Collection Burden Changes
Measure/ Response Description |
# Respondents (Facilities) |
Estimated Responses per Facility |
Total Annual Responses |
Time per Response (hours) |
Annual Time per Facility (hours) |
Total Annual Time (hours) |
Total Annual Cost ($) |
PIX Survey |
798 |
300 |
239,400 |
0.25 |
75 |
59,850 |
2,684,871.00 |
Table 18 summarizes the incremental changes in burden for IPFs associated with policies for data collection and submission in CYs 2024 through 2027 as well as updates to our estimated wage rate, facility counts, and case counts.
Table 18: Proposed Incremental Changes in Facility Burden
|
Total Responses |
Total Annual Time (hours) |
Total Annual Cost ($) |
Changes Associated with CY 2024 Updates |
(2,502,832) |
(625,746) |
(16,131,359) |
Changes Associated with CY 2025 Updates |
3,192 |
534 |
23,911 |
Changes Associated with CY 2026 Updates |
240,996 |
60,116 |
2,696,827 |
Changes Associated with CY 2027 Updates |
239,400 |
59,850 |
|
Total |
(2,019,244) |
(505,246) |
Table 19 summarizes the incremental changes in burden for patients due to data collection associated with policies for data collection and submission in CYs 2024 through CY 2026.
Table 19: Proposed Incremental Changes in Survey Burden for Patients
|
Total Responses |
Total Annual Time (hours) |
Total Annual Cost ($) |
Changes Associated with CY 2024 Updates |
503,139 |
16,604 |
343,860 |
Changes Associated with CY 2025 Updates |
1,748,817 |
78,778 |
1,631,496 |
Changes Associated with CY 2026 Updates |
239,400 |
28,967 |
599,915 |
Changes Associated with CY 2027 Updates |
No change |
No change |
No change |
Totals |
2,491,356 |
124,349 |
Table 20 shows the total changes in burden associated with the changes to the IPFQR Program.
Table 20: Total Changes in IPFQR Burden:
|
Total Responses |
Total Annual Time (hours) |
Total Annual Cost ($) |
CY 2024 Facility Changes |
(2,502,832) |
(625,746) |
(16,131,359) |
CY 2024 Patient Changes |
503,139 |
16,604 |
343,860 |
CY 2024 Subtotal |
(1,999,693) |
(609,142) |
(15,787,499) |
CY 2025 Facility Changes |
3,192 |
534 |
23,911 |
CY 2025 Patient Changes |
1,748,817 |
78,778 |
1,631,496 |
CY 2025 Subtotal |
1,752,009 |
79,312 |
1,655,407 |
CY 2026 Facility Changes |
240,996 |
60,116 |
2,696,827 |
CY 2026 Patient Changes |
239,400 |
28,967 |
599,915 |
CY 2026 Subtotal |
480,396 |
89,083 |
3,296,742 |
CY 2027 Facility Changes |
239,400 |
59,850 |
2,684,871 |
CY 2027 Patient Changes |
0 |
0 |
0 |
CY 2027 Subtotal |
239,400 |
59,850 |
2,684,871 |
Total |
472,112 |
(380,897) |
(8,150,479) |
IPFs will submit their measures through the Hospital Quality Reporting system. After IPFs have previewed their data, CMS will publicly display the measure rates on the CMS website. The following is the planned schedule of activities to reach these objectives.
Table 21 shows the timeline for measures for the FY 2026 payment determination.
Table 21: Timeline for FY 2026 Payment Determination
Date |
Scheduled Activity |
4/4/2023 |
Proposed Rule Displayed |
8/2/2023 |
Final Rule Published |
1/1/2024 |
Start of Reporting Period |
12/31/2024 |
End of Reporting Period |
7/1/2025 |
Begin Data Submission (approximate) |
8/15/2025 |
End Submission Deadline (approximate) |
8/15/2025 |
Deadline to Complete Data Accuracy and Completeness Acknowledgement (DACA) * |
FY 2026 |
Public Display of data on Care Compare* |
*Specific dates to be announced via subregulatory guidance
We will display the expiration date on associated forms.
There are no exceptions to the certification statement.
B. Collection of Information Employing Statistical Methods
The PIX survey does not require sampling and CMS will not employ any statistical methods or sampling in the calculation of survey results. However, IPFs can choose to use a valid sampling methodology for collecting survey data, though they are not required to do so.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | CMS |
| File Modified | 0000-00-00 |
| File Created | 2023-10-19 |