/ en Tue, 29 Apr 2025 22:59:48 -0500 Fri, 11 Apr 25 18:21:11 -0500 /news/headline/2025-04-11-inpatient-psychiatric-facilities-rule-would-increase-payments-24 <p>The Centers for Medicare & Medicaid Services April 11 issued a <a href="https://www.federalregister.gov/public-inspection/2025-06298/medicare-program-fiscal-year-2026-inpatient-psychiatric-facilities-prospective-payment-system---rate">proposed rule</a> for the inpatient psychiatric facility prospective payment system for fiscal year 2026.  <br> <br>CMS proposes to increase IPF payments by a net 2.4%, equivalent to $70 million, in FY 2026. The payment update reflects a proposed market-basket update of 3.2% minus a productivity adjustment of 0.8 percentage points. CMS also proposes to update the outlier threshold so that estimated outlier payments remain at 2.0% of total payments. In addition, the agency would increase the adjustment factors for IPFs with teaching status and rural location and recognize increases to IPF teaching caps as required by law.  <br> <br>For the IPF Quality Reporting Program, CMS proposes to remove four structural measures and revise the reporting period for its emergency department visit following the IPF discharge measure. The rule also includes requests for information on a potential star rating system for IPFs, nutrition and well-being measures for the IPFQRP, and the use of Fast Healthcare Interoperability Resources standards for reporting patient assessment data.   <br> <br>In addition, CMS has included in the rule its previously published request for information seeking input on opportunities to streamline regulations and reduce burdens on providers.  <br> <br>For more details, see the <a href="https://www.cms.gov/newsroom/fact-sheets/fiscal-year-2026-medicare-inpatient-psychiatric-facility-prospective-payment-system-and-quality">CMS fact sheet</a>. CMS will accept comments on this rule through June 10.</p> Fri, 11 Apr 2025 18:21:11 -0500 Psychiatric PPS <div class="container"><div class="row"><div class="col-md-8"><p>The Centers for Medicare & Medicaid Services (CMS) July 31 issued its fiscal year (FY) 2025<a href="https://www.federalregister.gov/public-inspection/2024-16909/medicare-program-fy-2025-inpatient-psychiatric-facilities-prospective-payment-system-rate-update" target="_blank" title="Final Rule"> final rule</a> for the inpatient psychiatric facility (IPF) prospective payment system (PPS).</p><div class="panel module-typeC"><div class="panel-heading"><h2>Key Highlights</h2><p>The final rule:</p><ul><li>Updates the IPF payment rate by a net 2.5% in FY 2025 as compared to FY 2024.</li><li>Clarifies eligibility criteria for filing all-inclusive cost reports.</li><li>Adopts one new quality measure, but will not require quarterly patient-level data reporting as originally proposed.</li></ul></div></div><h2>AHA TAKE </h2><p>The final rule contains mostly routine payment updates that do not deviate in significant ways from the proposed rule. However, the Medicare program’s market basket updates continue to fall well short of the sharply increased costs hospitals have faced in recent years. The AHA is disappointed CMS did not take steps to address these shortcomings and will continue to pursue potential modifications to these updates in the future. While we appreciate that CMS did not finalize its burdensome proposal to require more frequent data reporting, we are disappointed that the agency chose to adopt a quality measure that we believe will bring little value to patients and providers. </p><p>Highlights from the rule follow. </p><h2>FINAL IPF PPS PAYMENT PROVISIONS  </h2><p>CMS makes several updates to IPF payment rates. CMS increases IPF payments by a net 2.5%, equivalent to $65 million, in FY 2025. This includes a 3.3% market basket update, a 0.5% productivity cut as required by law, and a decrease in aggregate payments of 0.3% as a result of an update to the outlier threshold. The labor-related share for FY 2025 will be 78.8%, an increase from the FY 2024 labor-related share of 78.7%. The fixed dollar loss threshold amount will be $38,110 (an increase from the previous amount of $33,470) to maintain estimated outlier payments at 2% of the total estimated aggregate IPF PPS payments.</p><p><strong>All-Inclusive Cost Reporting</strong>. IPFs and psychiatric units are required to report data on ancillary services provided and file cost reports on an annual basis. However, CMS’ analysis has found a notable increase in the number of IPFs (specifically for-profit freestanding IPFs) that, on particular CMS worksheets, are erroneously identifying as being eligible for filing all-inclusive cost reports. The option to elect to file an all-inclusive rate cost report is limited to providers that do not have a charge structure (such as government-owned facilities) and thus must use a different way to apportion costs associated with their services. In other words, rather than reporting ancillary charges for items such as labs and drugs, certain facilities are incorrectly reporting that they have a single charge covering all services and items. </p><p>In response to a request for information on the topic in previous rulemaking, CMS clarifies in this rule that hospitals can only file all-inclusive cost reports if they have never had a charge structure in place; only government-owned or tribally owned facilities meet this criterion and will be permitted to file all-inclusive cost reports beginning with the cost reporting period that starts Oct. 1, 2024 (for which cost reports are submitted after Oct. 1, 2025). CMS will issue guidance specifying that a facility cannot convert to a system where they operate under an all-inclusive rate. All other IPFs must have a charge structure and must report ancillary costs and charges on their cost reports. This provision is not a proposed change to policy, but rather a clarification of existing regulations.</p><h2>IPF QUALITY REPORTING PROGRAM (IPFQRP) </h2><p>CMS will adopt one new quality measure to the IPFQRP, but it did not finalize its proposal to require more frequent reporting of patient-level measure data. </p><p><strong>Adoption of the All-Cause Risk-Standardized Emergency Department (ED) Visit Following IPF Discharge Measure</strong>. CMS will adopt this measure that assesses the number of ED visits and observation stays for any reason (related to their psychiatric hospitalization or not) within 30 days of IPF discharge beginning with the CY 2025 performance period (which informs FY 2027 payments).</p><p>The measure excludes patients discharged against medical advice from the IPF index admission, patients with unreliable data regarding death or demographics in their claims record, patients who died during the IPF stay, patients who were transferred to another care facility, and patients discharged but readmitted within three days of discharge (“interrupted stay.”) Measure calculation incorporates risk factors in the 12 months prior to index admission and comorbid conditions to “standardize” the ED visit rate for each IPF, meaning measure results would be comparable across IPFs regardless of the clinical complexity of each IPF’s patient population. The measure is calculated using information from Medicare claims (Part A and Part B) as well as Medicare beneficiary and coverage files; IPFs will not need to submit any additional data for this measure.</p><p>CMS submitted the measure to the consensus-based entity (CBE) for endorsement review; the CBE did not endorse the measure. The IPFQRP currently has three other measures that assess post-discharge outcomes: Follow-up after Psychiatric Hospitalization; Medication Continuation Following Inpatient Psychiatric Discharge; and 30-Day All Cause Unplanned Readmission Following Psychiatric Hospitalization. </p><p><strong>Not Finalized: Quarterly Reporting of Patient-level Data</strong>. CMS did not finalize its proposal to require IPFs to submit patient-level data to inform IPFQRP measures on a quarterly basis, rather than annually as currently required, beginning Jan. 1, 2025. </p><p>IPFs have been required to report patient-level data for chart-abstracted measures within the IPFQRP beginning in 2023 (for the FY 2024 payment determination). The experience of the past year has demonstrated that annual data submission requires IPFs to store large volumes of patient data to prepare for transmission to CMS, which creates the risk that CMS systems will be unable to handle all of this data in a single submission period. In addition, CMS argued in the proposed rule that quarterly reporting will allow them to better analyze measure trends over time. However, several commenters, including the AHA, expressed concerns regarding the challenges of transitioning to quarterly reporting. In response, CMS opted not to finalize the proposal and noted that if the agency proposed to adopt quarterly reporting in the future, it will consider the transition time required for IPFs to update their submissions, as well as the timing of the CMS Specifications Manual. </p><h2>FURTHER QUESTIONS </h2><p>If you have questions, please contact Caitlin Gillooley, AHA’s director for quality and behavioral health policy, at 202-626-2267 or <a href="mailto:cgillooley@aha.org" target="_blank" title="Caitlin Gillooley,">cgillooley@aha.org</a>.</p></div><div class="col-md-4"><p><a href="/system/files/media/file/2024/08/inpatient-psychiatric-facility-pps-final-rule-for-fy-2025-advisory-8-1-2024.pdf" target="_blank" title="Click here to download the Regulatory Advisory: Inpatient Psychiatric Facility PPS: Final Rule for FY 2025 PDF."><img src="/sites/default/files/2024-08/cover-inpatient-psychiatric-facility-pps-final-rule-for-fy-2025-advisory-8-1-2024.png" data-entity-uuid data-entity-type="file" alt="Regulatory Advisory: Inpatient Psychiatric Facility PPS: Final Rule for FY 2025 cover." width="NaN" height="NaN"></a></p></div></div></div> Thu, 01 Aug 2024 15:23:54 -0500 Psychiatric PPS /news/headline/2024-07-31-cms-final-rule-will-update-ipf-payments-25 <p>The Centers for Medicare & Medicaid Services July 31 issued the <a href="https://public-inspection.federalregister.gov/2024-16909.pdf" target="_blank">final rule</a> for the inpatient psychiatric facility prospective payment system for fiscal year 2025. CMS will increase IPF payments by a net 2.5%, equivalent to $65 million, in FY 2025. This increase includes a market-basket update of 3.3% minus a productivity adjustment of 0.50 percentage points; it also accounts for an update to the outlier threshold so that estimated outlier payments will remain at 2.0% of total payments, resulting in a 0.3% decrease to aggregate payments. CMS also clarifies the eligibility criteria for filing all-inclusive cost reports and makes operational changes such that, beginning Oct. 1, 2024, only government or tribally-owned IPFs can file this type of cost report. For the IPF Quality Reporting Program, CMS will adopt one new quality measure on all-cause emergency department visits following IPF discharge. The agency did not finalize its proposal to require IPFs to submit patient-level quality data on a quarterly basis, and will retain the current annual requirement. <br><br>AHA members will receive more information on the rule. </p> Wed, 31 Jul 2024 17:42:06 -0500 Psychiatric PPS /lettercomment/2024-05-28-aha-comments-inpatient-psychiatric-facility-fy-2025-proposed-payment-rule <div class="container"><div class="row"><div class="col-md-8"><p>May 28, 2024</p><p>The Honorable Chiquita Brooks-La Sure<br>Administrator<br>Centers for Medicare & Medicaid Services<br>Department of Health and Human Services<br>Attention: CMS-1806-P<br>P.O. Box 8010<br>Baltimore, MD 21244-8010</p></div><div class="col-md-4"><div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/system/files/media/file/2024/05/AHA-Comments-on-Inpatient-Psychiatric-Facility-FY-2025-Proposed-Payment-Rule-letter.pdf" target="_blank" title="Click here to download the AHA Comments on Inpatient Psychiatric Facility FY 2025 Proposed Payment Rule letter PDF.">Download the Letter PDF</a></div></div></div><div class="row"><div class="col-md-8"><p>Dear Administrator Brooks-LaSure:</p><p>On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations, our clinician partners and, especially, the 106 psychiatric hospitals and 846 hospitals with dedicated behavioral health beds, and our clinician partners — more than 270,000 affiliated physicians, two million nurses and other caregivers — and the 43,000 health care leaders who belong to our professional membership groups, the ���������� Association (AHA) appreciates the opportunity to comment on the Centers for Medicare & Medicaid Services’ (CMS) inpatient psychiatric facility (IPF) prospective payment system (PPS) proposed rule for fiscal year (FY) 2025.</p><p><strong>While we are grateful for the chance to provide feedback on the revisions to the IPF PPS as well as the development of an IPF patient assessment instrument (PAI), we urge CMS to proceed on the latter with more caution and less haste. We believe that the agency can both meet its statutory responsibilities and take its time to ensure high-quality and accurate results. In addition, we are concerned that CMS’ proposed market basket update is inadequate to ensure continued support of the vital services IPFs provide to their communities. Finally, we do not support the measure proposed for adoption in the IPF quality reporting (IPFQR) program.</strong></p><h2>Proposed IPF Payment Updates</h2><p>CMS proposes to increase payments to IPFs by a net 2.6%, or $70 million, in FY 2025 compared to FY 2024. This payment update includes a 3.1% market basket update minus a 0.4 percentage point productivity cut as required by the Affordable Care Act and a cut of 0.1 percentage point to keep outlier payments at 2%.</p><h3>Market Basket Update</h3><p>CMS’ proposed market basket update is woefully inadequate in the face of the enormous cost pressures faced by IPFs, which include inflationary pressures as well as longstanding underpayments by public payers. For example, in its June 2023 Report to Congress, the Medicare Payment Advisory Commission (MedPAC) determined that Medicare has failed to cover the cost of caring for patients in hospital-based and freestanding nonprofit IPFs since at least calendar year (CY) 2016.<a href="#fn1"><sup>1</sup></a> Notably, aggregate Medicare margins across all IPFs were <em>negative</em> 9.4% in CY 2021 and an astounding <em>negative</em> 28.3% for hospital-based nonprofit IPFs that same year. These data demonstrate the critical financial pressures faced by IPFs, largely related to skyrocketing labor, supply and inflationary costs faced by facilities since then. Indeed, by virtue of the directive to revise the IPF PPS payment methodology to better capture costs faced by these facilities, MedPAC and Congress themselves have also acknowledged that Medicare’s current payment system for IPFs is inadequate.</p><p>Further, IPFs and all hospitals have seen a dramatic increase in their costs over the last four years. The inflation seen by these facilities, particularly those who care for complexly ill patients like those served by IPFs, has created novel challenges such as employee and labor costs. For example, a recent report from the AHA finds that hospital employee compensation has grown by 45% since 2014.<a href="#fn2"><sup>2</sup></a> This contrasts with total inflation, which only grew by 28.7% in that time. Labor-related inflation has been driven in large part by a severe workforce shortage, which the Department of Health and Human Services (HHS) says will persist well into the future.<a href="#fn3"><sup>3</sup></a> Indeed, McKinsey finds that resignations per month among health care workers grew 50% from 2020 through 2023.<a href="#fn4"><sup>4</sup></a> Because of this, hospitals are turning to pricey contract labor to sustain operations. Indeed, contract labor costs increased by 258% from 2019 through 2023.<a href="#fn5"><sup>5</sup></a> These increased costs are felt acutely by IPFs as they struggle to maintain highly skilled staff in the form of psychiatrists, psychiatric mental health nurses, mental health technicians, clinical social workers, psychologists and therapists.</p><p>Drug and supply costs have also pressured hospital operations due to disruptions in the supply chain and other factors. In fact, HHS found that prices for nearly 2,000 drugs increased an average of 15.2% from 2017 through 2023, notably faster than the rate of general inflation.<a href="#fn6"><sup>6</sup></a> Further, the American Society of Health System Pharmacists has found that numerous drug shortages are having a critically negative impact on hospital operations.<a href="#fn7"><sup>7</sup></a></p><p>Administrative costs have also risen sharply for IPFs in recent years due to burdensome and unnecessary Medicare Advantage (MA) and commercial insurer practices. For example, a study by the U.S. Government Accountability Office found that prior authorization by commercial payers is less likely to be granted for mental health hospital stays compared with medical and surgical hospital stays, and these payers often deny payment for further coverage of inpatient treatment even if a physician determines that additional treatment is needed.<a href="#fn8"><sup>8</sup></a> Supporting this, McKinsey estimated that hospitals spent $10 billion annually dealing with insurer prior authorizations, and a 2023 study by Premier found that hospitals are spending just under $20 billion annually appealing denials.<a href="#fn9"><sup>9</sup></a> Despite recent efforts by CMS, IPFs report there has not been any relief from these practices in 2024, and hospitals and systems will need to continue to devote considerable resources toward them for the foreseeable future.</p><p>These escalating costs for essential clinicians, personnel, drugs, supplies and other items have put a strain on the entire health care continuum. In all, Kaufman Hall found that overall expenses have risen 18% for hospitals compared to 2021.<a href="#fn10"><sup>10</sup></a> This is felt keenly by IPFs, who care for high-acuity patients with unique care needs. <strong>For these reasons, we urge CMS to provide a more robust payment update for FY 2025 and in the future until a more accurate PPS methodology can be adopted.</strong></p><h3>All-inclusive Cost Reporting</h3><p>CMS clarifies in this proposed rule that hospitals can only use an all-inclusive rate or no charge structure if they have never had a charge structure in place. The agency states that only government- and tribally-owned facilities meet this criterion, and thus it states that only these facilities will be permitted to file all-inclusive cost reports beginning Oct. 1, 2024. <strong>While we understand and agree with CMS’ clarification of this issue, we request that they provide facilities with more time to come into compliance.</strong></p><p>Specifically, IPFs have not been filing all-inclusive cost reports to circumvent appropriate reporting of ancillary charges. Indeed, as demonstrated by L&M Policy Research’s report for MedPAC based on interviews with IPFs, facilities track ancillary services internally; however, reporting these services is time-consuming.<a href="#fn11"><sup>11</sup></a> Further, because IPFs are paid based on per-diem contract arrangements regardless of the scope or intensity of the ancillary services provided, the reporting of the services does not appear to have a direct influence on payment. We agree with CMS that IPF payments need to better represent costs incurred, and that reporting ancillary costs is one step in capturing this information. However, we suggest CMS be lenient with facilities as they transition from what they believed was a proper option for cost reporting.</p><h2>IPFQR Proposals</h2><h3>Adoption of the All-Cause Risk-Standardized Emergency Department (ED) Visit Following IPF Discharge Measure</h3><p>CMS proposes to adopt this measure that assesses the number of ED visits and observation stays for any reason within 30 days of IPF discharge beginning with the CY 2025 performance period (which informs FY 2027 payments). <strong>The AHA does not support the adoption of this measure for the IPFQR.</strong></p><p>The AHA understands the concept behind the measure in that the post-discharge period for IPF patients is particularly vulnerable, and that providers have the responsibility to thoughtfully prepare patients for discharge. However, the measure is so broadly defined that it is hard to determine how it would be used to improve inpatient psychiatric care. Indeed, the evidence provided in this measure’s specifications does not make a connection between specific evidence-based interventions and measure outcomes.</p><p>Even with risk standardization, counting ED visits for any cause — related to their psychiatric hospitalization or not — assigns responsibility to the discharging IPF for incidents the facility could not possibly predict or prevent. In other CMS quality reporting programs (such as those for inpatient rehabilitation facilities, skilled nursing facilities, long-term care facilities and home health agencies), CMS has shifted to using measures of potentially preventable readmissions; additional CMS programs, like those for Outpatient and Ambulatory Surgery Center services, use measures that assess hospitalizations or ED visits in specific contexts such as chemotherapy, particular surgery types or colonoscopy. It is unclear why CMS believes IPFs have a wider range of accountability for return ED visits than do other types of facilities.</p><p>Further, this measure failed endorsement by a Consensus-based Entity (CBE) because it was evaluated to have low scientific acceptability. According to the measure’s background documentation, facilities included in the measure’s testing found the measure difficult to understand and not useful for decision-making. We understand that CMS is not required to only use measures endorsed by a CBE in its programs, but when the measure demonstrates both statistical and conceptual weaknesses as this measure does, CMS should find it unworthy for its programs.</p><p>Finally, the AHA again — as we did in our <a href="/lettercomment/2023-06-05-aha-comments-fy-2024-proposed-rule-inpatient-psychiatric-facilities">comments on the FY 2024 IPF PPS proposed rule</a> — expresses our continuing disappointment with the lack of proposed new measures for the IPFQR that are specifically designed and tested to measure the provision of inpatient psychiatric care. The IPFQR currently has three other measures that assess post-discharge outcomes: Follow-up after Psychiatric Hospitalization; Medication Continuation Following Inpatient Psychiatric Discharge; and 30-Day All Cause Unplanned Readmission Following Psychiatric Hospitalization. Not only would the proposed all-cause ED visits measure likely overlap these measures, but it also would perpetuate the focus of IPF quality on what happens outside the IPF rather than on the care provided or safety of patients while in the facility.</p><h3>Quarterly Reporting of Patient-level Data</h3><p>CMS proposes to require IPFs to submit patient-level data to inform IPFQR measures on a quarterly basis beginning with data collected during the first quarter of 2025, rather than annually as has been required since 2023. The agency reasons that its systems may be unable to handle the volume of data when submitted in a single period, and that more frequent reporting will allow CMS to better analyze measure trends over time. We believe this quadrupling of effort would be a disruption for IPFs without much benefit. CMS reasons that it requires quarterly reporting of chart-abstracted data for certain measures in the Inpatient Quality Reporting System, but IPF discharges are just about 3% the volume of short-stay general acute care hospital discharges; the comparatively lower volumes in IPFs mean that shifts in trends would be difficult to detect in such small intervals, and CMS does not propose to update publicly reported quality measure data more frequently as a result of this proposed update. <strong>For these reasons, we urge CMS to continue with annual reporting to glean insights regarding IPF data reporting on more than just one year of experience and delay quarterly reporting beyond 2025.</strong></p><h2>Requests for Information</h2><h3>Revisions to Facility-level Adjustment Factors</h3><p>The Consolidated Appropriations Act (CAA) of 2023 requires CMS to implement revisions to the IPF PPS payment methodology beginning in FY 2025. In this proposed rule, CMS seeks feedback on whether it would be appropriate to consider proposing revisions to facility-level adjustments in the future based on the results of their recent analysis. Specifically, CMS requests input on adjustments for rural location, teaching status, and an indicator of low-income patient mix called the Medicare Safety Net Index (MSNI).</p><p><strong>The AHA discourages CMS from using the MSNI as a facility-level adjustment.</strong> MedPAC developed the MSNI as an alternative way to distribute disproportionate share hospital and uncompensated care payments due to what it determined to be inefficiencies with these current adjustments. The index is a composite adjustment comprised partially of a facility’s Medicare dependency ratio — the percentage of IPF stays covered by Medicare as opposed to other payers. Thus, it would put facilities that serve large proportions of low-income patients who are not Medicare beneficiaries (such as the uninsured, older adults on Medicaid or commercial insurance, or children on Medicaid) at an inappropriate disadvantage. CMS’ own analysis demonstrated that including MSNI in its regression would lead to a decrease in the adjustment for rural location and teaching status for IPFs, suggesting that the index is not consistent with other indicators of safety-net status. MedPAC did not develop the MSNI with the IPF PPS and specific patient/payer mix of IPFs in mind. The unique aspects of IPF payment — such as the Institutions for Mental Disease Exclusion and the 190-day lifetime limit under Medicare for inpatient psychiatric care coverage — might skew the application of the MSNI.</p><p>In addition, CMS does not issue impact files, which estimate payment impacts of various policy changes to the payment system, for IPFs. This makes it challenging at best to determine how the MSNI would affect their payments. Thus, for us to be able to fully and thoughtfully comment on the potential use of this adjustment, AHA requests that the agency provide detailed data for analysis.</p><h3>IPF Patient Assessment Instrument (IPF-PAI)</h3><p>The CAA of 2023 requires IPFs participating in the IPFQR program to collect and submit certain patient assessment data using a standardized PAI beginning with admissions and discharges in FY 2028. In its request for information on the development of this tool, CMS draws upon the experience from the development of standardized patient assessment data elements (SPADEs) for use across post-acute care settings as required by the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014.</p><p><strong>We urge CMS to avoid the approach the agency used to implement IMPACT Act requirements in developing the IPF-PAI. The overall process was rushed and has resulted in significant confusion and burden in the post-acute field, and a similar result for the IPF field would be a disservice to patients and providers.</strong> In attempting to meet the statutory requirements of the IMPACT Act, CMS first proposed 23 new SPADEs in the FY 2018 post-acute care prospective payment system proposed rules. Most of the elements were existing items used in other settings and proposed to be implemented without setting-specific revision or testing for validity and reliability. In response to concerns raised by stakeholders including the AHA, CMS did not finalize its proposals. Instead, the agency met its statutory duty by requiring post-acute care facilities to collect and submit patient assessment data on categories already required to be reported for the purposes of calculating existing quality measures. In the meantime, the agency conducted a national beta test of the SPADEs to further refine their proposals over the next two years. This disjointed rollout has introduced uncertainty and confusion to the post-acute care field around whether and how CMS might alter or expand its SPADE requirements.</p><p>In the case of the IPF-PAI, CMS notes that it anticipates convening a Technical Expert Panel (TEP) to provide input on data elements to include in the PAI and testing the elements for their ability to detect differences among patients and costs of treatment; however, the agency also states that it may not be possible to complete all testing before launching the IPF-PAI in FY 2028. This extremely quick turnaround is concerning.</p><p>We believe that CMS can meet its statutory duty to implement a PAI by FY 2028 as it did for the IMPACT Act by developing a tool limited in scope and then expand upon this tool after further data elements have been appropriately tested for validity and reliability. <strong>In other words, the AHA recommends that CMS use feedback from this RFI as well as TEPs and stakeholder input to build or build upon an existing tool that uses few and simple elements to meet the statutorily required domains.</strong> Then, the agency can develop not only a comprehensive patient assessment tool over time but can also work with clinical oversight bodies to come up with guidance on how IPFs can use the IPF-PAI to replace other assessment processes to reduce burden and encourage consistency.</p><p>The CAA calls for IPFs to collect and submit standardized patient assessment data on the categories of functional status; cognitive function and mental status; special services, treatments, and interventions; medical conditions and comorbidities; and impairments. IPFs already collect and submit patient data relevant to at least some of these categories. For example, facilities are required to report whether a patient was provided with tobacco use treatment for the TOB-3 measure (Tobacco Use Treatment Provided or Offered at Discharge), which CMS could consider reporting of the special services, treatments and interventions domain. Similarly, for the Screening for Metabolic Disorders measure, facilities are required to report whether they measured a patient’s blood glucose, blood pressure, body mass index, blood lipids and discharge disposition; CMS could consider reporting of this information to meet the medical conditions and comorbidities domain.</p><p><strong>In summary, we urge CMS to work with stakeholders to determine a reasonable timeline for the development of the IPF-PAI even if it goes beyond the FY 2028 date prescribed by the CAA; if necessary, the agency can meet these requirements with data already collected by IPFs.</strong></p><p>Again, we thank you for your consideration of our comments. Please contact me if you have questions, or feel free to have a member of your team contact Caitlin Gillooley, AHA’s director of policy, at <a href="mailto:cgillooley@aha.org?subject=RE: AHA Comments on Inpatient Psychiatric Facility FY 2025 Proposed Payment Rule letter">cgillooley@aha.org</a> or <a href="tel:1-202-626-2267">(202) 626-2267</a>.</p><p>Sincerely,</p><p>/s/</p><p>Ashley B. Thompson<br>Senior Vice President, Policy Analysis and Development</p><hr><ol><li id="fn1">MedPAC, Congressional Request: Behavioral Health Services in the Medicare Program (June 2023). <a href="https://www.medpac.gov/wp-content/uploads/2023/06/Jun23_Ch6_MedPAC_Report_To_Congress_SEC.pdf" target="_blank">https://www.medpac.gov/wp-content/uploads/2023/06/Jun23_Ch6_MedPAC_Report_To_Congress_SEC.pdf</a></li><li id="fn2"><a href="/system/files/media/file/2024/05/Americas-Hospitals-and-Health-Systems-Continue-to-Face-Escalating-Operational-Costs-and-Economic-Pressures.pdf" target="_blank">/system/files/media/file/2024/05/Americas-Hospitals-and-Health-Systems-Continue-to-Face-Escalating-Operational-Costs-and-Economic-Pressures.pdf</a></li><li id="fn3">ASPE Office of Health Policy, <em>Impact of the COVID-19 Pandemic on the Hospital and Outpatient Clinician Workforce,</em> HP-2022-13 at 1 (May 3, 2022).</li><li id="fn4"><a href="/system/files/media/file/2024/05/Americas-Hospitals-and-Health-Systems-Continue-to-Face-Escalating-Operational-Costs-and-Economic-Pressures.pdf" target="_blank">McKinsey & Company. (Sept. 2023). How Health Systems and Educators Can Work to Close the Talent Gap. </a><a href="https://www.mckinsey.com/industries/healthcare/our-insights/how-health-systems-and-educators-can-work-to-close-the-talent-gap" target="_blank">https://www.mckinsey.com/industries/healthcare/our-insights/how-health-systems-and-educators-can-work-to-close-the-talent-gap</a></li><li id="fn5">Syntellis and AHA, <em>Hospital Vitals: Financial and Operational Trends.</em> (Last visited May 8, 2023), <a href="https://www.syntellis.com/sites/default/files/2023-03/AHA%20Q2_Feb%202023.pdf" target="_blank">https://www.syntellis.com/sites/default/files/2023-03/AHA%20Q2_Feb%202023.pdf</a>.</li><li id="fn6">ASPE. (Oct. 2023). Changes in the List Prices of Prescription Drugs, 2017-2023. <a href="https://aspe.hhs.gov/reports/changes-list-prices-prescription-drugs" target="_blank">https://aspe.hhs.gov/reports/changes-list-prices-prescription-drugs</a></li><li id="fn7"><a href="https://news.ashp.org/-/media/assets/drug-shortages/docs/ASHP-2023-Drug-Shortages-Survey-Report.pdf" target="_blnak">https://news.ashp.org/-/media/assets/drug-shortages/docs/ASHP-2023-Drug-Shortages-Survey-Report.pdf</a></li><li id="fn8">DHHS GAO. (2022). Mental Health Care: Access Challenges for Covered Consumers and Relevant Federal Efforts. <a href="https://www.gao.gov/assets/gao-22-104597.pdf" target="_blank">https://www.gao.gov/assets/gao-22-104597.pdf</a></li><li id="fn9">McKinsey & Company. (2021). Administrative Simplification: How to Save a Quarter-Trillion Dollars in US Healthcare. <a href="https://www.mckinsey.com/~/media/mckinsey/industries/healthcare%20systems%20and%20services/our%20insights/administrative%20simplification%20how%20to%20save%20a%20quarter%20trillion%20dollars%20in%20us%20healthcare/administrative-simplification-how-to-save-a-quarter-trillion-dollars-in-us-healthcare.pdf" target="_blank">https://www.mckinsey.com/~/media/mckinsey/industries/healthcare%20systems%20and%20services/our%20insights/administrative%20simplification%20how%20to%20save%20a%20quarter%20trillion%20dollars%20in%20us%20healthcare/administrative-simplification-how-to-save-a-quarter-trillion-dollars-in-us-healthcare.pdf</a></li><li id="fn10"><a href="https://www.kaufmanhall.com/sites/default/files/2024-05/KH-NHFR_2024-04.pdf" target="_blank">https://www.kaufmanhall.com/sites/default/files/2024-05/KH-NHFR_2024-04.pdf</a></li><li id="fn11">Interviews with Inpatient Psychiatric Facilities, a Report by L&M Policy Research for the Medicare Payment Advisory Commission (March 2023). <a href="https://www.medpac.gov/wp-content/uploads/2023/06/Jun23_Interviews_with_IPFs_MedPAC_CONTRACTOR_SEC.pdf" target="_blank">https://www.medpac.gov/wp-content/uploads/2023/06/Jun23_Interviews_with_IPFs_MedPAC_CONTRACTOR_SEC.pdf</a></li></ol></div><div class="col-md-4"><p><a href="/system/files/media/file/2024/05/AHA-Comments-on-Inpatient-Psychiatric-Facility-FY-2025-Proposed-Payment-Rule-letter.pdf" target="_blank" title="Click here to download the AHA Comments on Inpatient Psychiatric Facility FY 2025 Proposed Payment Rule letter PDF."><img src="/sites/default/files/inline-images/Page-1-AHA-Comments-on-Inpatient-Psychiatric-Facility-FY-2025-Proposed-Payment-Rule-letter.png" data-entity-uuid="143eb8f9-f7f8-4902-8e44-764305379dc9" data-entity-type="file" alt="AHA Comments on Inpatient Psychiatric Facility FY 2025 Proposed Payment Rule letter page 1." width="695" height="900"></a></p></div></div></div> Tue, 28 May 2024 09:38:39 -0500 Psychiatric PPS <div class="container"><div class="row"><div class="col-md-8"><p>The Centers for Medicare & Medicaid Services (CMS) March 28 issued its fiscal year (FY) 2025 <a href="https://www.federalregister.gov/public-inspection/2024-06764/medicare-program-fy-2025-inpatient-psychiatric-facilities-prospective-payment-system---rate-update" target="_blank" title="Proposed Rule">proposed rule</a> for the inpatient psychiatric facility (IPF) prospective payment system (PPS).</p><div class="panel module-typeC"><div class="panel-heading"><h3>KEY Highlights</h3><p>The proposed rule would:</p><ul><li>Update the IPF payment rate by a net 2.6% in FY 2025 as compared to FY 2024.</li><li>Clarify eligibility criteria for filing all-inclusive cost reports.</li><li>Adopt one new quality measure and require quarterly patient-level data reporting. </li></ul><p>In addition, the agency:</p><ul><li>Solicits comments to inform the revisions to the IPF PPS required by law.</li><li>Solicits comments on the development of a patient assessment instrument.</li></ul></div></div><h2>WHAT YOU CAN DO</h2><p>CMS will accept comments on this rule through May 28.</p><ul><li>To submit comments, visit <a href="http://www.regulations.gov">http://www.regulations.gov</a> or send via regular mail to CMS.</li><li>AHA will be submitting comments on the rule and will share these comments with the field prior to the deadline.</li></ul><h2>PROPOSED IPF PPS PAYMENT PROVISIONS</h2><p>CMS proposes several updates to IPF payment rates.</p><ul><li>CMS proposes to increase IPF payments by a net 2.6%, equivalent to $70 million, in FY 2025.</li><li>The proposed 2.7% payment update is based on a 3.1% market basket update, a 0.4% productivity cut as required by law and a cut of 0.1 percentage point related to outlier payments.</li><li>Under these payment updates, the federal per diem base rate would be $874.93 (a decrease from the previous rate of $895.63). The electroconvulsive therapy (ECT) payment per treatment would be $660.30 (an increase from the previous rate of $385.58).</li><li>The labor-related share for FY 2025 is proposed to be 78.8%, an increase from the FY 2024 labor-related share of 78.7%.</li><li>The fixed dollar loss threshold amount would be $35,590 (an increase from the previous amount of $33,470) to maintain estimated outlier payments at 2% of the total estimated aggregate IPF PPS payments.</li></ul><h3>All-inclusive Cost Reporting</h3><p>IPFs and psychiatric units are required to report data on ancillary services provided and file cost reports on an annual basis. However, CMS’ analysis has found a notable increase in the number of IPFs (specifically for-profit freestanding IPFs) that, on particular CMS worksheets, are erroneously identifying as eligible for filing all-inclusive cost reports. The option to elect to file an all-inclusive rate cost report is limited to providers that do not have a charge structure (such as government-owned facilities) and thus must use a different way to apportion costs associated with their services. In other words, rather than reporting ancillary charges such as labs and drugs, non-government-owned facilities are incorrectly reporting that they have a single charge covering all services and items.</p><p>In response to a request for information on the topic in previous rulemaking, CMS clarifies in this proposed rule that hospitals can only use an all-inclusive rate or no charge structure if they have never had a charge structure in place; only government-owned or tribally owned facilities meet this criterion and will be permitted to file all-inclusive cost reports beginning Oct. 1, 2024. CMS will issue guidance specifying that a facility cannot convert to a system where they operate under an all-inclusive rate. All other IPFs must have a charge structure and must report ancillary costs and charges on their cost reports. This provision is not a proposed change to policy but rather a clarification of existing regulations.</p><h2>IPF QUALITY REPORTING PROGRAM</h2><p>CMS proposes to adopt one new quality measure to the IPF quality reporting program (IPFQR) and to require more frequent reporting of patient-level measure data.</p><p><strong>Proposed Adoption of the All-Cause Risk-Standardized Emergency Department (ED) Visit Following IPF Discharge Measure. </strong>CMS proposes to adopt this measure that assesses the number of ED visits and observation stays for any reason (related to psychiatric hospitalization or not) within 30 days of IPF discharge beginning with the calendar year (CY) 2025 performance period (which informs FY 2027 payments).</p><p>The measure excludes patients discharged against medical advice from the IPF index admission, patients with unreliable data regarding death or demographics in their claims record, patients who died during the IPF stay, patients transferred to another care facility, and patients discharged but readmitted within three days of discharge (“interrupted stay”). CMS would incorporate risk factors in the 12 months prior to index admission and comorbid conditions to “standardize” the ED visit rate for each IPF, meaning measure results would be comparable across IPFs regardless of the clinical complexity of each IPF’s patient population. The measure is calculated using information from Medicare claims (Part A and Part B) as well as Medicare beneficiary and coverage files; IPFs would not need to submit any additional data for this measure.</p><p>The Consensus-based Entity responsible for endorsement review chose to not endorse the measure. The IPFQR currently has three other measures that assess post-discharge outcomes: Follow-up after Psychiatric Hospitalization; Medication Continuation Following Inpatient Psychiatric Discharge; and 30-Day All-Cause Unplanned Readmission Following Psychiatric Hospitalization.</p><p><strong>Proposed Quarterly Reporting of Patient-Level Data. </strong>CMS proposes to require IPFs to submit patient-level data to inform IPFQR measures on a quarterly basis, rather than annually as currently required. If finalized, the requirement would begin with data collected during the first quarter of 2025 (Jan. 1, 2025-March 31, 2025), with a submission deadline of Nov. 15, 2025. Generally, data submission for each calendar quarter would be required during a period of at least 45 days beginning three months after the end of the calendar quarter.</p><p>IPFs have been required to report patient-level data for chart-abstracted measures within the IPFQR beginning in 2023 (for the FY 2024 payment determination). The experience of the past year has demonstrated that annual data submission requires IPFs to store large volumes of patient data to prepare for transmission to CMS, which creates the risk that CMS systems will be unable to handle all of this data in a single submission period. In addition, CMS argues that quarterly reporting will allow them to better analyze measure trends over time.</p><h2>REQUESTS FOR INFORMATION</h2><p><strong>Revisions to Facility-level Adjustment Factors IPF PPS. </strong>The Consolidated Appropriations Act (CAA) of 2023 requires CMS to implement revisions to the IPF PPS methodology beginning FY 2025. In this proposed rule, CMS seeks feedback on whether it would be appropriate to consider proposing revisions to facility-level adjustments in the future based on the results of their recent analysis. Specifically, CMS requests public input on the following adjustments to the payment methodology that could differentiate between facilities with higher costs.</p><p><u>Medicare Safety Net Index (MSNI):</u> Unlike other Medicare PPSs, the IPF PPS does not have a Medicaid disproportionate share adjustment, as policies unique to the IPF setting distort the effects of Medicaid coverage on cost (i.e., the Institutions for Mental Disease exclusion, which prohibits the use of federal Medicaid dollars to pay for care in facilities including IPFs with more than 16 beds). Instead, CMS is considering the MedPAC-created MSNI as an alternative. The MSNI for an IPF would consist of its low-income subsidy volume ratio, the proportion of revenue spent on uncompensated care,  and the Medicare dependency ratio. Incorporating the MSNI as a facility-level adjustment might require additional data collection via cost reports as well as policies to address aberrant circumstances (e.g., mergers of multiple facilities or hospitals that begin participation in the Medicare program after the available audited cost report data).</p><p><u>Rural location:</u><em> </em>Holding all other variables constant, stays at rural IPFs have approximately 19% higher cost per day than stays at urban IPFs; currently, CMS applies an adjustment factor of 1.17 (or an increase of 17%) to rural IPF payments. However, when including the MSNI variable described above, the adjustment factor for rural IPFs would decrease unless the facility had a high level of safety net patients.</p><p><u>Teaching status:</u><em> </em>Currently, CMS calculates a facility’s payment adjustment for teaching status by raising a facility’s teaching ratio to the power of the teaching status coefficient derived from CMS’ regression analysis. In its analysis, CMS finds that including the MSNI variable is also associated with a decrease in the teaching status adjustment factor.</p><p><strong>IPF Patient Assessment Instrument (IPF-PAI)</strong>. Also included in the CAA of 2023 is the requirement for IPFs participating in the IPFQR program to collect and submit certain standardized patient assessment data using a standardized patient assessment instrument (PAI) beginning with admissions and discharges in FY 2028. In this proposed rule, CMS solicits comments for the development of this IPF-PAI, specifically on the following four topics:</p><p><u>Framework for Development of the IPF-PAI:</u><em> </em>CMS uses the experience from the development of standardized patient assessment data elements for use across post-acute care settings as required by the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 to inform its considerations for the development of the IPF-PAI. The agency seeks feedback on four key concepts to use in assessing data elements for IPFs to collect: overall clinical relevance; interoperable exchange to facilitate care coordination during transitions in care; ability to capture medical complexity and risk factors that can inform both payment and quality; and scientific reliability, validity and usability.</p><p>CMS notes that it anticipates convening a Technical Expert Panel to provide input on data elements to include in the PAI and testing data elements for their ability to detect differences among patients and costs of treatment. However, the agency also states that it may not be possible to complete all testing before launching the IPF-PAI on the statutorily required timeframe.</p><p><u>Elements of the IPF-PAI:</u><em> </em>The CAA requires that the standardized patient assessment data to be collected in the IPF-PAI must be with respect to six specific categories: functional status; cognitive function and mental status; special services, treatments and interventions; medical conditions and comorbidities; impairments; and other categories deemed appropriate. In addition, CMS is interested in elements that would provide insight about any demographic factors as well as social determinants of health.</p><p><u>Implementation of the PAI — Data Submission:</u><em> </em>CMS welcomes public comment on tools and methods for submission of data that balance administrative burden and ease of use.</p><p><u>General PAI Feedback:</u><em> </em>CMS seeks information about PAIs that IPFs already use and how they use them, as well as the relationship between the IPF-PAI and the measures within the IPFQR program.</p><h2>FURTHER QUESTIONS</h2><p>If you have questions, please contact Caitlin Gillooley, AHA’s director for quality and behavioral health policy, at 202-626-2267 or <a href="mailto:cgillooley@aha.org">cgillooley@aha.org</a>. </p></div><div class="col-md-4"><a href="/system/files/media/file/2024/04/inpatient-psychiatric-facility-pps-proposed-rule-for-fy-2025-advisory-4-2-2024.pdf" target="_blank"><img src="/sites/default/files/inline-images/Page-1-Inpatient-Psychiatric-Facility-PPS-Proposed-Rule-for-FY-2025-20240409.png" data-entity-uuid="85151eb8-094c-47eb-856c-caff3193e201" data-entity-type="file" alt="Regulatory Advisory: Inpatient Psychiatric Facility PPS: Proposed Rule for FY 2025 page 1." width="695" height="900"></a></div></div></div> Tue, 02 Apr 2024 14:39:18 -0500 Psychiatric PPS <div class="container"> <div class="row"> <div class="col-md-8"> <p>The Centers for Medicare & Medicaid Services (CMS) July 27 issued its fiscal year (FY) 2024 <a href="https://public-inspection.federalregister.gov/2023-16083.pdf?utm_source=federalregister.gov&utm_medium=email&utm_campaign=pi+subscription+mailing+list" target="_blank">final rule</a> for the inpatient psychiatric facility (IPF) prospective payment system (PPS).</p> <div class="panel module-typeC"> <div class="panel-heading"> <h3>Key Highlights</h3> <p>The final rule:</p> <ul> <li>Updates the IPF payment rate by a net 2.4% in FY 2024 as compared to FY 2023.</li> <li>Rebases and revises the IPF PPS market basket using FY 2021 data.</li> <li>Adopts four new quality measures, modifies one, and removes two.</li> <li>Allows hospitals to open a new IPF unit at any time during the cost reporting period.</li> </ul> </div> </div> <h2>AHA Take</h2> <p>The AHA is disappointed that CMS disregarded AHA’s and other stakeholders’ recommendations to improve the IPF PPS and IPFQR. Even though the final payment update is higher than proposed, it is still insufficient to meet the critical financial pressures faced by psychiatric facilities. In addition, the agency failed to address several legitimate concerns regarding new quality measures that, as a result, will not provide useful information to patients or help providers advance quality of care. We will continue to work with CMS on enhancing measurement for psychiatric facilities to ensure meaningful assessment of clinical quality.</p> <h2>IPF PPS Payment Provisions</h2> <p finalized ipf payment several specifically to updates> </p><p>Under these payment updates, the federal per diem base rate will be $895.63 (an increase from the previous rate of $865.63). The electroconvulsive therapy (ECT) payment per treatment will be $385.58 (an increase from the previous rate of $372.67).</p> <p>CMS finalized a labor-related share for FY 2024 of 78.7%, an increase from the FY 2023 labor-related share of 77.4%. In addition, the fixed dollar loss threshold amount will be $33,470 (an increase from the previous amount of $24,630), which CMS states is necessary to maintain outlier payments at 2% of total estimated aggregate IPF PPS payments.</p> <h3>Rebase and Revise the IPF PPS Market Basket on 2021 Data</h3> <p>CMS rebases and revises the market basket periodically to reflect changes in the mix of goods and services IPFs purchase to furnish care. The agency last rebased and revised the market basket in the FY 2020 IPF PPS final rule, in which CMS used FY 2016 data. As such, CMS will again rebase and revise the market basket, and will do so using FY 2021 data. The finalized methodology is generally similar to the methodology used previously.</p> <h3>Modification to the Regulation on Excluded Units Paid under the IPF PPS</h3> <p>Currently, hospitals may only open a new IPPS-excluded psychiatric unit at the start of a cost reporting period due to administrative and regulatory complexities defining these units. In other words, a hospital is limited in when it can designate an existing unit as psychiatric or open a new psychiatric unit that is paid under the IPF PPS. Several stakeholders have suggested that these requirements are unnecessarily restrictive and burdensome; for example, the need to wait until the next cost reporting period may delay hospitals from opening needed psychiatric beds that would be paid under the IPF PPS. In response, CMS will allow a hospital to open a new IPF unit any time within the cost reporting period as long as the hospital notifies the CMS Regional Office and Medicare Administrative Contractor in writing of the change at least 30 days before the date of the change.</p> <h2>IPF Quality Reporting Program (IPFQR)</h2> <p>CMS finalizes several changes as proposed to the IPFQR, including to the measure set used in the program as well as to administrative requirements and policies.</p> <h4>Adoption of the Facility Commitment to Health Equity Measure</h4> <p>Beginning with the FY 2026 payment determination (data reporting in CY 2025 reflecting performance in CY 2024), CMS will adopt this structural measure that assesses whether an IPF demonstrates certain equity-focused organizational competencies. IPFs will be asked to attest to several statements within five domains, including:</p> <ol> <li>Equity is a strategic priority;</li> <li>Data collection;</li> <li>Data analysis;</li> <li>Quality improvement; and</li> <li>Leadership engagement.</li> </ol> <p>Several domains comprise multiple attestation statements; to receive credit for the domain, an IPF must to attest affirmatively to each statement within that domain (in other words, there is no partial credit). Performance is scored out of five points. The measure was adopted for the Inpatient Quality Reporting Program (IQR) in the FY 2023 Inpatient Prospective Payment System (IPPS) Final Rule. The measure is not endorsed by a consensus-based entity (CBE), and CMS has not submitted it for endorsement.</p> <h4>Adoption of the Screening for Social Drivers of Health Measure</h4> <p>Beginning with voluntary reporting in CY 2025 of data collected in CY 2024 and required reporting in CY 2026 of data collected in CY 2025 data (to inform the FY 2027 payment determination), CMS will adopt this structural measure that evaluates whether IPFs are screening patients for certain health-related social needs (HRSNs). CMS explains that IPFs could use a self-selected screening tool to collect data on HRSNs including:</p> <ul> <li>Food insecurity;</li> <li>Housing instability;</li> <li>Transportation needs;</li> <li>Utility difficulties; and</li> <li>Interpersonal safety.</li> </ul> <p>IPFs will report the number of inpatients admitted to the facility who are 18 years or older at the time of admission who were screened for all five HRSNs. The measure was adopted for the IQR in the FY 2023 IPPS Final Rule. The measure is not endorsed by a CBE, and CMS has not submitted it for endorsement.</p> <h4>Adoption of the Screen Positive Rate for Social Drivers of Health Measure</h4> <p>Beginning with voluntary reporting in CY 2025 of data collected in CY 2024 and required reporting in CY 2026 of data collected in CY 2025 data (to inform the FY 2027 payment determination), CMS will adopt this measure that assesses the percent of patients admitted to the IPF who were screened for the HRSNs listed above who screen positive for one or more. IPFs would report five separate rates (one for each need). The measure is intended to provide information to IPFs on the level of unmet HRSNs among patients served, “and not for comparison between IPFs.” The measure was adopted for the IQR in the FY 2023 IPPS Final Rule. The measure is not endorsed by a CBE, and CMS has not submitted it for endorsement.</p> <h4>Adoption of the Psychiatric Inpatient Experience (PIX) Survey</h4> <p>Beginning with voluntary reporting in CY 2026 and mandatory reporting in CY 2027, CMS will adopt a specific patient experience of care instrument, the PIX survey, and a measure based on patient responses on a 5-point Likert scale to survey items. The survey comprises 23 items across four domains, including:</p> <ul> <li>Relationship with treatment team;</li> <li>Nursing presence;</li> <li>Treatment effectiveness; and</li> <li>Healing environment.</li> </ul> <p>The measure will be reported as five separate rates: one for each of these four domains and one overall rate. Mean rates will publicly reported on Care Compare. CMS clarifies that facilities will be permitted to add questions to the survey if they wish to continue tracking specific metrics not otherwise captured by the PIX survey.</p> <p>The survey is distributed to patients, on paper or on a tablet computer, by administrative staff at a time beginning 24 hours prior to planned discharge. In the final rule, CMS clarifies that if it is not possible for a patient to complete the survey prior to discharge, the facility should provide a sealable, addressed envelope for the patient to return the survey following discharge. Patients are excluded from the measure if they are younger than 13 years old at discharge or unable to complete the survey due to cognitive or intellectual limitations.</p> <p>CMS acknowledges that IPFs already administer different patient experience of care survey instruments to their patients and will thus need to transition to the PIX survey. Because of this, the agency will implement the requirement using a voluntary reporting period during which IPFs will be able to begin administering the PIX survey and collecting survey data in CY 2025 to report on a voluntary basis in CY 2026, and then will be required to administer the survey and collect data during CY 2026 to report during CY 2027; this will affect the FY 2028 payment determination.</p> <h4>Modification of the COVID-19 Vaccination Coverage Among Healthcare Personnel (HCP) Measure</h4> <p>Beginning with the FY 2025 IPFQR, CMS will modify the current HCP COVID-19 vaccination measure used in the program. The current measure assesses the number of HCP who have received a complete vaccination course against COVID-19; in this rule, CMS will replace the definition of “complete vaccination course” with a definition of “up to date” with CDC recommended COVID-19 vaccines. The agency makes this modification to incorporate new CDC guidance related to booster doses and their associated timeframes.</p> <p>CMS did not propose any changes to the data submission or reporting processes for this measure. Compliance for the FY 2025 payment determination will be based on reporting of individuals who are up to date beginning in quarter four of CY 2023.</p> <h4>Measure Removals</h4> <p>Beginning with the FY 2025 payment determination, CMS will remove the following measures from the IPFQR:</p> <ul> <li>Patients Discharged on Multiple Antipsychotic Medications with Appropriate Justification (HBIPS-5): The agency believes that this measure is no longer aligned with current clinical guidelines and practice.</li> <li>Tobacco Use Brief Intervention Provided or Offered and Tobacco Use Brief Intervention Provided (TOB-2/2a): The agency believes that the costs associated with this measure outweigh its benefits; in addition, the agency will retain a related measure, Tobacco Use Treatment Provided or Offered at Discharge and Tobacco Use Treatment at Discharge (TOB-3/3a), which it believes better drives improvement in patient outcomes.</li> </ul> <h4>Data Validation Pilot Program</h4> <p>In the FY 2022 IPF PPS final rule, CMS adopted required patient-level data reporting beginning with data submitted in CY 2023, affecting the FY 2024 payment determination. In this rule, CMS finalizes its proposal to begin validating this data in a pilot program beginning with data submitted in CY 2024, affecting the FY 2025 payment determination. Specifically, CMS will request eight charts per quarter from each of 100 randomly selected IPFs. The agency notes that it will reimburse IPFs for the cost of submitting charts for validation at a rate of $3.00 per chart. Participation in the pilot is voluntary.</p> <h2>Further Questions</h2> <p>If you have questions, please contact Caitlin Gillooley, AHA’s director for quality and behavioral health policy, at <a href="tel:1-202-626-2267">202-626-2267</a> or <a href="mailto:cgillooley@aha.org?subject=Inpatient Psychiatric Facility PPS: Final Rule for FY 2024">cgillooley@aha.org</a>.</p> </div> <div class="col-md-4"> <p><a href="/system/files/media/file/2023/07/Inpatient-Psychiatric-Facility-PPS-Final-Rule-for-FY-2024.pdf" target="_blank" title="Click here to download the Regulatory Advisory: Inpatient Psychiatric Facility PPS: Final Rule for FY 2024 PDF."><img alt="Regulatory Advisory: Inpatient Psychiatric Facility PPS: Final Rule for FY 2024 page 1." data-entity-type="file" data-entity-uuid="4a25cf0b-c253-44ae-b14d-22fd5d7ae472" src="/sites/default/files/inline-images/Page-1-Inpatient-Psychiatric-Facility-PPS-Final-Rule-for-FY-2024.png" width="695" height="900"></a></p> </div> </div> </div> Thu, 27 Jul 2023 13:28:02 -0500 Psychiatric PPS /lettercomment/2023-07-17-aha-expresses-concern-lack-clear-and-actionable-guidance-environmental-risk-mitigation <p>July 17, 2023</p><p>April Tabor<br>Secretary<br>Federal Trade Commission<br>600 Pennsylvania Avenue NW Suite CC-5610 (Annex C)<br>Washington, DC 20580</p><p><strong>Re: Request for Extension on Proposed Rulemaking for the HSR Filing Process (Matter No. P239300) </strong></p><p>Dear Ms. Tabor:</p><p>On behalf of our members, we request that the Federal Trade Commission and the Department of Justice extend the comment period to the above-referenced rulemaking (the "Proposal") for an additional 60 days. Collectively, our associations represent a wide range of members that routinely evaluate and file HSR-reportable transactions as prospective purchasers, sellers, investors, or facilitators.</p><p>An extension would serve the interests of both the public and the agencies by allowing adequate time for more fulsome responses on a proposal that could reshape U.S. merger policy, business activity, and capital markets. A typical year sees more than 2,000 mergers whose aggregate transaction value approaches $3 trillion. The Proposal acknowledges that the new forms would almost quadruple average preparation time in each instance, imposing costs that "would be significant and impose additional burden on some filing parties." In its 133 pages, the Proposal solicits feedback on numerous specific ideas that touch upon complex questions of markets, labor, capital, regulatory costs, and attorney-client privilege. Every question could, by itself, easily produce a highly substantive and lengthy response.</p><p>The agencies are best served if the Proposal receives quality feedback. To allow sufficient time for detailed comments, we ask that you grant an extension.</p><p>Thank you for your consideration of this matter.</p><p>Sincerely,</p><p>American Coatings Association<br>���������� Association<br>American Hotel & Lodging Association<br>American Investment Council<br>Alternative Investment Management Association<br>Biotechnology Innovation Organization (BIO)<br>Business Roundtable<br>Consumer Brands Association<br>Consumer Technology Association (CTA)<br>Engine<br>Federation of ����������s<br>ITI — Information Technology Industry Council<br>Managed Funds Association<br>Metals Service Center Institute<br>NACS | Advancing Convenience & Fuel Retailing<br>Pharmaceutical Research and Manufacturers of America (PhRMA)<br>Retail Industry Leaders Assocation<br>Securities Industry and Financial Markets Association<br>SIFM Asset Management Group<br>Software & Informaiton Industry Association (SIIA)<br>TechNet<br>US Chamber of Commerce</p> Mon, 17 Jul 2023 14:52:51 -0500 Psychiatric PPS /lettercomment/2023-06-05-aha-comments-fy-2024-proposed-rule-inpatient-psychiatric-facilities <p>The Honorable Chiquita Brooks-La Sure<br /> Administrator<br /> Centers for Medicare & Medicaid Services<br /> Department of Health and Human Services<br /> Hubert H. Humphrey Building<br /> 200 Independence Avenue SW, Room 445–G<br /> Washington, DC 20201</p> <p>Dear Administrator Brooks-LaSure:</p> <p>On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations, our clinician partners and, especially, the 105 psychiatric hospitals and 846 hospitals with dedicated behavioral health beds, the ���������� Association (AHA) appreciates the opportunity to comment on the Centers for Medicare & Medicaid Services’ (CMS) inpatient psychiatric facility (IPF) prospective payment system (PPS) proposed rule for fiscal year (FY) 2024.</p> <p><strong>While we appreciate certain proposed provisions in this rule, we are concerned that CMS’ proposed payment adjustment will be inadequate to support the vital services IPFs provide to their communities. In addition, we have a number of concerns about proposals for measures to be adopted in the IPF quality reporting (IPFQR) program.</strong></p> <p>View the detailed letter below.</p> Mon, 05 Jun 2023 12:57:05 -0500 Psychiatric PPS /lettercomment/2023-05-18-aha-expresses-concern-lack-clear-and-actionable-guidance-environmental-risk-mitigation <p>The Honorable Chiquita Brooks-LaSure<br>Administrator<br>Centers for Medicare & Medicaid Services<br>Department of Health and Human Services<br>Hubert H. Humphrey Building<br>200 Independence Avenue SW, Room 445–G<br>Washington, DC 20201</p><p>Dear Administrator Brooks-LaSure:</p><p>On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations, the American Society for Health Care Engineering and American Society for Health Care Risk Management, our clinician partners and, especially, the 105 psychiatric hospitals and 846 hospitals with dedicated behavioral health beds, the ���������� Association (AHA) expresses its concern with the ongoing lack of clear and actionable guidance on environmental risk mitigation in facilities that provide psychiatric services. <strong>We again urge the Centers for Medicare & Medicaid Services’ (CMS) to issue the guidance these providers need in order to ensure compliance with federal laws and regulations.</strong></p><p>Hospitals and health systems are committed to the safety of our patients and take precautions to minimize the risk that anyone intending self-harm can succeed. CMS issued draft guidance on ligature risk on April 19, 2019; this guidance sought to clarify existing interpretive guidelines to provide details on requirements for abating risk for patient harm within psychiatric facilities. Unfortunately, this draft guidance failed to address a number of concerns and areas of confusion for our members. Further, the draft guidance was never finalized. As such, these providers have been waiting for four years for clear instructions on what is expected of them by CMS surveyors. Meanwhile, hospitals have continued to be surveyed against the existing unclear and arbitrary guidance.</p><p>This lack of clarity has had negative consequences for patients. Facilities have sometimes been compelled by CMS surveyors to take otherwise usable psychiatric beds temporarily offline to make changes they were not aware were needed, thereby worsening wait times for inpatient psychiatric care. Some facilities also have spent millions of dollars making facility changes asked for by CMS surveyors but with no guarantee these changes align with requirements that CMS could require in the near future. <strong>Wasteful spending driven by regulatory uncertainty hinders hospitals’ efforts to maintain access to inpatient behavioral health care. This is especially worrisome at a time when both behavioral health care access and hospital finances are severely constrained.</strong></p><p>Hospitals need clear, specific and timely information about the standards they are required to meet, as well as the oversight process for compliance with those standards. <strong>We urge CMS to issue interpretive guidance immediately laying out the risk mitigation steps hospitals are expected to take, or, alternatively, issue guidance to surveyors that clearly permits hospitals and their staffs to use their own best judgement in determining what mitigation steps to take.</strong></p><h2>Background</h2><p>Psychiatric facilities and units in general acute care hospitals are subject to unique structural requirements in the Conditions of Participation due to the vulnerability of the patients they serve; specifically, psychiatric facilities and units must meet standards involving patient harm risk abatement. By statute and per the Code of Federal Regulations, psychiatric facilities and units participating in Medicare are required to uphold a patient’s right to receive care in a safe setting. In part, CMS has interpreted this to mean that facilities should take steps to mitigate opportunities for patient self-harm. These requirements result in an estimated $1.7 billion in compliance costs annually to inpatient psychiatric facilities alone.<sup>1,2</sup></p><p>In December 2017, CMS issued interim guidance regarding general definitions for ligature “resistant” or ligature “free” environments, timeframes for corrections of ligature risk deficiencies, and qualifications for waivers from this Condition of Participation.<sup>3</sup></p><p>While CMS originally announced that this guidance would be reviewed by a CMS psychiatric task force, the task force did not convene as planned in July 2018 because the agency determined that “the proposed psychiatric task force to address environmental risks is not the most appropriate vehicle.”<sup>4</sup> Instead, CMS announced it would incorporate outcomes of The Joint Commission’s Suicide Panel into its interpretive guidance; in the interim, the agency noted that state survey agencies and accrediting organizations “may use their judgment” in determining whether facilities were in compliance.</p><p>This lack of clarity in how surveyors were to evaluate compliance led to multiple reports by facilities of citations by surveyors that would require expensive environmental updates to remediate. AHA reported these concerns to CMS and, in April 2019, CMS issued a draft update to its guidance for comment. The updated guidance if finalized, would have clarified the definition of risk, differentiated requirements for locked versus unlocked psychiatric units, provided processes to request extensions for corrections, set new requirements for education and training, and changed survey procedures.<sup>5</sup> Although AHA and others submitted <a href="/system/files/media/file/2019/06/cms-proposed-guidance-on-ligature-risk-6-17-2019.pdf" target="_blank">comments</a> on this guidance by the June 19, 2019 deadline, it was never finalized.</p><h2>New Issues</h2><p>While waiting for updates on ligature risk guidance, AHA brought a new issue to CMS’ attention: the use of medical beds in psychiatric units. While The Joint Commission allows the use of medical beds in psychiatric units (along with appropriate risk mitigation procedures),<sup>6</sup> AHA members surveyed by CMS surveyors are told that the agency does not allow them under any circumstances and instead mandates the use of behavioral health-specific platform beds. Members have reported that surveyors have even prohibited them from admitting psychiatric patients to an available medical bed. This has resulted in some facilities having to replace medical beds (sometimes dozens of them) with platform beds and/or take otherwise usable beds offline; patients with medical needs being excluded from psychiatric facilities; psychiatric patients waiting for a free platform bed in a medical unit, but in the meantime laying in a medical bed; patients with medical issues and suicidal ideation being put in platform bed, thereby being at greater at risk for falls and aspiration; and patients waiting long periods of time without a bed (in a chair or even on the floor) in the ED for placement in a non-medical bed.</p><p>Hospitals and health systems have reported other consequences of a result of conflicting guidance from surveyors. For example, some purchased behavioral health-specific beds at significant cost, only to be told by surveyors that the beds are not compliant. Members have also reported citations on beds that were deemed in compliance on a previous survey without any change in policy or guidance. These mixed messages add substantial cost to the health care system. A bed sold by a major manufacturer that is touted to be in compliance with “the FDA’s monitored Entrapment Zones 1 – 4” retails for $3,336, plus a $928 mattress.<sup>7</sup> According to the most recent National Mental Health Services Survey, the average psychiatric facility has 56 beds designated for mental health treatment.<sup>8</sup> That means that it would cost the average facility $238,784 to replace all of their beds with products that may not be necessary to serve the needs of their patients or meet regulatory requirements. According to the Medicare Payment Advisory Commission (MedPAC)’s most recent analysis, the average margin across all inpatient psychiatric facilities is -2.4%, with not-for-profit hospital-based facilities seeing an average margin of -18.5%.<sup>9</sup> Funds that could be spent on hiring additional staff, such as additional psychiatry-specialized nurse practitioners, are instead going to potentially unnecessary or wasteful equipment purchases. <strong>The unnecessary costs that these facilities have incurred as a result of unclear guidance on how to comply with risk abatement requirements are a substantial threat to access, as facilities may be forced to close beds rather than replace them in order to maintain operations.</strong></p><h2>Next Steps</h2><p>Issuing subregulatory guidance that is not only based on clinical evidence, but also practicable, clear and meaningful to providers and patients is never easy. The issues of ligature risk and environmental risk abatement in psychiatric units and facilities is particularly sensitive. Our member hospitals seek to prevent every preventable death in our hospitals, and data show that across all hospitals, the annual incidence of suicide within a hospital facility is extremely low (between 31-51 psychiatric inpatients per year, far fewer than the 1,500 per year figure that is commonly cited, or 3.2 per 100,000 psychiatric inpatient admissions).<sup>10,11</sup> Still, any suicide is one too many.</p><p>At the same time, behavioral health needs have increased. Barriers to access to care, including a lack of available beds when needed, exist across the nation. <strong>When behavioral health facilities must expend resources to determine how to comply with nebulous standards not backed by evidence, they have fewer resources to dedicate to needed patient care.</strong></p><p>Given the considerable impact on patient access to care, as well as wasteful costs to the system, we request that the agency immediately issue the interpretive guidance, ensuring that it provides clarity on the following topics:</p><ul><li>Types of fixtures, beds and supplies considered in compliance;</li><li>Differences in ligature risk abatement requirements between locked and unlocked psychiatric units, including specifically what constitutes a “locked unit;”</li><li>Requirements for dedicated psychiatric beds in emergency departments;</li><li>Examples of appropriate patient assessments beyond that used by the Department of Veterans Affairs;</li><li>CMS’ intent relating to a staff “immediately available to intervene” when using 1:1 video monitoring for at-risk patients;</li><li> Processes for hospitals approved for a ligature-risk extension request, unannounced surveys and Immediate Jeopardy designations;</li><li>Education and training requirements for contracted employees and short-term employees; and</li><li>Updates to survey procedures and CMS’s surveyor training processes.</li></ul><p>If that is not possible, then we ask that the agency make clear that each hospital caring for patients who may have suicidal ideations must have policies in place identifying the actions it will take to keep patients safe from self-harm, and then instruct surveyors to review those policies and the hospital’s compliance with its own policies. Hospitals share CMS’ goal of protecting patients and have access to available scientific and other information on risks for self-harm. They know the communities and populations they serve. They are able to craft policies that appropriately manage the risks for their patients while allowing treatment of their mental and physical health issues.</p><p>The AHA has a robust and engaged membership with vast expertise in behavioral health, and we are eager to provide insight to ensure our patients are safe while in our care.</p><p>We thank you for your consideration of our requests. Please contact me if you have questions or feel free to have a member of your team contact Caitlin Gillooley, director of policy, at <a href="http://mailto:cgillooley@aha.org" target="_blank">cgillooley@aha.org</a> or (202) 626-2267.</p><p>Sincerely,</p><p>/s/</p><p>Ashley B. Thompson<br>Senior Vice President</p><p>__________</p><p><span><small><span><sup>1</sup> “The High Cost of Compliance: Assessing the Regulatory Burden on Inpatient Psychiatric Facilities.” National Association for Behavioral Healthcare, March 2019. </span></small></span><span><small><span>https://www.nabh.org/wp-content/uploads/2019/03/The-High-Cost-of-Compliance.pdf </span></small></span><br><span><small><span><sup>2</sup> The AHA does not have discrete data for the cost of implementing these requirements in general acute care hospital units. </span></small></span><br><span><small><span><sup>3</sup> S&C Memo: 18-06 Hospitals, “Clarification of Ligature Risk Policy,” December 8, 2017. </span></small></span><span><small><span>https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-18-06.pdf </span></small></span><br><span><small><span><sup>4</sup> QSO: 18-21 All Hospitals, “CMS Clarification of Psychiatric Environmental Risks,” July 20, 2018. </span></small></span><span><small><span>https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/QSO18-21-Hospitals.pdf </span></small></span><span><small><span> </span></small></span><br><span><small><span><sup>5 </sup>Ref: DRAFT-QSO-19-12 Hospitals, “DRAFT ONLY –Clarification of Ligature Risk Interpretive Guidelines – FOR ACTION,” April 19, 2019. </span></small></span><span><small><span>https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/QSO-19-12-Hospitals.pdf </span></small></span><br><span><small><span><sup>6</sup> Behavioral Health: National Patient Safety Goals; First published date: June 27, 2018. Last reviewed by Standards Interpretation: February 1, 2022. </span></small></span><span><small><span>https://www.jointcommission.org/standards/standard-faqs/behavioral-health/national-patient-safety-goals-npsg/000002201/ </span></small></span><span><small><span> <sup>7</sup> Stryker Spirit® Behavioral Health Bed: </span></small></span><span><small><span>https://www.stryker.com/content/dam/stryker/acute-care/products/spiritselect/resources/Spirit%20Behavioral%20Health_SS_Mkt%20Lit-1059.pdf </span></small></span><br><span><small><span><sup>8</sup> National Mental Health Services Survey (N-MHSS): 2020, Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, September 2021. </span></small></span><span><small><span>https://www.samhsa.gov/data/sites/default/files/reports/rpt35336/2020_NMHSS_final.pdf </span></small></span><br><span><small><span><sup>9 </sup>“Assessing Medicare’s Payments for Services Provided in Inpatient Psychiatric Facilities,” MedPAC, October 4, 2018. </span></small></span><span><small><span>https://www.medpac.gov/wp-content/uploads/import_data/scrape_files/docs/default-source/default-document-library/psych-pps-october-2018-public-final.pdf </span></small></span><br><span><small><span><sup>10 </sup>Williams, S. “Incidence and Method of Suicide in Hospitals in the United States,” </span></small><em><small><span>The Joint Commission Journal on Quality and Patient Safety, </span></small></em><small><span>2018; 44:643-650. </span></small></span><span><small><span>https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/suicide-prevention/nvdrs_williams_2018.pdf </span></small></span><br><span><small><span><sup>11</sup> Mills, P. “Suicide Risk in the Hospital,” WebM&M: Case Studies, Agency for Healthcare Research and Quality, May, 2018. </span></small></span><span><small><span>https://psnet.ahrq.gov/web-mm/suicide-risk-hospital </span></small></span><span><small><span> </span></small></span></p> Thu, 18 May 2023 14:52:51 -0500 Psychiatric PPS /advisory/2023-04-14-inpatient-psychiatric-facility-pps-proposed-rule-fy-2024 <p>The Centers for Medicare & Medicaid Services (CMS) April 4 issued its fiscal year (FY) 2024 <a href="https://www.federalregister.gov/public-inspection/2023-07122/medicare-program-fy-2024-inpatient-psychiatric-facilities-prospective-payment-system---rate-update" target="_blank">proposed rule</a> for the inpatient psychiatric facility (IPF) prospective payment system (PPS). .pane { border: solid 1px #9d2235 !important; } .module-typeC { border: solid 1px #9d2235 !important; } </p> <div class="panel module-typeC"> <div class="panel-heading"> <h3 class="panel-title">Key Highlights</h3> </div> <div class="panel-body"> <p>The proposed rule would:</p> <ul> <li>Update the IPF payment rate by a net 1.9% in FY 2024 as compared to FY 2023;</li> <li>Rebase and revise the IPF PPS market basket based on 2021 data;</li> <li>Adopt four new quality measures, modify one and remove two.</li> </ul> <p>In addition, the agency:</p> <ul> <li>Solicits comments to inform the revisions to the IPF PPS required by law;</li> <li>Proposes to allow hospitals to open a new IPF unit at any time during the cost reporting period.</li> </ul> <p> </p> </div> </div> <h2>WHAT YOU CAN DO</h2> <p>CMS will accept comments on this rule through June 5.</p> <ul> <li>To submit comments, visit <a href="http://www.regulations.gov/" target="_blank">http://www.regulations.gov</a> or send via regular mail to CMS.</li> <li>AHA will be submitting comments on the rule and will share these comments with the field prior to the deadline.</li> </ul> <h2>PROPOSED IPF PPS PAYMENT PROVISIONS</h2> <p>CMS proposes several updates to IPF payment rates.</p> <ul> <li>CMS proposes to increase IPF payments by a net 1.9% equivalent to $55 million in FY 2024.</li> <li>This 1.9% payment update includes a 3.2% market basket update, a 0.2% productivity cut as required by law and a cut of one percentage point related to outlier payments.</li> <li>Under these payment updates, the federal per diem base rate would be $892.58 (an increase from the previous rate of $865.63). The electroconvulsive therapy payment per treatment would be $384.27 (an increase from the previous rate of $372.67).</li> <li>The labor-related share for FY 2024 is proposed to be 78.5%, an increase from the FY 2023 labor-related share of 77.4%.</li> <li>The fixed dollar loss threshold amount would be $34,750 (an increase from the previous amount of $24,630) to maintain estimated outlier payments at 2% of the total estimated aggregate IPF PPS payments.</li> </ul> <p><strong>Proposal to Rebase and Revise the IPF PPS Market Basket on 2021 Data.</strong> CMS rebases and revises the market basket periodically to reflect more recent changes in the mix of goods and services IPFs purchase to furnish care. The agency last rebased and revised the market basket in the FY 2020 IPF PPS final rule, in which CMS used 2016 data. Therefore, CMS proposes to rebase the market basket using 2021 data. The proposed methodology is generally similar to the methodology used for the last revision and rebasing.</p> <p><strong>Proposed Modification to the Excluded Units Paid Regulation under the IPF PPS</strong>. Currently, hospitals may only open a new IPPS-excluded psychiatric unit at the start of a cost reporting period due to complex administrative and regulatory complexities defining these units. In other words, a hospital is limited in when it can designate an existing unit as psychiatric or open a new psychiatric unit that is paid under the IPF PPS. Several stakeholders have suggested that these requirements are unnecessarily restrictive and burdensome; for example, the need to wait until the next cost reporting period may delay hospitals from opening needed psychiatric beds that would be paid under the IPF PPS. In response, CMS proposes to allow a hospital to open a new IPF unit any time within the cost reporting period as long as the hospital notifies the CMS Regional Office and Medicare Administrative Contractor in writing of the change at least 30 days before the date of the change.</p> <h2>REQUESTS FOR INFORMATION</h2> <p><strong>Revisions to the IPF PPS.</strong> The Consolidated Appropriations Act of 2023 requires revisions to the IPF PPS beginning in FY 2025. It also requires the secretary to collect data on cost reports beginning Oct. 1, 2023 to inform these revisions. CMS seeks public feedback about specific additional data and information psychiatric hospitals and units might report that could be appropriate and useful to help inform possible revisions to the methodology for payment rates under the IPF PPS. The agency also requests input on potential available data and information sources, including using additional elements of current cost reports and claims.</p> <p>In addition, CMS is interested in better understanding IPF industry billing practices pertaining to ancillary services. The agency requests information on the reporting of charges for ancillary services such as labs and drugs on IPF claims. CMS states that it is considering whether to require charges for these services to be reported on claims and potentially reject claims with no ancillary services reported as inappropriate or erroneous.</p> <p><strong>Social Drivers of Health (SDOH)</strong>. CMS has conducted analysis on the association of ICD-10 codes that indicate certain SDOH with differences in costs. Their findings demonstrate mixed results, but the agency has found that specific codes (specifically particular Z-codes) tend to increase relative costliness of IPF stays. CMS seeks comment on their findings as well as whether it would be appropriate to consider incorporating these codes into the IPF PPS in the future as a patient-level adjustment.</p> <h2>IPF QUALITY REPORTING PROGRAM (IPFQR)</h2> <p>CMS proposes several changes to the IPFQR, including to the measure set used in the program and administrative requirements and policies.</p> <p><strong>Proposed Adoption of the Facility Commitment to Health Equity Measure</strong>. Beginning with the FY 2026 payment determination (data reporting in calendar year (CY) 2025 reflecting performance in CY 2024), CMS proposes to adopt this structural measure that assesses whether an IPF demonstrates certain equity-focused organizational competencies. IPFs would be asked to attest to several statements within five domains, including:</p> <ol> <li>Equity is a strategic priority;</li> <li>Data collection;</li> <li>Data analysis;</li> <li>Quality improvement; and</li> <li>Leadership engagement.</li> </ol> <p>Several domains comprise multiple attestation statements; to receive credit for the domain, an IPF would have to attest affirmatively to each statement within that domain (in other words, there is no partial credit). Performance would be scored out of five points. The measure was adopted for the IQR in the FY 2023 Inpatient Prospective Payment System (IPPS) final rule. The measure is not endorsed by a consensus-based entity (CBE), and CMS has not submitted it for endorsement.</p> <p><strong>Proposed Adoption of the Screening for Social Drivers of Health Measure</strong>. Beginning with voluntary reporting in CY 2025 of data collected in CY 2024 and required reporting in CY 2026 of data collected in CY 2025 data (to inform the FY 2027 payment determination), CMS proposes to adopt this structural measure that evaluates whether IPFs are screening patients for certain health-related social needs (HRSNs). CMS explains that IPFs could use a self-selected screening tool to collect data on HRSNs including:</p> <ul> <li>Food insecurity;</li> <li>Housing instability;</li> <li>Transportation needs;</li> <li>Utility difficulties; and</li> <li>Interpersonal safety.</li> </ul> <p>IPFs would report the number of inpatients admitted to the facility who are 18 years or older at the time of admission who were screened for all five HRSNs. The measure was adopted for the IQR in the FY 2023 IPPS Final Rule. The measure is not endorsed by a CBE, and CMS has not submitted it for endorsement.</p> <p><strong>Proposed Adoption of the Screen Positive Rate for Social Drivers of Health Measure</strong>. Beginning with voluntary reporting in CY 2025 of data collected in CY 2024 and required reporting in CY 2026 of data collected in CY 2025 data (to inform the FY 2027 payment determination), CMS proposes to adopt this measure that assesses the percent of patients admitted to the IPF who were screened for the HRSNs listed above who screen positive for one or more. IPFs would report five separate rates (one for each need). The measure is intended to provide information to IPFs on the level of unmet HRSNs among patients served, “and not for comparison between IPFs.” The measure was adopted for the IQR in the FY 2023 IPPS final rule. The measure is not endorsed by a CBE, and CMS has not submitted it for endorsement.</p> <p><strong>Proposed Adoption of the Psychiatric Inpatient Experience (PIX) Survey.</strong> Beginning with voluntary reporting in CY 2026 and mandatory reporting in CY 2027, CMS proposes to adopt a specific patient experience of care instrument, the PIX survey, and a measure based on patient responses on a 5-point Likert scale to survey items. The survey comprises 23 items across four domains, including:</p> <ul> <li>Relationship with treatment team;</li> <li>Nursing presence;</li> <li>Treatment effectiveness; and</li> <li>Healing environment.</li> </ul> <p>The measure would be reported as five separate rates: one for each of these four domains and one overall rate. Mean rates would be publicly reported on Care Compare.</p> <p>The survey is distributed to patients, on paper or on a table computer, by administrative staff at a time beginning 24 hours prior to planned discharge. Patients would be excluded from the measure if they are younger than 13 years old at discharge or unable to complete the survey due to cognitive or intellectual limitations.</p> <p>CMS acknowledges that IPFs already administer different patient experience of care survey instruments to their patients and would thus need to transition to the PIX survey. Because of this, the agency proposes a voluntary reporting period during which IPFs would be able to begin administering the PIX survey and collecting survey data in CY 2025 to report on a voluntary basis in CY 2026, and would be required to administer the survey and collect data during CY 2026 to report during CY 2027; this would affect the FY 2028 payment determination.</p> <p><strong>Proposed Modification of the COVID-19 Vaccination Coverage Among Healthcare Personnel (HCP) Measure</strong>. Beginning with the FY 2025 IPFQR, CMS would modify the current HCP COVID-19 vaccination measure used in the program. The current measure the number of HCP who have received a complete vaccination course against COVID-19; in this rule, CMS proposes to replace the definition of “complete vaccination course” with a definition of “up to date” with CDC recommended COVID-19 vaccines. The agency proposes this modification to incorporate new CDC guidance related to booster doses and their associated timeframes.</p> <p>CMS does not propose any changes to the data submission or reporting processes for this measure. Compliance for the FY 2025 payment determination would be based on reporting of individuals who are up to date beginning in quarter four of CY 2023.</p> <p><strong>Proposed Measure Removals</strong>. Beginning with the FY 2025 payment determination, CMS would remove the following measures from the IPFQR:</p> <ul> <li>Patients Discharged on Multiple Antipsychotic Medications with Appropriate Justification (HBIPS-5): The agency believes that this measure is no longer aligned with current clinical guidelines and practice.</li> <li>Tobacco Use Brief Intervention Provided or Offered and Tobacco Use Brief Intervention Provided (TOB-2/2a): The agency believes that the costs associated with this measure outweigh its benefits; in addition, the agency would retain a related measure, Tobacco Use Treatment Provided or Offered at Discharge and Tobacco Use Treatment at Discharge (TOB-3/3a), which it believes would better drive improvement in patient outcomes.</li> </ul> <p><strong>Proposed Data Validation Pilot Program</strong>. In the FY 2022 IPF PPS final rule, CMS adopted required patient-level data reporting beginning with data submitted in CY 2023, affecting the FY 2024 payment determination. In this rule, CMS proposes to begin validating this data in a pilot program beginning with data submitted in CY 2024, affecting the FY 2025 payment determination. Specifically, CMS proposes to request eight charts per quarter from each of 100 randomly selected IPFs. The agency notes that it would reimburse IPFs for the cost of submitting charts for validation at a rate of $3.00 per chart. The pilot would be voluntary.</p> <h2>FURTHER QUESTIONS</h2> <p>If you have questions, please contact Caitlin Gillooley, AHA’s director for quality and behavioral health policy, at 202-626-2267 or <a href="http://mailto:cgillooley@aha.org" target="_blank">cgillooley@aha.org</a>.</p> Fri, 14 Apr 2023 10:12:39 -0500 Psychiatric PPS