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OMB Control No: 0938-1171	ICR Reference No: 201408-0938-003
Status: Historical Active	Previous ICR Reference No: 201310-0938-011
Agency/Subagency: HHS/CMS	Agency Tracking No: 20794
Title: Inpatient Psychiatric Facility Quality Reporting Program (CMS-10432)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/30/2014
Retrieve Notice of Action (NOA)	Date Received in OIRA: 08/18/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2017	36 Months From Approved	02/28/2017
Responses	904,056	0	596,200
Time Burden (Hours)	1,939,005	0	2,279,200
Cost Burden (Dollars)	0	0	0

Abstract: Section 10322 of the Affordable Care Act authorizes the establishment of a new quality reporting program for Inpatient Psychiatric Facilities (IPFs). It builds on a voluntary Inpatient Psychiatric Facilities Quality Reporting (IPFQR) program which remains in effect. The IPFQR began with an initial set of 6 measures for FY 2014 and FY 2015 and for the IPPS 2016 and subsequent years; will add an additional 4 for a total of 10 IPFQR measures.IPFs failing to submit the quality measures will receive a 2% reduction in their Annual Payment Update (APU). In an effort to minimize burden and maximize efficiency, CMS has leveraged existing systems within CMS to collect aggregated and calculated measure rates from the IPFs, in a form, manner and time as specified by CMS, via a secure portal known as the QualityNet Web site beginning of October 1, 2012 for FY2014 payment determination year. These procedural requirements involve submitting necessary forms (e.g. Notice of Participation Form, Reconsideration Request Form, Disaster Waiver Form, etc.) to comply with the IPFQR Program and align with current CMS reporting requirements for other hospital quality reporting programs. When adding new measures, the law requires CMS, when "feasible and practical" to select measures put forward by "one or more national consensus building entities". Section 3013 of the Affordable Care Act (ACA) modified by Section 931 of the Public Health Service Act requires CMS to perform a gap analysis for needed quality measures every three years. Section 3014 of the ACA modified Section 1890(b) of the Social Security Act requires CMS to develop quality and efficiency measures through a "consensus-based entity". Consequently, the Measure Applications Partnership (MAP), convened by the National Quality Forum (NQF), was formed to develop measures consistent with these requirements.

Authorizing Statute(s): PL: Pub.L. 111 - 148 10322 Name of Law: Affordable Care Act

Citations for New Statutory Requirements: None

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AS08	Final or interim final rulemaking	79 FR 45938	08/06/2014

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 26040	05/06/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 45938	08/06/2014
Did the Agency receive public comments on this ICR? No

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Inpatient Psychiatric Facility Quality Reporting Program	CMS-10432, CMS-10432, CMS-10432, CMS-10432	IPF Screen Shots , SUB-1 Measure , TOB & IMM Measures , EHR & Patient Exp of Care Measures

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Agency Discretion	Change Due to Adjustment in Estimate
Annual Number of Responses	904,056	596,200	307,856	0
Annual Time Burden (Hours)	1,939,005	2,279,200	-445	-339,750
Annual Cost Burden (Dollars)	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The number of IPF hospitals is constantly changing. For purposes of the FY 2016 and FY 2017 IPFQR Program final rule, there are approximately 1,626 IPFs eligible for the Program. The number of measures included in its data collection requirements have increased. Specifically, for the FY 2016 payment determination and subsequent years, 2 new measures were added, and for the FY 2017 payment determination, 4 new measures were added. This Program reduces the reporting burden for quality of care information collected by allowing hospitals to abstract data directly into electronic systems instead of submitting paper charts, or to utilize electronic data that they already report to the Joint Commission (JCO) for accreditation. In our effort to foster alignment across quality reporting programs, we are removing the Extraordinary Circumstances Exception form and the Reconsideration Request form, and now submitting these forms as part of the Hospital Inpatient Quality Reporting (HIQR) Program's PRA package (OMB control number 0938-1022). While the currently approved iteration of this IPF package inadvertently excluded the burden for completing these forms, this package, consequently, does not set out any burden changes pertaining to removing either of these forms. Importantly, burden changes would also not apply since the 15 minutes for chart abstraction also includes the time for completing and submitting any forms related to the measures. For purposes of the FY 2016 and FY 2017 IPFQR Program final rule, we are revising the HBIPS Measure Data Collection form, SUB-1 Measure Data Collection form, Vendor Authorization form, and Data Accuracy Acknowledgement to reflect minor updates. We are also updating the Notice of Participation Agreement such that it now can be used by IPFs to also indicate their intent not to participate or withdraw from the Program. We are in turn removing the previous Decline to Participate form and Participation Withdrawal form from this year's PRA package. Because these changes are minor, we do not anticipate any measureable increase in burden on IPFs associated with these changes. We are also adjusting our burden estimates, -We estimate that there will be approximately 574 fewer IPF facilities (or 1,626 facilities) nationwide eligible to participate in the IPFQR Program. -We estimate that the average facility submits measure data on 556 cases per year (previously 271 cases per year). -1,626 IPF facilities, with approximately 556 cases per facility, results in a total of 904,056 cases per year. -Beginning in FY 2016, participating IPFs will need to submit data on 10 measures. Because IPFs have been submitting 8 of the 10 measures to CMS, the amount of training required to submit data should be reduced to training for facilities new to the Program and training on the collection of data and submission only for the 2 new measures. - Beginning in FY 2017, participating IPFs will need to submit data on 14 measures. Because IPFs have been submitting 10 of the 14 measures to CMS, the amount of training required to submit data should be reduced to training for facilities new to the Program and training on the collection of data and submission only for the 4 new measures. -For this year's PRA package, we are adding the Use of an Electronic Health Record and Assessment of Patient Experience of Care form, and the TOB and IMM Data Collection form. We anticipate only a negligible burden on IPFs to complete and submit these forms. Changes to the Program for the FY 2016 and FY 2017 payment determinations, including more measures on which to report and an increase in the wage rate, leads to an increase in the total Program burden. For the FY 2017 payment determination and subsequent years, hourly burden per IPF increases by 431.5 hours and by 701,619 hours across all IPFs, while total cost per IPF increases by $27,366 and by $44,496,677 across all IPFs.

Annual Cost to Federal Government: $106,839

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

Agency Contact: Mitch Bryman 410 786-5258 Mitch.Bryman@cms.hhs.gov

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