Inpatient Psychiatric Facility Quality Reporting Program (CMS-10432)

OMB Control No: 0938-1171	ICR Reference No: 201908-0938-011
Status: Active	Previous ICR Reference No: 201812-0938-001
Agency/Subagency: HHS/CMS	Agency Tracking No: CCSQ
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: 11/05/2019
Retrieve Notice of Action (NOA)	Date Received in OIRA: 08/27/2019
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2022	36 Months From Approved	01/31/2022
Responses	13,517,629	0	13,710,742
Time Burden (Hours)	3,381,086	0	3,431,153
Cost Burden (Dollars)	0	0	0

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Abstract: Section 10322 of the Affordable Care Act (ACA) authorizes the establishment of a new quality reporting program for Inpatient Psychiatric Facilities (IPFs). The program began with an initial set of 6 measures for FY 2014 and FY 2015 and currently includes 18 measures. For FY 2020 we propose adding one measure calculated from administrative claims. IPFs that fail to comply with the program’s requirements will receive a 2% reduction in their Annual Payment Update (APU). To minimize burden and maximize efficiency, CMS has leveraged existing systems within CMS to collect aggregated data 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. CMS will use the FY 2014 procedural requirements designed to align with current quality reporting programs. These procedural requirements involve submitting necessary forms (e.g., Notice of Participation Form, Reconsideration Request Form) to comply with the program and align with current CMS reporting requirements for other hospital quality reporting programs. When adding new measures, the law requires CMS, where “feasible and practical”, to select measures put forward by “one or more national consensus building entities”. Section 3013 of the ACA requires CMS to perform a gap analysis for needed quality measures every three years. Section 3014 of the ACA 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. CMS reviewed the MAP’s formal recommendations prior to identifying IPFQR measures for the FY 2018 IPPS/LTCH PPS rule.

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

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AT69	Final or interim final rulemaking	84 FR 38424	08/06/2019

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 16980	04/23/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 38424	08/06/2019
Did the Agency receive public comments on this ICR? No

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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 IPF Screenshots (see Supporting Statement A, section 12,under the list of Information Collection Instruments and Instruction/Guidance Documents) ,   Notice of Participation

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	13,517,629	13,710,742	0	0	-193,113	0
Annual Time Burden (Hours)	3,381,086	3,431,153	0	0	-50,067	0
Annual Cost Burden (Dollars)	0	0	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: No

Burden Reduction Due to:

Short Statement: In the FY 2020 IPF PPS final rule, we adopted one new measure, Medication Continuation Following Inpatient Psychiatric Discharge (NQF #3205). This measure will not require facilities to submit data on any cases since CMS will collect the data under Medicare Part A, Part B, and Part D reporting. Therefore, we do not believe that there is any change of burden associated with this new measure. Our currently approved information collection request estimates 1,734 IPFs, as indicated above we now estimate 1,679 facilities, or a decrease of 55 IPFs. Based on more recent data, we are updating our estimate for measures that do not allow sampling to 1,283 cases per facility (a change of +70 cases for each of these 2 measures), and are not changing our estimate for measures that allow sampling. We continue to assume an average of 0.25 hours of effort per case. Overall, we are adjusting our burden estimates by -50,067 hours and -193,113 responses.

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Annual Cost to Federal Government: $106,839

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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 [email protected]

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
		(a) It is necessary for the proper performance of agency functions;
		(b) It avoids unnecessary duplication;
		(c) It reduces burden on small entities;
		(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
		(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
		(f) It indicates the retention periods for recordkeeping requirements;
		(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
			(i) Why the information is being collected;
			(ii) Use of information;
			(iii) Burden estimate;
			(iv) Nature of response (voluntary, required for a benefit, or mandatory);
			(v) Nature and extent of confidentiality; and
			(vi) Need to display currently valid OMB control number;
		(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
		(i) It uses effective and efficient statistical survey methodology (if applicable); and
		(j) It makes appropriate use of information technology.
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
Certification Date: 08/27/2019

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