42 U.S.C. § 1395lll — Standardized post-acute care (PAC) assessment data for quality, payment, and discharge planning
submitted 91 years ago by Pub. L. 113-185 to r/title-42-THE-PUBLIC-HEALTH-AND-WELFARE · 3,572 words · no verdicts yet
This section requires certain post-acute care providers to report standardized patient-assessment data and data about quality, resource use, and other measures. It sets deadlines, reporting and public-disclosure rules, discharge-planning requirements, funding, and limits on review.
(a) Requirement for standardized assessment data
(1) In general
The Secretary* must—
(A) require, under the applicable reporting provisions, post-acute care providers (defined in paragraph (2)(A)) to report—
(i) standardized patient-assessment data as required by subsection (b);
(ii) data about the quality measures under subsection (c)(1); and
(iii) data about resource-use and other measures under subsection (d)(1);
(B) require the data in subparagraph (A) to be standardized and interoperable. It must be possible to exchange the data among these post-acute care providers and other providers, and for providers to use data that has been exchanged. This includes using common standards and definitions. The purpose is to give providers access to information about a person* over time, to support coordinated care and better outcomes for Medicare beneficiaries; and
(C) consistent with subsections (b)(1) and (c)(2), modify the PAC assessment instruments (defined in paragraph (2)(B)) used for post-acute care providers so that the instruments—
(i) allow providers to submit standardized patient-assessment data under this subchapter; and
(ii) allow that assessment data to be compared across all providers to which the data applies.
(2) Definitions
For this section: the terms defined below have the following meanings.
(A) Post-acute care (PAC) provider
“Post-acute care provider” and “PAC provider” mean any of these:
(i) a home health agency*;
(ii) a skilled nursing facility*;
(iii) an inpatient rehabilitation facility; or
(iv) a long-term care hospital, except for a hospital classified under section 1395ww(d)(1)(B)(vi) of this title.
(B) PAC assessment instrument
“PAC assessment instrument” means the following instrument, depending on the provider:
(i) For a home health agency, it means the instrument used to report and make assessments for the Outcome and Assessment Information Set (OASIS), as described in sections 484.55 and 484.250 of title 42 of the Code of Federal Regulations*, or any successor regulation. It also means any other instrument used for those purposes for home health agencies.
(ii) For a skilled nursing facility, it means the resident’s assessment under section 1395i–3(b)(3) of this title.
(iii) For an inpatient rehabilitation facility, it means any Medicare-beneficiary assessment instrument established by the Secretary for purposes of section 1395ww(j) of this title.
(iv) For a long-term care hospital, it means the Medicare-beneficiary assessment instrument used for those hospitals to collect the data elements needed to calculate quality measures, as described in the August 18, 2011, Federal Register (76 Fed. Reg. 51754–51755), including for purposes of section 1395ww(m)(5)(C) of this title. It also means any other instrument used for assessment purposes for those hospitals.
(C) Applicable reporting provision
“Applicable reporting provision” means the following provision for each kind of provider:
(i) For home health agencies: section 1395fff(b)(3)(B)(v) of this title.
(ii) For skilled nursing facilities: section 1395yy(e)(6) of this title.
(iii) For inpatient rehabilitation facilities: section 1395ww(j)(7) of this title.
(iv) For long-term care hospitals: section 1395ww(m)(5) of this title.
(D) PAC payment system
“PAC payment system” means the following prospective payment system:
(i) For a home health agency, the system under section 1395fff of this title.
(ii) For a skilled nursing facility, the system under section 1395yy(e) of this title.
(iii) For an inpatient rehabilitation facility, the system under section 1395ww(j) of this title.
(iv) For a long-term care hospital, the system under section 1395ww(m) of this title.
(E) Specified application date
“Specified application date” means the dates below.
(i) Quality measures
For quality measures under subsection (c)(1):
(I) For the domain in subsection (c)(1)(A), concerning functional status, cognitive function, and changes in function and cognitive function—
(aa) for PAC providers described in paragraph (2)(A)(ii) and (iii), October 1, 2016;
(bb) for PAC providers described in paragraph (2)(A)(iv), October 1, 2018; and
(cc) for PAC providers described in paragraph (2)(A)(i), January 1, 2019.
(II) For the domain in subsection (c)(1)(B), concerning skin integrity and changes in skin integrity—
(aa) for PAC providers described in paragraph (2)(A)(ii), (iii), and (iv), October 1, 2016; and
(bb) for PAC providers described in paragraph (2)(A)(i), January 1, 2017.
(III) For the domain in subsection (c)(1)(C), concerning medication reconciliation—
(aa) for PAC providers described in paragraph (2)(A)(i), January 1, 2017; and
(bb) for PAC providers described in paragraph (2)(A)(ii), (iii), and (iv), October 1, 2018.
(IV) For the domain in subsection (c)(1)(D), concerning the occurrence of major falls—
(aa) for PAC providers described in paragraph (2)(A)(ii), (iii), and (iv), October 1, 2016; and
(bb) for PAC providers described in paragraph (2)(A)(i), January 1, 2019.
(V) For the domain in subsection (c)(1)(E), concerning accurate communication of the existence of health information and care preferences and providing for their transfer—
(aa) for PAC providers described in paragraph (2)(A)(ii), (iii), and (iv), October 1, 2018; and
(bb) for PAC providers described in paragraph (2)(A)(i), January 1, 2019.
(ii) Resource use and other measures
For resource-use and other measures under subsection (d)(1)—
(I) for PAC providers described in paragraph (2)(A)(ii), (iii), and (iv), October 1, 2016; and
(II) for PAC providers described in paragraph (2)(A)(i), January 1, 2017.
(F) Medicare beneficiary
“Medicare beneficiary” means a person entitled to benefits under part A or, when appropriate, enrolled for benefits under part B. This section does not otherwise define the term.
(b) Standardized patient assessment data
(1) Requirement for reporting assessment data
(A) In general
By October 1, 2018, at the latest, for the PAC providers described in subsection (a)(2)(A)(ii), (iii), and (iv), and by January 1, 2019, at the latest, for the providers described in subsection (a)(2)(A)(i), the Secretary must require PAC providers to submit to the Secretary, under the applicable reporting provisions and through PAC assessment instruments, the standardized patient-assessment data described in subparagraph (B). The Secretary must require this data for a person’s admission and discharge. The data may be submitted more often if the Secretary considers that appropriate.
(B) Standardized patient assessment data described
For subparagraph (A), the standardized patient-assessment data is data needed for at least the quality measures in subsection (c)(1), covering these categories:
(i) Functional status, such as mobility and self-care when a person enters a PAC provider and before the person leaves one.
(ii) Cognitive function, such as the ability to express ideas and understand, and mental status, such as depression and dementia.
(iii) Special services, treatments, and interventions, such as a need for a ventilator, dialysis, chemotherapy, a central-line placement, or total parenteral nutrition.
(iv) Medical conditions and co-morbidities, such as diabetes, congestive heart failure, and pressure ulcers.
(v) Impairments, such as incontinence or a reduced ability to hear, see, or swallow.
(vi) Other categories that the Secretary decides are necessary and appropriate.
(2) Alignment of claims data with standardized patient assessment data
As far as practicable, by October 1, 2018, at the latest, for the PAC providers described in subsection (a)(2)(A)(ii), (iii), and (iv), and by January 1, 2019, at the latest, for the providers described in subsection (a)(2)(A)(i), the Secretary must match claims data with assessment data under this section. The purpose is to assess earlier service use and service use at the same time, such as earlier use of a hospital or PAC provider. The Secretary may use the matched data for other purposes the Secretary decides are appropriate.
(3) Replacement of certain existing data
If patient-assessment data used with a PAC assessment instrument duplicates or overlaps standardized patient-assessment data in a category listed in paragraph (1), the Secretary must, as soon as practicable, revise or replace the existing data with the standardized data.
(4) Clarification
Standardized patient-assessment data submitted under this subsection may not be used to require that a person receive post-acute care from a particular type of PAC provider in order for that care to qualify for payment under this subchapter.
(c) Quality measures
(1) Requirement for reporting quality measures
By the specified application date that applies to the measure and PAC provider, the Secretary must specify quality measures. Under the applicable reporting provisions, PAC providers must submit the standardized patient-assessment data described in subsection (b)(1) and other necessary data specified by the Secretary for those measures. The measures must cover at least these areas:
(A) Functional status, cognitive function, and changes in functional status and cognitive function.
(B) Skin integrity and changes in skin integrity.
(C) Medication reconciliation.
(D) The occurrence of major falls.
(E) Accurately communicating that an individual’s health information and care preferences exist, and arranging for their transfer to the individual, the individual’s family caregiver, and providers that furnish items and services to the individual, when the individual moves—
(i) from a hospital or critical access hospital to another applicable setting, including a PAC provider or the individual’s home; or
(ii) from a PAC provider to another applicable setting, including a different PAC provider, a hospital, a critical access hospital, or the individual’s home.
(2) Reporting through PAC assessment instruments
(A) In general
To the extent possible, the Secretary must require PAC providers to report the quality measures under paragraph (1) through a PAC assessment instrument. The Secretary must modify the instrument as needed so it can be used for those quality measures.
(B) Limitation
The Secretary may not make significant changes to a PAC assessment instrument more than once in a calendar year or fiscal year, as applicable, unless the Secretary publishes a justification for the significant change in the Federal Register.
(3) Adjustments
(A) In general
The Secretary must consider applying adjustments to the quality measures under this subsection, taking into account the studies under section 2(d) of the IMPACT Act of 2014.
(B) Risk adjustment
The quality measures must be adjusted for risk when the Secretary decides that is appropriate.
(d) Resource use and other measures
(1) Requirement for resource use and other measures
By the specified application date that applies to the measure and PAC provider, the Secretary must specify resource-use and other measures. Under the applicable reporting provisions, PAC providers must submit any necessary data specified by the Secretary. That data may include standardized assessment data in addition to claims data. The measures must cover at least these areas:
(A) Resource-use measures, including the total estimated Medicare spending per beneficiary.
(B) Discharge to the community.
(C) Measures showing all-condition, risk-adjusted rates of potentially preventable hospital readmissions.
(2) Aligning methodology adjustments for resource use measures
(A) Period of time
For the period used to calculate the measures under paragraph (1)(A), the Secretary must, to the extent the Secretary considers appropriate, align resource use with the method used for section 1395ww(o)(2)(B)(ii) of this title.
(B) Geographic and other adjustments
For the domain in paragraph (1)(A), the Secretary must standardize the measures for geographic differences in payment rates and payment differences, and for other adjustments when applicable. The standardization must be consistent with the method published in the Federal Register on August 18, 2011 (76 Fed. Reg. 51624 through 51626), or with later changes to that method.
(C) Medicare spending per beneficiary
For the domain in paragraph (1)(A), the Secretary must, when appropriate, adjust the measures for the factors applied under section 1395ww(o)(2)(B)(ii) of this title.
(3) Adjustments
(A) In general
For the domain in paragraph (1)(A), the Secretary must consider applying adjustments to the resource-use and other measures specified under this subsection, taking into account the studies under section 2(d) of the IMPACT Act of 2014.
(B) Risk adjustment
The resource-use and other measures must be adjusted for risk when the Secretary decides that is appropriate.
(e) Measurement implementation phases; selection of quality measures and resource use and other measures
(1) Measurement implementation phases
For quality measures specified under subsection (c)(1) and resource-use and other measures specified under subsection (d)(1), this section must be implemented in these phases:
(A) Initial implementation phase
For a measure, the initial implementation phase must, as applicable under subsections (c) and (d), include—
(i) specifying the measure. This includes telling the public the measure’s numerator, denominator, exclusions, and any other parts the Secretary decides are necessary;
(ii) collecting data. For quality measures, this includes requiring PAC providers to report the data elements needed to calculate the measure; and
(iii) analyzing data. For resource-use and other measures, this includes using claims data to calculate the measure.
(B) Second implementation phase
For a measure, the second implementation phase consists of providing feedback reports to PAC providers under subsection (f).
(C) Third implementation phase
For a measure, the third implementation phase consists of publicly reporting PAC providers’ performance on the measure under subsection (g).
(2) Consensus-based entity
(A) In general
Subject to subparagraph (B), every measure the Secretary specifies under this section must be endorsed by the entity that has a contract under section 1395aaa(a) of this title.
(B) Exception
If the Secretary decides that a specified area or medical topic is appropriate, but the entity with a contract under section 1395aaa(a) of this title has not endorsed a feasible and practical measure for it, the Secretary may specify a measure without that endorsement. The Secretary must give due consideration to measures endorsed or adopted by a consensus organization identified by the Secretary.
(3) Treatment* of application of pre-rulemaking process (measure applications partnership process)
(A) In general
Subject to subparagraph (B), section 1395aaa–1 of this title applies to a quality measure specified under subsection (c) and to a resource-use or other measure specified under subsection (d).
(B) Exceptions
(i) Expedited procedures
To satisfy subparagraph (A), the Secretary may use expedited procedures, such as ad hoc reviews, when necessary. This applies to a quality measure under subsection (c) or a resource-use or other measure under subsection (d) that is required for data submissions under the applicable reporting provisions during the 1-year period before the specified application date for the measure and the provider involved.
(ii) Option to waive provisions
The Secretary may waive application of section 1395aaa–1 of this title for a quality measure or resource-use or other measure described in clause (i) if applying that section, including through an expedited procedure described in clause (i), would prevent the Secretary from meeting any deadline in this section for the measure.
(f) Feedback reports to PAC providers
(1) In general
Beginning one year after the specified application date that applies to the PAC providers and to the quality measures or resource-use and other measures under this section, the Secretary must give those PAC providers confidential feedback reports about their performance on the measures required under the applicable provisions.
(2) Frequency
As far as feasible, the Secretary must provide these feedback reports at least quarterly. However, for measures reported annually, the Secretary may provide the feedback reports annually.
(g) Public reporting of PAC provider performance
(1) In general
Subject to the rest of this subsection, the Secretary must arrange for public reporting of PAC providers’ performance on the quality measures under subsection (c)(1) and the resource-use and other measures under subsection (d)(1). This includes procedures for making information about each PAC provider’s performance on those measures available to the public.
(2) Opportunity to review
The procedures must ensure that a PAC provider can review the data and information about the provider that will be made public and submit corrections before the data is made public. The procedures must do this, including through a process consistent with the process used for similar purposes under section 1395ww(b)(3)(B)(viii)(VII) of this title.
(3) Timing
The procedures must provide that, for a measure and PAC provider, the data and information described in paragraph (1) become publicly available no later than two years after the specified application date for that measure and provider.
(4) Coordination with existing programs
The procedures must provide that the data and information described in paragraph (1), for the quality measures and resource-use and other measures under subsections (c)(1) and (d)(1), become public consistently with these provisions:
(A) For home health agencies, section 1395fff(b)(3)(B)(v)(III) of this title.
(B) For skilled nursing facilities, sections 1395i–3(i) and 1396r(i) of this title.
(C) For inpatient rehabilitation facilities, section 1395ww(j)(7)(E) of this title.
(D) For long-term care hospitals, section 1395ww(m)(5)(E) of this title.
(h) Removing, suspending, or adding measures
(1) In general
The Secretary may remove, suspend, or add a quality measure or a resource-use or other measure described in subsection (c)(1) or (d)(1). Subject to paragraph (2), the Secretary may do so only if the Secretary publishes a justification in the Federal Register and provides a notice-and-comment period.
(2) Exception
If there is a reason to believe that continuing to collect a measure could raise safety concerns or cause other unintended consequences, the Secretary may promptly suspend or remove it. The Secretary can satisfy paragraph (1) by publishing a justification for the suspension or removal in the Federal Register during the next rulemaking cycle after the suspension or removal.
(i) Use of standardized assessment data, quality measures, and resource use and other measures to inform discharge planning and incorporate patient preference
(1) In general
By January 1, 2016, and periodically after that, but at least once every 5 years, the Secretary must issue regulations that modify conditions of participation and later interpretive guidance for PAC providers, hospitals, and critical access hospitals. The regulations and guidance must require those providers to consider quality measures, resource-use measures, and other measures under the applicable reporting provisions in the discharge-planning process. When available, this includes measures specified under subsections (c) and (d), as well as other relevant measures.
More specifically, the regulations and guidance must address the settings to which a patient may be discharged. They must help subsection (d) hospitals, critical access hospitals, hospitals described in section 1395ww(d)(1)(B)(v) of this title, PAC providers, patients, and patients’ families plan discharge from inpatient settings, including those hospitals, and from PAC-provider settings. The regulations and guidance must also include procedures addressing—
(A) patients’ treatment preferences; and
(B) patients’ goals of care.
(2) Discharge planning
All requirements imposed under paragraph (1) must be used to help inform and require the discharge-planning process.
(3) Clarification
The regulations may not require a person to receive post-acute care from a particular type of PAC provider in order for that care to qualify for payment under this subchapter.
(j) Stakeholder input
Before the first rulemaking process to implement this section, the Secretary must allow input from stakeholders. This may include town halls, open-door forums, and submissions by mail.
(k) Funding
To carry out this section, the Secretary must provide for $130,000,000 to be transferred to the Centers for Medicare & Medicaid Services Program Management Account. The money must come from the Federal Hospital Insurance Trust Fund under section 1395i of this title and the Federal Supplementary Medical Insurance Trust Fund under section 1395t of this title, in the proportions the Secretary considers appropriate. Half of the amount must be available on October 6, 2014. The other half must be divided equally among fiscal years 2015 through 2019. The money remains available until it is spent.
(l) Limitation
There may be no administrative or judicial review under sections 1395ff and 1395oo of this title, or otherwise, of the standardized patient-assessment data that is required, the measures that are determined, or the systems used under this section to report the standardized data.
(m) Non-application of Paperwork Reduction Act
Chapter 35 of title 44, commonly called the “Paperwork Reduction Act of 1995,” does not apply to this section or to the sections referred to in subsection (a)(2)(B) that must be modified to standardize patient-assessment data.
The Secretary* shall—
require under the applicable reporting provisions post-acute care providers (as defined in paragraph (2)(A)) to report—
standardized patient assessment data in accordance with subsection (b);
data on quality measures under subsection (c)(1); and
data on resource use and other measures under subsection (d)(1);
require data described in subparagraph (A) to be standardized and interoperable so as to allow for the exchange of such data among such post-acute care providers and other providers and the use by such providers of such data that has been so exchanged, including by using common standards and definitions, in order to provide access to longitudinal information for such providers to facilitate coordinated care and improved Medicare beneficiary outcomes; and
in accordance with subsections (b)(1) and (c)(2), modify PAC assessment instruments (as defined in paragraph (2)(B)) applicable to post-acute care providers to—
provide for the submission of standardized patient assessment data under this subchapter with respect to such providers; and
enable comparison of such assessment data across all such providers to whom such data are applicable.
For purposes of this section:
The terms “post-acute care provider” and “PAC provider” mean—
a home health agency*;
a skilled nursing facility*;
an inpatient rehabilitation facility; and
a long-term care hospital (other than a hospital classified under section 1395ww(d)(1)(B)(vi) of this title).
The term “PAC assessment instrument” means—
in the case of home health agencies, the instrument used for purposes of reporting and assessment with respect to the Outcome and Assessment Information Set (OASIS), as described in sections 484.55 and 484.250 of title 42, the Code of Federal Regulations*, or any successor regulation, or any other instrument used with respect to home health agencies for such purposes;
in the case of skilled nursing facilities, the resident’s assessment under section 1395i–3(b)(3) of this title;
in the case of inpatient rehabilitation facilities, any Medicare beneficiary assessment instrument established by the Secretary for purposes of section 1395ww(j) of this title; and
in the case of long-term care hospitals, the Medicare beneficiary assessment instrument used with respect to such hospitals for the collection of data elements necessary to calculate quality measures as described in the August 18, 2011, Federal Register (76 Fed. Reg. 51754–51755), including for purposes of section 1395ww(m)(5)(C) of this title, or any other instrument used with respect to such hospitals for assessment purposes.
The term “applicable reporting provision” means—
for home health agencies, section 1395fff(b)(3)(B)(v) of this title;
for skilled nursing facilities, section 1395yy(e)(6) of this title;
for inpatient rehabilitation facilities, section 1395ww(j)(7) of this title; and
for long-term care hospitals, section 1395ww(m)(5) of this title.
The term “PAC payment system” means—
with respect to a home health agency, the prospective payment system under section 1395fff of this title;
with respect to a skilled nursing facility, the prospective payment system under section 1395yy(e) of this title;
with respect to an inpatient rehabilitation facility, the prospective payment system under section 1395ww(j) of this title; and
with respect to a long-term care hospital, the prospective payment system under section 1395ww(m) of this title.
The term “specified application date” means the following:
In the case of quality measures under subsection (c)(1)—
with respect to the domain described in subsection (c)(1)(A) (relating to functional status, cognitive function, and changes in function and cognitive function)—
for PAC providers described in clauses (ii) and (iii) of paragraph (2)(A), October 1, 2016;
for PAC providers described in clause (iv) of such paragraph, October 1, 2018; and
for PAC providers described in clause (i) of such paragraph, January 1, 2019;
with respect to the domain described in subsection (c)(1)(B) (relating to skin integrity and changes in skin integrity)—
for PAC providers described in clauses (ii), (iii), and (iv) of paragraph (2)(A), October 1, 2016; and
for PAC providers described in clause (i) of such paragraph, January 1, 2017;
with respect to the domain described in subsection (c)(1)(C) (relating to medication reconciliation)—
for PAC providers described in clause (i) of such paragraph, January 1, 2017; and
for PAC providers described in clauses (ii), (iii), and (iv) of such paragraph, October 1, 2018;
with respect to the domain described in subsection (c)(1)(D) (relating to incidence of major falls)—
for PAC providers described in clauses (ii), (iii), and (iv) of paragraph (2)(A), October 1, 2016; and
for PAC providers described in clause (i) of such paragraph, January 1, 2019; and
with respect to the domain described in subsection (c)(1)(E) (relating to accurately communicating the existence of and providing for the transfer of health information and care preferences)—
for PAC providers described in clauses (ii), (iii), and (iv) of paragraph (2)(A), October 1, 2018; and
for PAC providers described in clause (i) of such paragraph, January 1, 2019.
In the case of resource use and other measures under subsection (d)(1)—
for PAC providers described in clauses (ii), (iii), and (iv) of paragraph (2)(A), October 1, 2016; and
for PAC providers described in clause (i) of such paragraph, January 1, 2017.
The term “Medicare beneficiary” means an individual entitled to benefits under part A or, as appropriate, enrolled for benefits under part B.
Beginning not later than October 1, 2018, for PAC providers described in clauses (ii), (iii), and (iv) of subsection (a)(2)(A) and January 1, 2019, for PAC providers described in clause (i) of such subsection, the Secretary shall require PAC providers to submit to the Secretary, under the applicable reporting provisions and through the use of PAC assessment instruments, the standardized patient assessment data described in subparagraph (B). The Secretary shall require such data be submitted with respect to admission and discharge of an individual (and may be submitted more frequently as the Secretary deems appropriate).
For purposes of subparagraph (A), the standardized patient assessment data described in this subparagraph is data required for at least the quality measures described in subsection (c)(1) and that is with respect to the following categories:
Functional status, such as mobility and self care at admission to a PAC provider and before discharge from a PAC provider.
Cognitive function, such as ability to express ideas and to understand, and mental status, such as depression and dementia.
Special services, treatments, and interventions, such as need for ventilator use, dialysis, chemotherapy, central line placement, and total parenteral nutrition.
Medical conditions and co-morbidities, such as diabetes, congestive heart failure, and pressure ulcers.
Impairments, such as incontinence and an impaired ability to hear, see, or swallow.
Other categories deemed necessary and appropriate by the Secretary.
To the extent practicable, not later than October 1, 2018, for PAC providers described in clauses (ii), (iii), and (iv) of subsection (a)(2)(A), and January 1, 2019, for PAC providers described in clause (i) of such subsection, the Secretary shall match claims data with assessment data pursuant to this section for purposes of assessing prior service use and concurrent service use, such as antecedent hospital or PAC provider use, and may use such matched data for such other uses as the Secretary determines appropriate.
In the case of patient assessment data being used with respect to a PAC assessment instrument that duplicates or overlaps with standardized patient assessment data within a category described in paragraph (1), the Secretary shall, as soon as practicable, revise or replace such existing data with the standardized data.
Standardized patient assessment data submitted pursuant to this subsection shall not be used to require individuals to be provided post-acute care by a specific type of PAC provider in order for such care to be eligible for payment under this subchapter.
Not later than the specified application date, as applicable to measures and PAC providers, the Secretary shall specify quality measures on which PAC providers are required under the applicable reporting provisions to submit standardized patient assessment data described in subsection (b)(1) and other necessary data specified by the Secretary. Such measures shall be with respect to at least the following domains:
Functional status, cognitive function, and changes in function and cognitive function.
Skin integrity and changes in skin integrity.
Medication reconciliation.
Incidence of major falls.
Accurately communicating the existence of and providing for the transfer of health information and care preferences of an individual to the individual, family caregiver of the individual, and providers of services furnishing items and services to the individual, when the individual transitions—
from a hospital or critical access hospital to another applicable setting, including a PAC provider or the home of the individual; or
from a PAC provider to another applicable setting, including a different PAC provider, a hospital, a critical access hospital, or the home of the individual.
To the extent possible, the Secretary shall require such reporting by a PAC provider of quality measures under paragraph (1) through the use of a PAC assessment instrument and shall modify such PAC assessment instrument as necessary to enable the use of such instrument with respect to such quality measures.
The Secretary may not make significant modifications to a PAC assessment instrument more than once per calendar year or fiscal year, as applicable, unless the Secretary publishes in the Federal Register a justification for such significant modification.
The Secretary shall consider applying adjustments to the quality measures under this subsection taking into consideration the studies under section 2(d) of the IMPACT Act of 2014.
Such quality measures shall be risk adjusted, as determined appropriate by the Secretary.
Not later than the specified application date, as applicable to measures and PAC providers, the Secretary shall specify resource use and other measures on which PAC providers are required under the applicable reporting provisions to submit any necessary data specified by the Secretary, which may include standardized assessment data in addition to claims data. Such measures shall be with respect to at least the following domains:
Resource use measures, including total estimated Medicare spending per beneficiary.
Discharge to community.
Measures to reflect all-condition risk-adjusted potentially preventable hospital readmission rates.
With respect to the period of time used for calculating measures under paragraph (1)(A), the Secretary shall, to the extent the Secretary determines appropriate, align resource use with the methodology used for purposes of section 1395ww(o)(2)(B)(ii) of this title.
The Secretary shall standardize measures with respect to the domain described in paragraph (1)(A) for geographic payment rate differences and payment differentials (and other adjustments, as applicable) consistent with the methodology published in the Federal Register on August 18, 2011 (76 Fed. Reg. 51624 through 51626), or any subsequent modifications made to the methodology.
The Secretary shall adjust, as appropriate, measures with respect to the domain described in paragraph (1)(A) for the factors applied under section 1395ww(o)(2)(B)(ii) of this title.
The Secretary shall consider applying adjustments to the resource use and other measures specified under this subsection with respect to the domain described in paragraph (1)(A), taking into consideration the studies under section 2(d) of the IMPACT Act of 2014.
Such resource use and other measures shall be risk adjusted, as determined appropriate by the Secretary.
In the case of quality measures specified under subsection (c)(1) and resource use and other measures specified under subsection (d)(1), the provisions of this section shall be implemented in accordance with the following phases:
The initial implementation phase, with respect to such a measure, shall, in accordance with subsections (c) and (d), as applicable, consist of—
measure specification, including informing the public of the measure’s numerator, denominator, exclusions, and any other aspects the Secretary determines necessary;
data collection, including, in the case of quality measures, requiring PAC providers to report data elements needed to calculate such a measure; and
data analysis, including, in the case of resource use and other measures, the use of claims data to calculate such a measure.
The second implementation phase, with respect to such a measure, shall consist of the provision of feedback reports to PAC providers, in accordance with subsection (f).
The third implementation phase, with respect to such a measure, shall consist of public reporting of PAC providers’ performance on such measure in accordance with subsection (g).
Subject to subparagraph (B), each measure specified by the Secretary under this section shall be endorsed by the entity with a contract under section 1395aaa(a) of this title.
In the case of a specified area or medical topic determined appropriate by the Secretary for which a feasible and practical measure has not been endorsed by the entity with a contract under section 1395aaa(a) of this title, the Secretary may specify a measure that is not so endorsed as long as due consideration is given to measures that have been endorsed or adopted by a consensus organization identified by the Secretary.
Subject to subparagraph (B), the provisions of section 1395aaa–1 of this title shall apply in the case of a quality measure specified under subsection (c) or a resource use or other measure specified under subsection (d).
For purposes of satisfying subparagraph (A), the Secretary may use expedited procedures, such as ad-hoc reviews, as necessary, in the case of a quality measure specified under subsection (c) or a resource use or other measure specified in subsection (d) required with respect to data submissions under the applicable reporting provisions during the 1-year period before the specified application date applicable to such a measure and provider involved.
The Secretary may waive the application of the provisions of section 1395aaa–1 of this title in the case of a quality measure or resource use or other measure described in clause (i), if the application of such provisions (including through the use of an expedited procedure described in such clause) would result in the inability of the Secretary to satisfy any deadline specified in this section with respect to such measure.
Beginning one year after the specified application date, as applicable to PAC providers and quality measures and resource use and other measures under this section, the Secretary shall provide confidential feedback reports to such PAC providers on the performance of such providers with respect to such measures required under the applicable provisions.
To the extent feasible, the Secretary shall provide feedback reports described in paragraph (1) not less frequently than on a quarterly basis. Notwithstanding the previous sentence, with respect to measures described in such paragraph that are reported on an annual basis, the Secretary may provide such feedback reports on an annual basis.
Subject to the succeeding paragraphs of this subsection, the Secretary shall provide for public reporting of PAC provider performance on quality measures under subsection (c)(1) and the resource use and other measures under subsection (d)(1), including by establishing procedures for making available to the public information regarding the performance of individual PAC providers with respect to such measures.
The procedures under paragraph (1) shall ensure, including through a process consistent with the process applied under section 1395ww(b)(3)(B)(viii)(VII) of this title for similar purposes, that a PAC provider has the opportunity to review and submit corrections to the data and information that is to be made public with respect to the provider prior to such data being made public.
Such procedures shall provide that the data and information described in paragraph (1), with respect to a measure and PAC provider, is made publicly available beginning not later than two years after the specified application date applicable to such a measure and provider.
Such procedures shall provide that data and information described in paragraph (1) with respect to quality measures and resource use and other measures under subsections (c)(1) and (d)(1) shall be made publicly available consistent with the following provisions:
In the case of home health agencies, section 1395fff(b)(3)(B)(v)(III) of this title.
In the case of skilled nursing facilities, sections 1395i–3(i) and 1396r(i) of this title.
In the case of inpatient rehabilitation facilities, section 1395ww(j)(7)(E) of this title.
In the case of long-term care hospitals, section 1395ww(m)(5)(E) of this title.
The Secretary may remove, suspend, or add a quality measure or resource use or other measure described in subsection (c)(1) or (d)(1), so long as, subject to paragraph (2), the Secretary publishes in the Federal Register (with a notice and comment period) a justification for such removal, suspension, or addition.
In the case of such a quality measure or resource use or other measure for which there is a reason to believe that the continued collection of such measure raises potential safety concerns or would cause other unintended consequences, the Secretary may promptly suspend or remove such measure and satisfy paragraph (1) by publishing in the Federal Register a justification for such suspension or removal in the next rulemaking cycle following such suspension or removal.
Not later than January 1, 2016, and periodically thereafter (but not less frequently than once every 5 years), the Secretary shall promulgate regulations to modify conditions of participation and subsequent interpretive guidance applicable to PAC providers, hospitals, and critical access hospitals. Such regulations and interpretive guidance shall require such providers to take into account quality, resource use, and other measures under the applicable reporting provisions (which, as available, shall include measures specified under subsections (c) and (d), and other relevant measures) in the discharge planning process. Specifically, such regulations and interpretive guidance shall address the settings to which a patient may be discharged in order to assist subsection (d) hospitals, critical access hospitals, hospitals described in section 1395ww(d)(1)(B)(v) of this title, PAC providers, patients, and families of such patients with discharge planning from inpatient settings, including such hospitals, and from PAC provider settings. In addition, such regulations and interpretive guidance shall include procedures to address—
treatment preferences of patients; and
goals of care of patients.
All requirements applied pursuant to paragraph (1) shall be used to help inform and mandate the discharge planning process.
Such regulations shall not require an individual to be provided post-acute care by a specific type of PAC provider in order for such care to be eligible for payment under this subchapter.
Before the initial rulemaking process to implement this section, the Secretary shall allow for stakeholder input, such as through town halls, open door forums, and mail-box submissions.
For purposes of carrying out this section, the Secretary shall provide for the transfer to the Centers for Medicare & Medicaid Services Program Management Account, from the Federal Hospital Insurance Trust Fund under section 1395i of this title and the Federal Supplementary Medical Insurance Trust Fund under section 1395t of this title, in such proportion as the Secretary determines appropriate, of $130,000,000. Fifty percent of such amount shall be available on October 6, 2014, and fifty percent of such amount shall be equally proportioned for each of fiscal years 2015 through 2019. Such sums shall remain available until expended.
There shall be no administrative or judicial review under sections 1395ff and 1395oo of this title or otherwise of the specification of standardized patient assessment data required, the determination of measures, and the systems to report such standardized data under this section.
Chapter 35 of title 44 (commonly referred to as the “Paperwork Reduction Act of 1995”) shall not apply to this section and the sections referenced in subsection (a)(2)(B) that require modification in order to achieve the standardization of patient assessment data.
Source credit: (Aug. 14, 1935, ch. 531, title XVIII, § 1899B, as added Pub. L. 113–185, § 2(a), Oct. 6, 2014, 128 Stat. 1952; amended Pub. L. 114–255, div. C, title XV, § 15008(d)(1), Dec. 13, 2016, 130 Stat. 1321.)
- 1935Enacted · Pub. L. 113-185 · 128 Stat. 1952
- 2016Amended · Pub. L. 114-255 · 130 Stat. 1321
A history note hasn’t been published yet. The record shows enactment by Pub. L. 113-185 on 1935-08-14.
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