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Federal Register / Vol. 86, No. 147 / Wednesday, August 4, 2021 / Rules and Regulations extent to which hospices had taken advantage of the exemption, and thus the extent to which data and measure scores might be affected. We observed that the HIS data submission rate for Q4
2019 was in fact 1.8 percent higher than the previous CY Q4 2018. For the CAHPS Hospice Survey, 2.1 percent more hospices submitted data in Q4
2019 than in Q4 2018. We note that Q4
2019 ended before the onset of the COVID19 PHE in the United States U.S.. Thus, we proceeded with including these data in measure calculations for the November 2020
refresh.
As for Q1 and Q2 2020, we determined that we would not use HIS
or CAHPS data from these quarters for public reporting given the timing of the COVID19 PHE onset. All refreshes, during which we decided to hold these data constant, included more than 2
quarters of data that were affected by the CMS-issued COVID reporting exceptions; thus we did not have an adequate amount of data to reliably calculate and publicly display provider measures scores. Consequently, we determined to freeze the data displayed, that is, holding data constant after the November 2020 refresh without subsequently updating the data through November 2021. This decision was communicated to the public in a Public Reporting Tip Sheet, which is located at: https www.cms.gov/Medicare/
Quality-Initiatives-Patient-AssessmentInstruments/Hospice-Quality-Reporting/
HQRP-Requirements-and-Best-Practices.
3. Public Reporting of HIS-based Measures With Fewer Than Standard Numbers of Quarters Due to COVID19
PHE Exemption in February 2022

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As noted previously, we used Q4
2019 data for public reporting in November 2020 and froze that data for the February, May, August, and November 2021 refreshes. This addressed five of the six COVID19
PHE-affected quarters for HIS-based
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measures, and five of the 11 COVID19
PHE-affected quarters of CAHPS-based measures.
Because November 2020 refresh data will become increasingly out-of-date and thus less useful for consumers, we analyzed whether it would be possible to use fewer quarters of data for the last refresh affected by the exemption February 2022 and thus more quickly resume public reporting with updated quality data. Using fewer quarters of more recent data, the first option, would require that 1 a sufficient percentage of providers would still likely have enough assessment data to report quality measures reportability; and 2 fewer quarters would likely produce similar measure scores for hospices, and thus not unfairly represent the quality of care hospices provide during the period reported in a given refresh reliability.
To assess these criteria, we conducted reportability and reliability analysis using 3 quarters of data in a refresh, instead of the standard 4 quarters of data for reporting HIS-based measures.
Specifically, we used historical data to calculate HIS-based quality measures under two scenarios:
Standard Public Reporting SPR
Scenario: We used data from the four quarters of CY 2019, which represent CY 2020 public reporting in the absence of the temporary exemption from the submission of PAC quality data, as the basis for comparing simulated alternatives. For HIS-based measures, we used quarters Q1 through Q4 2019.
COVID19 PHE Affected Reporting CAR Scenario: We calculated quality measures using Q2 2019, Q3 2019, and Q4 2019 data, to simulate using only Q3
2020, Q4 2020, and Q1 2021 data for public reporting.
The HIS Comprehensive Assessment Measure is based on the receipt of care processes at the time of admission.
Therefore for the COVID19 Affected Reporting CAR Scenario, we excluded data for patient stays with admission dates in Q1 2019.

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For each scenario, we calculated the reportability as the percent of hospices meeting the 20-case minimum for public reporting the public reporting threshold. To test the reliability of restricting the providers included in the Standard Public Reporting SPR
Scenario to those included in the CAR
Scenario, we performed three tests.
First, we evaluated measure correlation using the Pearson and Spearman correlation coefficients, which assess the alignment of hospices HIS
Comprehensive Assessment Measure scores between scenarios. Second, for each scenario, we conducted a split-half reliability analysis and estimated intraclass correlation ICC scores, where higher scores imply better internal reliability. Modest differences in ICC
scores between scenarios would suggest that using fewer quarters of data does not impact the internal reliability of the results. Third, we estimated reliability scores. A higher value in these scores indicates that HIS Comprehensive Assessment Measure values are relatively consistent for patients admitted to the same hospice and variation in the measure reflects true differences across providers.
Testing results show that the CAR
scenariospecifically using 3 quarters of data for the HIS Comprehensive Assessment Measuredemonstrates acceptable levels of reportability and reliability. As displayed in Table 14, the number of providers who met the public reporting threshold for the HIS
Comprehensive Assessment Measure decreases by 236 or by 5.2 percentage points when reporting three versus four quarters of data. In the FY 2014 Hospice Wage Index and Payment Rate Update final rule 78 FR 48234 we stated that reportability of 71 percent through 90
percent is acceptable. Therefore using 3
quarters of data for the HIS
Comprehensive Assessment Measure would achieve acceptable reportability shown in Table 14.
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