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Federal Register / Vol. 86, No. 147 / Wednesday, August 4, 2021 / Rules and Regulations
recommendation on using this measure at the health system level, we believe the commenter is recommending adopting this measure to evaluate performance of regional or local health systems such as those affiliated with large hospital networks. We note that the IPFQR Program applies to Medicare participating freestanding psychiatric hospitals and psychiatric units and we believe that health systems that have IPFs that participate in the IPFQR
Program would find this measure useful as they assess access and referral network adequacy within their systems.
Comment: Some commenters observed that some follow-ups, especially for substance use disorders, may not be identifiable in claims. A few commenters specifically noted that some providers who often provide follow-ups are not covered by Medicare for example, therapists or that some follow-ups may be covered by other insurers. These commenters observed that this may lead the measure to undercount follow-ups provided. A few of these commenters did not support measure adoption because of this undercount. However, one commenter that expressed this concern supported measure adoption because the commenter believes that burden reduction associated with claims reporting outweighs the potential undercounting.
Response: We acknowledge that, like the Follow-Up After Hospitalization for Mental Illness FUH, NQF 0576
measure that we proposed to replace with the FAPH measure, the FAPH
measure would not be able to capture follow-up visits provided by professionals outside of Medicare, or if the patient uses another payer or selfpay to cover the patients follow-up care, which could lead to an undercount. However, we believe that the data captured by the measure would be sufficient to inform consumers and to provide data for quality improvement initiatives. Further, we agree with the commenter that the burden reduction associated with using claims-based measures outweighs the potential undercounting.
Comment: Some commenters expressed concern that this measure may be difficult for some IPFs to perform well on due to factors outside of the IPFs control. One commenter observed that many rural hospitals lack community resources and therefore cannot refer patients to outpatient psychiatrists. Another commenter observed that some patients may be unwilling to see an outpatient psychiatrist. Other commenters observed that this measure captures
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patient behavior, not provider actions.
Some of these commenters observed that lack of transportation, access barriers, homelessness or other patient characteristics outside of the IPFs control may affect performance. Some of these commenters expressed preference for a process measure that tracks whether IPFs performed interventions to improve follow-up rates before or during discharge.
Response: We recognize that there is regional variation in access to outpatient resources and that patients have varying comfort levels with different provider types. However, we believe that this updated measure helps to address some of the commenters concerns.
Specifically, we note that this measure expands the definition of follow-up to include a wider range of outpatient providers, including family or general practice physicians, internal medicine physicians, nurse practitioners, and physician assistants. We agree with commenters that there are factors that influence follow-up that are outside of an IPFs control including patient behavior, lack of transportation, access barriers, homelessness, among others.
As described in the FY 2022 IPF PPS
proposed rule 86 FR 19504 through 19505, there are interventions that allow facilities to improve their followup adherence. We believe it is incumbent upon facilities to identify potential barriers to follow-up adherence and apply appropriate interventions to improve adherence. We believe that this measure is preferable to a process measure because it provides insight into the success of interventions by identifying follow-up rates. As discussed in the FY 2014 IPPS/LTCH
PPS final rule 78 FR 50894 through 50895 and the FY 2022 IPF PPS
proposed rule in our proposal to adopt the FAPH measure 86 FR 19504
through 19507 we do not expect 100
percent of patients discharged from IPFs to receive follow-up care within 7 or 30
days of discharge because of factors both within and outside of the control of facilities such as availability of providers in the referral network.
Comment: Some commenters opposed the FAPH measure because it is not NQF endorsed and because it was not fully supported by the MAP. A few commenters observed that the measure may undergo changes to achieve NQF
endorsement which would create burden if the measure were in the program when these changes occurred.
Some commenters recommended delaying implementation until NQFs concerns are fully addressed. One commenter observed that the similar NQF-endorsed FUH measure is
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available and therefore CMS has not properly considered available consensus endorsed measures.
Response: We appreciate the commenters concerns about the FAPH
measures lack of NQF endorsement. As we stated in the proposed rule, after having given due consideration to similar measures, FUH measure NQF
0576 and Continuity of Care after Inpatient or Residential Treatment for SUD NQF 3453, we believe that the FAPH measure is an improvement over the FUH measure currently in the IPFQR Program 86 FR 19507. The FAPH measure expands the number of discharges in the denominator by adding patients with SUD or dementia, populations that also benefit from timely follow-up care. We propose updates to the IPFQR program measure set on an annual basis through the rulemaking process. During the measure evaluation process, we carefully consider the potential burden to clinicians, health systems, and patients of any updates that are under consideration.
The primary concerns of some NQF
Behavioral Health and Substance Use Standing Committee members with the FAPH measure were exclusions for patients who died during the 30-day follow-up period or who were transferred. While we respect the NQFs concerns, we note that these same exclusions align with the exclusions in the Follow-Up After Hospitalization for Mental Illness FUH, NQF 0576
measure which is already NQF
endorsed, and which we adopted under the IPFQR Program in the FY 2014
IPPS/LTCH PPS final rule. This measure has a very similar denominator 78 FR
50893 through 50895. The clinical expert work group and technical expert panel convened by our contractor supported these exclusions as being appropriate for both measures.
After having given due consideration to similar measures, FUH measure NQF
0576 and Continuity of Care after Inpatient or Residential Treatment for SUD NQF 3453, we believe that the FAPH measure is an improvement over the FUH measure which is currently in the IPFQR Program, because it includes patients with SUD or dementia, populations that also benefit from timely follow-up care 86 FR 19504
through 19506.
Comment: Some commenters recommended further research or testing. Some commenters recommended that CMS continue to consider evidence supporting the expanded patient cohort.
Response: We thank commenters for these recommendations and will
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