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Federal Register / Vol. 86, No. 147 / Wednesday, August 4, 2021 / Rules and Regulations
lotter on DSK11XQN23PROD with RULES5

percentiles for the 7-day rate and a 17.4
percent absolute difference for the 30day rate. If all facilities achieved the benchmark follow-up rates for their Medicare FFS patients as calculated using the AHRQ Achievable Benchmarks of Care method, 143 53,841
additional discharges would have a 7day follow-up visit, and 47,552 would have a 30-day follow-up visit.144
During the development process, we used the CMS Quality Measures Public Comment Page to ask for public comments on the measure.145 We accepted public comments from January 25, 2019, to February 13, 2019. During this period, we received comments from 29 organizations or individuals. Many commenters acknowledged the importance of developing a measure that assesses acute care providers for follow-up post-hospitalization. Some commenters expressed skepticism about the measures appropriateness as a tool for evaluating the performance of discharging IPFs due to factors beyond the IPFs control that can affect whether a patient receives timely post-discharge follow-up care. Ten stakeholders expressed support for the measure based on the expanded list of qualifying diagnoses in the denominator and the inclusion of more patients who could benefit from post-discharge follow-up visits.146
We reviewed the comments we received with the TEP, whose members shared similar feedback regarding the importance of follow-up for patients with both mental health diagnoses and substance use disorders, as well as concerns about the ability of IPFs to influence follow-up care. We agree with commenters that some factors that influence follow-up are outside of an IPFs control. However, as described previously in this section, we believe that there are interventions such as predischarge transition interviews, appointment reminder letters or reminder phone calls, meetings with outpatient clinicians before discharge, and meetings with inpatient staff familiar to patients at the first postdischarge appointment that allow facilities to improve their follow-up adherence. We remain committed to monitoring follow-up to improve health 143 https nhqrnet.ahrq.gov/inhqrdr/resources/
methodsBenchmarks.
144 Quality AfHRa. 2017 National Healthcare Quality and Disparities Report. Rockville, MD:
Services USDoHaH; 2018.
145 https www.cms.gov/Medicare/QualityInitiatives-Patient-Assessment-Instruments/MMS/
Downloads/IPF_-Follow-Up-After-PsychiatricHospitalization_Public-Comment-Summary.pdf.
146 Mathematica. FAPH public comment summary. April 2019.

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outcomes and view this measure as an expansion of our ability to measure appropriate follow-up care established by FUH.
b. Overview of Measure 1. Measure Calculation The FAPH measure would be calculated by dividing the number of discharges that meet the numerator criteria by the number that meet the denominator criteria. Two rates are reported for this measure: the 7-day rate and the 30-day rate.
a Numerator The first rate that would be reported for this measure includes discharges from an IPF that are followed by an outpatient visit for treatment of mental illness or SUD within 7 days. The second rate reported for this measure would include discharges from an IPF
that are followed by an outpatient visit for treatment of mental illness or SUD
within 30 days. Outpatient visits are defined as outpatient visits, intensive outpatient encounters, or partial hospitalization and are defined by the Current Procedural Terminology CPT, Healthcare Common Procedure Coding System HCPCS, and Uniform Billing UB Revenue codes. Claims with codes for emergency room visits do not count toward the numerator.
b Denominator The denominator includes discharges paid under the IPF prospective payment system during the performance period for Medicare FFS patients with a principal diagnosis of mental illness or SUD. Specifically, the measure includes IPF discharges for which the patient was:
Discharged with a principal diagnosis of mental illness or SUD that would necessitate outpatient follow-up care, Alive at the time of discharge, Enrolled in Medicare Parts A and B
during the month of the discharge date and at least one month after the discharge date to ensure that data are available to capture the index admission and follow-up visits, and Age 6 or older on the date of discharge, because follow-up treatment for mental illness or SUD might not always be recommended for younger children.
The denominator excludes IPF
discharges for patients who:
Were admitted or transferred to acute and non-acute inpatient facilities within the 30-day follow-up period, because admission or transfer to other institutions could prevent an outpatient follow-up visit from taking place,
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Were discharged against medical advice, because the IPF could have limited opportunity to complete treatment and prepare for discharge, Died during the 30-day follow-up period, or Use hospice services or elect to use a hospice benefit at any time during the measurement year regardless of when the services began, because hospice patients could require different followup services.
The FAPH measure differs from FUH
mostly in the expansion of the measure population to include SUD and other mental health diagnoses in the measures denominator, but it includes some additional differences:
The FAPH measure simplifies the exclusion of admission or transfer to acute or non-acute inpatient facilities within 30 days after discharge by aligning with the HEDIS Inpatient Stay Value Set used in both the HEDIS FUH
and the HEDIS Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence FUA measures to identify acute and non-acute inpatient stays. A discharge is excluded from the FAPH measure if it is followed by an admission or a transfer with one of the codes in the value set.
The FAPH measure uses Medicare UB Revenue codes rather than inpatient discharge status code, which the FUH
measure uses to identify discharge or transfer to other health care institutions.
This is to align better with the intent of the HEDIS FUH and HEDIS FUA
measures.
The FAPH measure allows mental illness or SUD diagnoses in any position on the follow-up visit claim to count toward the numerator and does not require that it be in the primary position as the FUH measure does.
2 Measure Reliability and Validity In 2019, CMS used the final measure specifications to complete reliability and validity testing, which revealed that the FAPH measure provides reliable and valid IPF-level rates of follow-up after psychiatric hospitalization. We evaluated measure reliability based on a signal-to-noise analysis,147 in which a score of 0.0 implies that all variation is attributed to measurement error noise, and a score of 1.0 implies that all measure score variation is caused by a real difference in performance across IPFs. Using that approach, we established a minimum denominator size of 40 discharges to attain an overall 147 For additional information on reliability tests see http www.qualityforum.org/Measuring_
Performance/Improving_NQF_Process/Measure_
Testing_Task_Force_Final_Report.aspx.

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