Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals (IPPS) and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year (FY) 2026 Rates; Changes to the FY 2025 IPPS Rates Due to Court Decision; Requirements for Quality Programs; and Other Policy Changes; Health Data, Technology, and Interoperability: Electronic Prescribing, Real-Time Prescription Benefit and Electronic Prior Authorization

The basic methodology for determining LTCH PPS standard Federal payment rates is currently set forth at 42 CFR 412.515 through 412.533 and 412.535. In this section, we discuss the factors that we used to update the LTCH PPS standard Federal payment rate for FY 2026, that is, effective for LTCH discharges occurring on or after October 1, 2025, through September 30, 2026. Under the dual rate LTCH PPS payment structure required by statute, beginning with discharges in cost reporting periods beginning in FY 2016, only LTCH discharges that meet the criteria for exclusion from the site neutral payment rate are paid based on the LTCH PPS standard Federal payment rate specified at 42 CFR 412.523. (For additional details on our finalized policies related to the dual rate LTCH PPS payment structure required by statute, we refer readers to the FY 2016 IPPS/LTCH PPS final rule (80 FR 49601 through 49623).)

Prior to the implementation of the dual payment rate system in FY 2016, all LTCH discharges were paid similarly to those now exempt from the site neutral payment rate. That legacy payment rate was called the standard Federal rate. For details on the development of the initial standard Federal rate for FY 2003, we refer readers to the August 30, 2002, LTCH PPS final rule (67 FR 56027 through 56037). For subsequent updates to the standard Federal rate from FYs 2003 through 2015, and LTCH PPS standard Federal payment rate from FY 2016 through present, as implemented under 42 CFR 412.523(c)(3), we refer readers to the FY 2020 IPPS/LTCH PPS final rule (84 FR 42445 through 42446).

In this FY 2026 IPPS/LTCH PPS final rule, we present our policies related to the annual update to the LTCH PPS standard Federal payment rate for FY 2026.

The update to the LTCH PPS standard Federal payment rate for FY 2026 is presented in section V.A. of the Addendum to this final rule. The components of the annual update to the LTCH PPS standard Federal payment rate for FY 2026 are discussed in this section, including the statutory reduction to the annual update for LTCHs that fail to submit quality reporting data for FY 2026 as required by the statute (as discussed in section IX.C.2.c. of the preamble of this final rule). As we proposed, we made an adjustment to the LTCH PPS standard Federal payment rate to account for the estimated effect of the changes to the area wage level for FY 2026 on estimated aggregate LTCH PPS payments, in accordance with 42 CFR 412.523(d)(4) (as discussed in section V.B. of the Addendum to this final rule). 2. FY 2026 LTCH PPS Standard Federal Payment Rate Annual Market Basket Update a. Overview

Historically, the Medicare program has used a market basket to account for input price increases in the services furnished by providers. The market basket used for the LTCH PPS includes both operating and capital-related costs of LTCHs because the LTCH PPS uses a single payment rate for both operating and capital-related costs. We adopted the 2022-based LTCH market basket for use under the LTCH PPS beginning in FY 2025. For additional details on the historical development of the market basket used under the LTCH PPS, we refer readers to the FY 2013 IPPS/LTCH PPS final rule (77 FR 53467 through 53476), and for a complete discussion of the LTCH market basket and a description of the methodologies used to determine the operating and capital-related portions of the 2022-based LTCH market basket, we refer readers to the FY 2025 IPPS/LTCH PPS final rule (89 FR 69435 through 69455).

Section 3401(c) of the Affordable Care Act provides for certain adjustments to any annual update to the LTCH PPS standard Federal payment rate and refers to the timeframes associated with such adjustments as a “rate year.” We note that, because the annual update to the LTCH PPS policies, rates, and factors now occurs on October 1, we adopted the term “fiscal year” (FY) rather than “rate year” (RY) under the LTCH PPS beginning October 1, 2010, to conform with the standard definition of the Federal fiscal year (October 1 through September 30) used by other PPSs, such as the IPPS (75 FR 50396 through 50397). Although the language of sections 3004(a), 3401(c), 10319, and 1105(b) of the Affordable Care Act refers to years 2010 and thereafter under the LTCH PPS as “rate year,” consistent with our change in the terminology used under the LTCH PPS from “rate year” to “fiscal year,” for purposes of clarity, when discussing the annual update for the LTCH PPS standard Federal payment rate, including the provisions of the Affordable Care Act, we use “fiscal year” rather than “rate year” for 2011 and subsequent years. b. Annual Update to the LTCH PPS Standard Federal Payment Rate for FY 2026

As previously noted, we adopted the 2022-based LTCH market basket for use under the LTCH PPS beginning in FY 2025. The 2022-based LTCH market basket is primarily based on the Medicare cost report data submitted by LTCHs and, therefore, specifically reflects the cost structures of LTCHs. For additional details on the development of the 2022-based LTCH market basket, we refer readers to the FY 2025 IPPS/ LTCH PPS final rule (89 FR 69435 through 69455). We continue to believe that the 2022-based LTCH market basket appropriately reflects the cost structure of LTCHs for the reasons discussed when we adopted its use in the FY 2025 IPPS/LTCH PPS final rule. Therefore, in this final rule, as we proposed, we used the 2022-based LTCH market basket to update the LTCH PPS standard Federal payment rate for FY 2026.

Section 1886(m)(3)(A) of the Act provides that, beginning in FY 2010, any annual update to the LTCH PPS standard Federal payment rate is reduced by the adjustments specified in clauses (i) and (ii) of subparagraph (A), as applicable. Clause (i) of section 1886(m)(3)(A) of the Act provides for a reduction, for FY 2012 and each subsequent rate year, by “the productivity adjustment” described in section 1886(b)(3)(B)(xi)(II) of the Act. Section 1886(b)(3)(B)(xi)(II) of the Act, as added by section 3401(a) of the Affordable Care Act, defines this productivity adjustment as equal to the 10-year moving average of changes in annual economy-wide, private nonfarm business multifactor productivity (as projected by the Secretary for the 10-

year period ending with the applicable fiscal year, year, cost reporting period, or other annual period). The U.S. Department of Labor's Bureau of Labor Statistics (BLS) publishes the official measures of private nonfarm business productivity for the U.S. economy. We note that previously the productivity measure referenced in section 1886(b)(3)(B)(xi)(II) was published by BLS as private nonfarm business multifactor productivity. Beginning with the November 18, 2021, release of productivity data, BLS replaced the term multifactor productivity with total factor productivity (TFP). BLS noted that this is a change in terminology only and will not affect the data or methodology. As a result of the BLS name change, the productivity measure referenced in section 1886(b)(3)(B)(xi)(II) is now published by BLS as private nonfarm business total factor productivity. However, as mentioned, the data and methods are unchanged. Please see www.bls.gov for the BLS historical published TFP data. A complete description of IGI's TFP projection methodology is available on the CMS website at https://www.cms.gov/data-research/statistics-trends-and-reports/medicare-program-rates-statistics/market-basket-research-and-information. Section 1886(m)(3)(A)(ii) of the Act provided for a reduction, for each of FYs 2010 through 2019, by the “other adjustment” described in section 1886(m)(4)(F) of the Act.

Section 1886(m)(3)(B) of the Act provides that the application of paragraph (3) may result in the annual update being less than zero for a rate year, and may result in payment rates for a rate year being less than such payment rates for the preceding rate year. c. Adjustment to the LTCH PPS Standard Federal Payment Rate Under the Long-Term Care Hospital Quality Reporting Program (LTCH QRP)

In accordance with section 1886(m)(5) of the Act, the Secretary established the Long-Term Care Hospital Quality Reporting Program (LTCH QRP). The reduction in the annual update to the LTCH PPS standard Federal payment rate for failure to report quality data under the LTCH QRP for FY 2014 and subsequent fiscal years is codified under 42 CFR 412.523(c)(4). The LTCH QRP, as required for FY 2014 and subsequent fiscal years by section 1886(m)(5)(A)(i) of the Act, requires that a 2.0 percentage points reduction be applied to any update under 42 CFR 412.523(c)(3) for an LTCH that does not submit quality reporting data to the Secretary in accordance with section 1886(m)(5)(C) of the Act with respect to such a year (that is, in the form and manner and at the time specified by the Secretary under the LTCH QRP under 42 CFR 412.523(c)(4)(i)). Section 1886(m)(5)(A)(ii) of the Act provides that the application of the 2.0 percentage points reduction may result in an annual update that is less than 0.0 for a year, and may result in LTCH PPS payment rates for a year being less than such LTCH PPS payment rates for the preceding year. Furthermore, section 1886(m)(5)(B) of the Act specifies that the 2.0 percentage points reduction is applied in a noncumulative manner, such that any reduction made under section 1886(m)(5)(A) of the Act shall apply only with respect to the year involved and shall not be taken into account in computing the LTCH PPS payment amount for a subsequent year. These requirements are codified in the regulations at 42 CFR 412.523(c)(4). (For additional information on the history of the LTCH QRP, including the statutory authority and the selected measures, we refer readers to section X.E. of the preamble of this final rule.) d. Annual Market Basket Update Under the LTCH PPS for FY 2026

Consistent with our historical practice, we estimate the market basket percentage increase and the productivity adjustment based on IHS Global Inc.'s (IGI's) forecast using the most recent available data. Based on IGI's fourth quarter 2024 forecast, the proposed FY 2026 market basket percentage increase for the LTCH PPS using the 2022-based LTCH market basket was 3.4 percent. The proposed productivity adjustment for FY 2026 based on IGI's fourth quarter 2024 forecast was 0.8 percentage point.

For FY 2026, section 1886(m)(3)(A)(i) of the Act requires that any annual update to the LTCH PPS standard Federal payment rate be reduced by the productivity adjustment, described in section 1886(b)(3)(B)(xi)(II) of the Act. Consistent with the statute, we proposed to reduce the FY 2026 market basket percentage increase by the FY 2026 productivity adjustment. To determine the proposed market basket update for LTCHs for FY 2026 we subtracted the proposed FY 2026 productivity adjustment from the proposed FY 2026 market basket percentage increase. (For additional details on our established methodology for adjusting the market basket percentage increase by the productivity adjustment, we refer readers to the FY 2012 IPPS/LTCH PPS final rule (76 FR 51771).) In addition, for FY 2026, section 1886(m)(5) of the Act requires that, for LTCHs that do not submit quality reporting data as required under the LTCH QRP, any annual update to an LTCH PPS standard Federal payment rate, after application of the adjustments required by section 1886(m)(3) of the Act, shall be further reduced by 2.0 percentage points.

In the FY 2026 IPPS/LTCH PPS proposed rule (90 FR 18322), in accordance with the statute, we proposed to reduce the proposed FY 2026 market basket percentage increase of 3.4 percent (based on IGI's fourth quarter 2024 forecast of the 2022-based LTCH market basket) by the proposed FY 2026 productivity adjustment of 0.8 percentage point (based on IGI's fourth quarter 2024 forecast). Therefore, under the authority of section 123 of the BBRA as amended by section 307(b) of the BIPA, consistent with 42 CFR 412.523(c)(3)(xvii), we proposed to establish an annual market basket update to the LTCH PPS standard Federal payment rate for FY 2026 of 2.6 percent (that is, the proposed LTCH PPS market basket percentage increase of 3.4 percent less the proposed productivity adjustment of 0.8 percentage point). For LTCHs that fail to submit quality reporting data under the LTCH QRP, under 42 CFR 412.523(c)(3)(xvii) in conjunction with 42 CFR 412.523(c)(4), we proposed to further reduce the annual update to the LTCH PPS standard Federal payment rate by 2.0 percentage points, in accordance with section 1886(m)(5) of the Act. Accordingly, we proposed to establish an annual update to the LTCH PPS standard Federal payment rate of 0.6 percent (that is, the proposed 2.6 percent LTCH market basket update minus 2.0 percentage points) for FY 2026 for LTCHs that fail to submit quality reporting data as required under the LTCH QRP. Consistent with our historical practice, we proposed in the FY 2026 IPPS/LTCH PPS proposed rule (90 FR 18322) that if more recent data subsequently became available (for example, a more recent estimate of the market basket percentage increase and productivity adjustment), we would use such data, if appropriate, to determine the FY 2026 market basket percentage increase and productivity adjustment in the final rule. We note that, consistent with historical practice, we also proposed to adjust the FY 2026 LTCH PPS standard Federal payment rate by an area wage level budget neutrality factor in accordance with 42 CFR 412.523(d)(4) (as discussed in section V.B.6. of the Addendum to this final rule).

Comment: A few commenters appreciated and supported the proposed rate increase for LTCHs with a commenter stating it will help hospitals meet patient needs and improve access to care. Several commenters were concerned about the proposed 3.4 percent market basket increase based on the LTCH market basket and whether it will adequately support the operational and clinical demands faced by LTCHs. Commenters stated they believe the proposed payment increase is insufficient in light of the current rate of inflation and escalating costs (including labor, drugs, supplies, and equipment) facing LTCHs due to health care workforce shortages and supply chain disruptions.

Commenters provided data and cited recent studies and reports regarding increasing labor costs, state minimum wage requirements, medical supply and pharmaceuticals costs, dialysis costs, total operating costs, administrative costs, impact of tariffs, and hourly rates for contract labor, which the commenters stated highlights the need for additional increases in payments to cover these significant increases in costs. Commenters stated that these increases in costs, combined with the reimbursement pressures on LTCHs, have resulted in a significant decline in the number of LTCHs in operation and the total number of Medicare discharges from LTCHs.

Commenters requested that CMS either modify its methodology used to determine the market basket update, provide for a special increase to the proposed market basket update, or apply a special payment adjustment to account for significantly higher labor and supply costs incurred by LTCHs in recent years and in FY 2026. Another commenter urged CMS to provide a more adequate market basket update in the final rule that reflects actual inflation in the LTCH cost structure and use all available administrative flexibilities to increase the net payment update. A commenter stated that the cumulative impact of inflationary pressure coupled with the proposed low Medicare payment increases for FY 2026 will continue to have negative effects on LTCH PPS operating margins. The commenter urged CMS to use more current data that includes the recent inflationary increases in cost and in the absence of such data, the commenter urged CMS to consider an alternative approach to better align the market basket increases with the rising cost of treating patients.

Response: CMS has historically used a market basket to account for input price increases in the services furnished by fee-for-service providers. Since the inception of the LTCH PPS, the LTCH PPS standard Federal payment rates (with the exception of statutorily mandated updates) have been updated based on a projection of a market basket percentage increase. The LTCH market basket (as well as other CMS market baskets) is a fixed-weight, Laspeyres type index that measures price changes over time and does not reflect increases in costs associated with changes in the volume or intensity of input goods and services until the index is rebased. As such, the LTCH market basket percentage increase reflects the prospective price pressures described by the commenters as increasing during a high inflation period (such as faster wage growth or higher energy prices) but does not inherently reflect other factors that might increase the level of costs, such as the quantity of labor used (which may be associated with intensity of services). However, the impact of changes in quantity or use of services on the market basket cost weights are captured when the market basket is rebased.

We appreciate the commenters' concern regarding inflationary pressure, including labor and supply costs, encountered by LTCHs. We would highlight that the market basket percentage increase is a forecast of the price pressures that LTCHs are expected to face in FY 2026. We also note that when developing its forecast for the various price indexes used in the LTCH market basket, IGI considers industry- specific and overall economic conditions. More specifically for the Employment Cost Index (ECI) for hospital workers, IGI considers overall labor market conditions (including the impact of wage pressures on skill mix) as well as trends in contract labor wages, which both have an impact on wage pressures for workers employed directly by the hospital.

As is our general practice, we proposed that if more recent data became available, we would use such data, if appropriate, to derive the final FY 2026 LTCH market basket increase for the final rule. For this final rule, we are using an updated forecast of the price proxies underlying the market basket that incorporates more recent historical data and reflects a revised outlook regarding the U.S. economy. Based on IGI's second quarter 2025 forecast with historical data through the first quarter of 2025, the projected 2022-based LTCH market basket percentage increase for FY 2026 is 3.4 percent, the same increase as in the proposed rule.

As discussed earlier, we believe the LTCH market basket percentage increase appropriately reflects the expected input price growth (including compensation price growth) that LTCHs incur in providing medical services. We also believe the LTCH market basket is methodologically sound and uses the best available data for FY 2026. Therefore, we disagree with the commenters that CMS should increase the market basket update or apply a “special” payment adjustment to the LTCH PPS rates.

Comment: A commenter also expressed concern about the lack of transparency from CMS regarding the LTCH market basket and the use of the IHS Global Inc. data. The commenter referenced CMS' responses in the FY 2025 IPPS/LTCH PPS final rule (89 FR 68986, 69450) regarding commenter's concerns about the lack of transparency in the market basket. The commenter stated that in the FY 2026 IPPS/LTCH PPS proposed rule, CMS did not provide greater transparency about the IHS Global Inc. data used for the market basket update that CMS is proposing for FY 2026. The commenter claimed that it is still not possible to replicate exactly how CMS arrived at the proposed 3.4 percent market basket update for FY 2026. The commenter requested that CMS provide more transparency in the final rule regarding the IHS Global Inc. data that led to this proposed market basket update.

Response: As discussed in the FY 2025 IPPS/LTCH PPS final rule (89 FR 69450), information on the CMS market baskets can be found at the CMS website: https://www.cms.gov/data-research/statistics-trends-and-reports/medicare-program-rates-statistics/market-basket-research-and-information. This website provides information including, but not limited to, how a top-line market basket level is derived from the detailed cost categories, how a four-quarter percent change moving average is calculated, and a link to a spreadsheet containing an example of how the detailed market basket cost weights are calculated for the 2006-based IPPS market basket, which is similar to the approach followed for the LTCH market basket as well as most of the other CMS market baskets. In addition, the latest publicly available CMS market baskets are available at the CMS website: https://www.cms.gov/data-research/statistics-trends-and-reports/medicare-program-rates-statistics/market-basket-data. We note that publicly available market baskets on the CMS website would reflect an updated forecast only after a proposed or final rule is published. Using these spreadsheets, stakeholders are able to replicate the top-line market

basket index levels in the historical time period by multiplying the detailed index level for each cost category by the associated cost weight. These products (weight multiplied by index level) can then be summed up to derive the aggregate market basket index level.

In response to the commenter's request for more transparency, in this final rule, we are also providing the projected increase for FY 2026 for some of the aggregated cost categories that underlie the most recent forecast of the FY 2026 LTCH market basket increase (3.4 percent). This detail is consistent with the level of information that we publish on the CMS website on a quarterly basis as described previously. We note that prices for the compensation cost weight, which accounts for about 62 percent of the market basket are projected to increase 3.4 percent in FY 2026; prices for All Other Products and Services, which accounts for about 28 percent of the market basket are projected to increase 3.2 percent; and prices for Capital-Related costs, which accounts for about 8.5 percent of the LTCH market basket are projected to increase 3.5 percent. While the projected market basket increase is calculated using the aggregation of the detailed price forecasts multiplied by their respective cost weights for each of the 26 individual cost categories, we want to provide an estimate of how the broader cost categories are contributing to the overall increase. We strive for transparency regarding our methods. Stakeholders are free to ask further questions or request further clarifications regarding the market baskets via email at [email protected].

Comment: Several commenters were concerned about the proposed productivity adjustment of 0.8 percentage point. A commenter stated that the market basket update is effectively eroded by the excessive 0.8 percentage point productivity cut--a reduction that is especially damaging for hospitals already operating on slim or negative margins. Commenters stated that CMS should at least temporarily suspend the productivity adjustment because COVID-19, inflation, increased labor costs, and labor shortages have reduced hospital productivity.

A commenter also requested that CMS provide more transparency about how the productivity adjustment is calculated. The commenter cited CMS' response to similar comments in the FY 2025 IPPS/LTCH PPS final rule; however, the commenter stated that CMS did not address the obvious incongruity of applying the productivity adjustment during periods when the actual productivity of hospitals is clearly declining. The commenter stated that if CMS believes it lacks statutory authority to temporarily suspend the productivity adjustment, then CMS should use its broad ratesetting authority to make other changes that would reduce the impact of the productivity adjustment. For example, the commenter stated that CMS could either apply an offsetting payment adjustment to reduce the productivity adjustment, in whole or in part; or modify the data used by IHS Global Inc. in a manner that would reduce the amount of the productivity adjustment. The commenter claimed that either of these changes would be an appropriate use of the broad authority granted by Congress.

Commenters stated that the productivity adjustment is flawed as it is unlikely that productivity for LTCHs is increasing at the same rate as other non-hospital industries because of the unique challenges facing hospitals. A commenter requested that CMS make an adjustment for LTCHs to account for flaws in the productivity adjustment. Commenters urged CMS to eliminate the proposed 0.8 percentage point productivity cut and use all available administrative flexibilities to increase the net payment update.

A commenter stated that the use of private nonfarm business total factor productivity effectively assumes the hospital field can mirror productivity gains achieved by private nonfarm businesses. However, the commenter claimed that it is well proven by the economic literature that the hospital and health care field cannot do this. For example, the commenter stated that by focusing only on private businesses, this measure excludes nonprofit and government businesses, which account for more than 60 percent of hospitals and health systems. Thus, the commenter stated that this measure is not an appropriate or reliable predictor of productivity for the hospital field. The commenter stated that CMS itself has acknowledged that hospitals are unable to achieve the same productivity gains as the general economy over the long run. Thus, the commenter stated that using the private nonfarm business sector TFP to adjust the market basket inappropriately exacerbates Medicare's chronic underpayments to LTCHs. The commenter stated that it is puzzling how an indicator based on a 10-year moving average could yield such an increase in the productivity cut from FY 2025 to FY 2026; however, the commenter was unable to fully analyze the projections due to a lack of transparency from CMS. In addition, the commenter found it troubling that the productivity adjustment is used only when it decreases Medicare payments. Given all of this, the commenter asked CMS to re-examine the magnitude of this adjustment and its impact on Medicare payments.

Response: Section 1886(m)(3)(A)(i) of the Act requires the application of the productivity adjustment. As set forth in section 1886(b)(3)(B)(xi) of the Act, the FY 2026 productivity adjustment is derived based on the 10-year moving average growth in economy-wide private nonfarm business total factor productivity for the period ending in FY 2026. We recognize the concerns of the commenters regarding the appropriateness of the productivity adjustment; however, as we explained in response to similar comments in the FY 2023, FY 2024 and FY 2025 IPPS/LTCH PPS final rules, section 1886(m)(3)(A)(i) of the Act requires the application of the specific productivity adjustment described in section 1886(b)(3)(B)(xi) of the Act.

We have always made available on the CMS website the general method for calculating the productivity adjustment. This includes providing a link to the most recent BLS historical TFP data (http://www.bls.gov), which allows interested parties to obtain historical TFP annual index levels for 1987 through 2024. We also provided the IGI projection model (https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/medicareprogramratesstats/downloads/tfp_methodology.pdf), which is used to derive annual TFP growth rates for 2025 and 2026. The annual index level derived from this method is then interpolated to quarterly levels, and the FY 2026 productivity adjustment is equal to the percent change in the 40-quarter moving average projected level for the period ending September 30, 2026 relative to the 40-quarter moving average projected level for the period ending September 30, 2025. We believe our methodology for the productivity adjustment is consistent with section 1886(b)(3)(B)(xi)(II) of the Act, which states that the productivity adjustment is equal to the 10-year moving average of changes in annual economy-wide private nonfarm business multi-factor productivity (as projected by the Secretary for the 10-year period ending with the applicable fiscal year, year, cost reporting period, or other annual period).

At the time of this final rule, the FY 2026 productivity adjustment reflects BLS historical TFP data through 2024 (released on March 21, 2025) and IGI's forecasted TFP growth for 2025 and

2026. The average annual growth rate of historical TFP published by BLS for 2017 through 2024 is currently 0.9 percent and IGI is projecting average TFP growth of about 0.0 percent for 2025 and 2026 based on IGI's second-quarter 2025 forecast. Combining the historical and projected TFP data over the entire 10-year time period results in a compound annual growth rate of TFP of 0.7 percent for 2026. The productivity adjustment (based on the 10-year period ending with FY 2026) for this FY 2026 IPPS/LTCH PPS final rule is 0.1 percentage point lower than in the FY 2026 IPPS/LTCH PPS proposed rule, and primarily reflects the incorporation of a revised outlook from IGI that has lower projected economic growth over 2025 and 2026. The 0.7 percentage point productivity adjustment for FY 2026 in this final rule is larger than the productivity adjustment in prior final rules for FY 2023 and FY 2024 mainly due to the incorporation of updated BLS historical data.

Comment: Several commenters stated that CMS has “under-forecast” the market basket used to update Medicare payments to LTCHs for FY 2021 through FY 2025, which the commenters claimed has resulted in a cumulative underpayment to LTCHs of 5.1 percent, or $130 million per year. A commenter requested CMS also provide for a forecast error adjustment of 4.3 percentage points for the combined understatement of the FY 2021 through FY 2024 LTCH market baskets. The commenter stated that adopting this one-time forecast error adjustment to address the exceptional and unprecedented circumstances surrounding the COVID-19 PHE would make the LTCH PPS update equal to 3.4 percent plus 4.3 percentage points for forecast error less 0.8 percentage point productivity adjustment, or a net 6.9 percent. Commenters stated that even more problematic is the fact that these forecast errors will be incorporated into the LTCH PPS payment rates indefinitely because all future updates are based on the current year's payment rate.

The commenters cited CMS' response in the FY 2024 IPPS/LTCH PPS final rule of evaluating the FY 2012 through FY 2020 market baskets for ratesetting and finding that they were higher than the actual market baskets as unreasonable as they failed to account for the unprecedented COVID-19 pandemic and its lasting impact on hospital costs. The commenters stated that CMS' response in the FY 2025 IPPS/LTCH PPS final rule that upward price pressures were expected to slow in 2025 relative to 2022 and 2023 was inadequate because CMS set the market basket update for FY 2025 at 3.5 percent, but the commenter stated that the four-quarter moving averages of the IHS Global Inc. forecast for Q4 2024 through Q3 2025 are currently 3.9 percent, 3.8 percent, 3.7 percent, and 3.6 percent and have exceeded this increase, suggesting that CMS is underpaying LTCHs in FY 2025.

Therefore, the commenters stated that CMS should use the most recent forecast data to apply a special, one-time payment adjustment to account for the differences between the FYs 2021 through 2025 market basket updates and the actual market baskets for those years. The commenter also stated that going forward, CMS must ensure that the market basket update reflects the actual increase in the cost of LTCH goods and services.

Response: In responding to similar comments in the FY 2023, FY 2024 and FY 2025 IPPS/LTCH PPS final rules (87 FR 49165, 88 FR 59136, 89 FR 69434), we explained that under the law, the LTCH PPS is a per- discharge prospective payment system that uses a market basket percentage increase to set the annual update prospectively. This means that the update relies on a mix of both historical data for part of the period for which the update is calculated and forecasted data for the remainder. (For instance, the 2022-based LTCH market basket growth rate for FY 2026 in this final rule is based on IGI's second quarter 2025 forecast with historical data through the first quarter of 2025.) While there is currently no mechanism to adjust for market basket forecast error in the LTCH PPS payment update, the forecast error for a market basket update is equal to the actual market basket percentage increase for a given year less the forecasted market basket percentage increase. Due to the uncertainty regarding future price trends, forecast errors can be both positive and negative.

While the projected LTCH market basket updates for FY 2021 through FY 2024 (the last historical fiscal year) were under forecast (actual increases less forecasted increases were positive), this was largely due to unanticipated inflation and labor market pressures as the economy emerged from the COVID-19 PHE. The forecast error of the LTCH market basket has been both positive and negative during past years, and over longer periods of time the cumulative forecast has not deviated significantly from the historical measures. For these reasons, we are not adopting the commenters' requests to implement an adjustment for FY 2026 to account for the difference between the actual and forecasted LTCH market basket updates for FYs 2021 through 2024, and, for the reasons stated previously, we disagree that we wrongly dismissed commenters' requests to apply an adjustment that accounts for forecast errors in the FY 2023, FY 2024 and FY 2025 IPPS/LTCH PPS final rules.

Comment: A commenter expressed concern that there is a more systemic issue with IHS Global Inc.'s forecasting that biases towards under-forecasting growth. The commenter stated that one such factor may be the use of the ECI to measure changes in labor compensation in the market basket. The commenter stated that the use of the ECI may not be adequately capturing employment and labor cost growth and stated that they continue to stand ready to work with CMS to examine the market basket compensation indices and proxies to improve the accuracy of these measures.

Response: We believe that the ECI for wages and salaries for hospital workers is accurately reflecting the price change associated with the labor used to provide hospital care. The ECI appropriately does not reflect other factors that might affect the rate of price changes associated with labor costs, such as a shift in the occupations that may occur due to increases in case-mix or shifts in hospital purchasing decisions (for instance, to hire or to use contract labor). We believe that the prices of employed staff and contract labor are influenced by the same factors and should generally grow at similar rates.

In most periods when there are not significant occupational shifts or significant shifts between employed and contract labor, the data has shown that the growth in the ECI for wages and salaries for hospital workers has generally been consistent with overall hospital wage trends. For example, our more recent analysis of the Medicare cost report data shows from 2018 to 2023, the compound annual growth rate of IPPS Medicare allowable salaries, benefits and contract labor costs per hour was about 4 percent, consistent with the growth rate of the compensation price increases in the 2022-based LTCH market basket as measured by the ECIs for hospital workers over the same period.

After consideration of public comments, we are finalizing the LTCH PPS payment rate update using the most recent forecast of the 2022- based LTCH market basket percentage increase and productivity adjustment. As such, based on IGI's second quarter 2025 forecast, the FY 2026 market basket percentage increase for the LTCH PPS using the 2022-based LTCH market basket is 3.4

percent. The current estimate of the productivity adjustment for FY 2026 based on IGI's second quarter 2025 forecast is 0.7 percentage point. Therefore, under the authority of section 123 of the BBRA as amended by section 307(b) of the BIPA, consistent with 42 CFR 412.523(c)(3)(xvii), we are establishing an annual market basket update to the LTCH PPS standard Federal payment rate for FY 2025 of 2.7 percent (that is, the most recent estimate of the LTCH PPS market basket percentage increase of 3.4 percent less the productivity adjustment of 0.7 percentage point). For LTCHs that fail to submit quality reporting data under the LTCH QRP, under 42 CFR 412.523(c)(3)(xvii) in conjunction with 42 CFR 412.523(c)(4), as we proposed, we are further reducing the annual update to the LTCH PPS standard Federal payment rate by 2.0 percentage points, in accordance with section 1886(m)(5) of the Act. Accordingly, we are establishing an annual update to the LTCH PPS standard Federal payment rate of 0.7 percent (that is, the 2.7 percent LTCH market basket update minus 2.0 percentage points) for FY 2026 for LTCHs that fail to submit quality reporting data as required under the LTCH QRP.

We have previously issued requests for information (RFIs) to gather public input on the transition to digital quality measurement (dQM) for CMS programs.\230\ In the FY 2026 IPPS/LTCH PPS proposed rule, we issued this RFI (90 FR 18323 through 18328) and provided updates on our progress and sought input as we continue our path forward in the dQM transition.

\230\ We refer readers to the following rules which contain the previous RFIs: FY 2022 IPPS/LTCH PPS final rule (86 FR 45342 through 86 FR 45349); FY 2023 IPPS/LTCH PPS final rule (87 FR 49181 through 87 FR 49188); CY 2022 Physician Fee Schedule (PFS) final rule (86 FR 65377 through 86 FR 65382); CY 2023 PFS proposed rule (87 FR 46259 through 87 FR 46262); CY 2022 Outpatient Prospective Payment System (OPPS)/Ambulatory Surgical Center (ASC) final rule (86 FR 63815 through 86 FR 63822); and CY 2022 End-Stage Renal Disease (ESRD) PPS final rule (86 FR 61941 through 86 FR 61948).

In the RFI, we solicited comments on our anticipated approach to the use of Health Level Seven[supreg] (HL7[supreg]) Fast Healthcare Interoperability Resources[supreg] (FHIR[supreg]) in electronic clinical quality measure (eCQM) reporting. Several CMS programs currently use, or are considering using, eCQMs for various clinicians, facilities, providers, and other organizations to report their respective quality performance. These CMS programs include the Hospital Inpatient Quality Reporting (IQR) Program, the Hospital Outpatient Quality Reporting (OQR) Program, and the Medicare Promoting Interoperability Program. We sought feedback on FHIR-based eCQM activities in these programs. We included a similar request in the CY 2026 Physician Fee Schedule (PFS) proposed rule to solicit comments on FHIR-based eCQM activities in the Medicare Shared Savings Program and the Merit-based Incentive Payment System (MIPS) quality performance category (90 FR 32685).

In this RFI, we solicited comments on our anticipated approach to FHIR-based patient assessment reporting in the Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program. While we sought comments in this RFI for the IPFQR Program in the FY 2026 IPPS/LTCH PPS proposed rule (as a majority of IPFs are hospital-based),\231\ we sought similar feedback in the FY 2026 Inpatient Psychiatric Facility (IPF) Prospective Payment System (PPS) proposed rule (90 FR 18520).

\231\ We refer readers to the FY 2025 IPF PPS-Rate Update final rule, Table 24 (89 FR 64670). Based on this data, 59.3 percent of IPFs were hospital-based units, a figure derived by dividing the sum of urban and rural units by the total number of facilities.

We thank commenters for their feedback and we will continue to consider the feedback received as we refine our dQM transition efforts and plan the strategic modernization of our quality measurement enterprise. 1. Background

Having immediate access to electronic health information, in near real-time, supports quality measurement efforts, provides the ability to use these data for patient care considerations, and may lead to improved clinical outcomes. To support this, we aim to transition to a fully dQM landscape that promotes interoperability and increases the value of reporting quality measure data. In the coming years, we will continue to seek ways to advance technical infrastructure, update program regulations, and engage Federal partners and the public to support this dQM transition.\232\

\232\ Read more about the dQM transition in the Electronic Clinical Quality Improvement (eCQI) Resource Center here: https://ecqi.healthit.gov/dqm?qt-tabs_dqm=about-dqms.

We are collaborating with Federal agencies, including the Assistant Secretary for Technology Policy (ASTP) and Office of the National Coordinator for Health Information Technology (ONC) (collectively, ASTP) \233\ to support data standardization and alignment of requirements for the development and reporting of digital quality measures. Advancements in the interoperability of healthcare data and corresponding requirements from ASTP/ONC have created the technical foundation across health information technology (IT) systems to pursue modernization of CMS' quality measurement systems. The 21st Century Cures Act: Interoperability, Information Blocking, and the ONC Health IT Certification Program final rule (85 FR 25642) and the Health Data, Technology, and Interoperability: Certification Program Updates, Algorithm Transparency, and Information Sharing (HTI-1) final rule (89 FR 1192) advanced policy approaches that enable flexible, granular data sharing from the certified health IT systems used by many healthcare providers, facilities, and clinicians. Aligning technology requirements for healthcare providers, payers, public health agencies, and health IT developers allows for advancement of an interoperable health IT infrastructure that ensures providers and patients have access to health data when and where it is needed.

\233\ On July 29, 2024, notice was posted in the Federal Register that ONC would be dually titled to the Assistant Secretary for Technology Policy and Office of the National Coordinator for Health Information Technology (89 FR 60903).

We continue to collaborate with ASTP/ONC on future versions of the United States Core Data for

Interoperability (USCDI),\234\ which establishes a baseline set of data elements referenced in health information exchange certification criteria under the ONC Health IT Certification Program. In addition, the ASTP/ONC USCDI+ program supports identification and establishment of domain-specific datasets that build on the USCDI foundation.\235\ The USCDI+ Quality domain,\236\ which we discuss in more detail in section X.2.b. of the preamble of this final rule, aims to harmonize data needs for quality measurement across Federal agencies and other interested parties, and inform supplemental standards necessary to support quality measurement. We also continue to work with ASTP/ONC to advance the interoperability of patient assessment data through collaboration with interested parties to develop FHIR standards through the CMS-sponsored Post-Acute Care Interoperability (PACIO) Project.\237\

\234\ https://www.healthit.gov/isp/united-states-core-data-interoperability-uscdi.

\235\ https://www.healthit.gov/topic/interoperability/uscdi-plus.

\236\ https://uscdiplus.healthit.gov/uscdiplus?id=uscdi_record&table=x_g_sshh_uscdi_domain&sys_id=7ddf78228745b95098e5edb90cbb3525&view=sp.

\237\ https://pacioproject.org/.

Moreover, the CMS Innovation Center's Enhancing Oncology Model recently completed its first reporting period in which FHIR-based application programming interfaces (APIs) were used by model participants to submit clinical data elements to CMS. This specification for reporting was developed as part of the USCDI+ Cancer domain, in close collaboration with ASTP/ONC, the National Institutes of Health (NIH), and the National Cancer Institute (NCI).\238\

\238\ https://www.cms.gov/priorities/innovation/innovation-models/enhancing-oncology-model.

We are also collaborating with the Centers for Disease Control and Prevention (CDC) and the Health Resources and Services Administration (HRSA) in our dQM transition strategy. The CDC National Healthcare Safety Network (NHSN) is leading the development of fully electronic and automated digital quality measures for patient safety and public health surveillance, preparedness, and response.\239\ We are working together with NHSN to explore a modernized approach for reporting quality measures to CMS via the NHSN data pipeline. There are currently nine digital quality measures reported to NHSN that are used in CMS programs.\240\ CMS and CDC are working together to transition to fully automated digital quality measures using a two-pronged approach: (1) Develop new measures to address patient safety gaps; and (2) Update current measures to a FHIR-based format.

\239\ https://www.cdc.gov/nhsn/fhirportal/index.html.

\240\ https://www.cdc.gov/nhsn/cms/index.html.

The NHSN dQM approach uses a reusable reporting framework (NHSN Digital Quality Measure Reporting Implementation Guide (IG)) \241\ in conjunction with content based in national, interoperable data standards (USCDI and USCDI+) that are aligned with CMS requirements, and submitted via secure data transfer via open-source FHIR API (NHSNLink).\242\ Promoting the use of these standards-based, flexible, advanced data reporting methods will reduce the reporting burden on facilities while increasing timeliness and completeness, and will improve the accuracy and quality of data, enhancing health system readiness and response capacity through near real-time data collection.

\241\ https://build.fhir.org/ig/HL7/nhsn-dqm/.

\242\ https://www.cdc.gov/nhsn/fhirportal/about.html.

Our partners at HRSA are also making efforts to modernize reporting of eCQMs.\243\ As part of the Uniform Data System (UDS) modernization, HRSA has developed the Uniform Data Systems Plus (UDS+), which provides for the electronic submission (using FHIR) of de-identified patient- level data including data elements aligned to select CMS eCQMs that health centers are required to report.\244\ HRSA developed a UDS+ FHIR IG, which specifies the FHIR API requirements for structuring and transmitting these data elements based on program requirements.

\243\ https://bphc.hrsa.gov/data-reporting/uds-training-and-technical-assistance/uniform-data-system-uds-modernization-initiative.

\244\ https://www.fhir.org/guides/hrsa/uds-plus/dataelements.html.

All of these efforts to leverage standardized data and the FHIR model are intended to accelerate and support the transition to a data- driven healthcare system that will ultimately reduce provider burden, support the patient experience, and improve quality of care. Shifting towards approaches based on the FHIR standard will help us pave the way for future digital quality measures.\245\

\245\ https://ecqi.healthit.gov/dqm?qt-tabs_dqm=about-dqms.

We thank the public for providing feedback through industry conferences, direct conversations with CMS and our Federal partners, and submitting comments to RFIs in this and previous rulemaking. As we support healthcare providers, facilities, and clinicians, the health IT industry, and Federal partners in their respective activities, we requested public input on this RFI to better inform our ongoing strategy to transition to a fully digital quality landscape. Note that any substantive updates to program-specific requirements related to providing data for quality measurement and reporting would be addressed through future notice-and-comment rulemaking, as necessary. 2. Approach to eCQM Reporting Using FHIR in CMS Quality Programs

In this section, we described the current state and requested input on key components of the ongoing dQM transition related to FHIR-based eCQMs for the Hospital IQR Program, the Hospital OQR Program, and the Medicare Promoting Interoperability Program. These components include: (1) FHIR-based eCQM conversion progress; (2) Data standardization for quality measurement and reporting; (3) The timeline under consideration for FHIR-based eCQM reporting; and (4) Measure development and reporting tools. a. eCQM FHIR Conversion Activities

Currently, eligible hospitals are required to report eCQMs for the Hospital IQR Program and the Hospital OQR Program, and eligible hospitals and critical access hospitals (CAHs) must report eCQMs through the Medicare Promoting Interoperability Program. Additionally, Medicare Shared Savings Program Accountable Care Organizations (ACOs) and eligible clinicians participating in the Merit-based Incentive Payment System (MIPS) can report eCQMs for their quality reporting. Electronic health record (EHR) and other health IT systems certified under the ONC Health IT Certification Program use patient data to calculate the results for each eCQM based upon the measure specifications for the eCQM.\246\

\246\ https://ecqi.healthit.gov/sites/default/files/eCQM-Basics-508.pdf.

An important initial step in our dQM strategy is to ensure current eCQMs are specified using the FHIR standard and allow these measures to be calculated consistently using standardized data represented in FHIR. Standardized digital data can support multiple use cases, including quality measurement, quality improvement efforts, clinical decision support, research, and public health. The eCQMs currently use structured data defined by the Quality Data Model (QDM) and measure logic in Clinical Quality Language to evaluate a

clinician's, provider's, facility's, or organization's performance on a measure concept.\247\

\247\ https://ecqi.healthit.gov/sites/default/files/Digital%20Quality%20Measurement%20eCQMs%20reference%20brief_508ed.pdf .

As we move to FHIR-based eCQMs, we continue to convert current eCQMs (authored using the QDM) to eCQMs authored using the HL7 FHIR[supreg] Quality Improvement Core (QI-Core) IG, updating to new versions as appropriate. We are conducting advanced validation of FHIR data exchange through ongoing HL7 Connectathons and integrated systems testing, leveraging and refining IGs to enhance interoperability and data standardization.\248\ While new eCQMs continue to be developed, proposed, and adopted in existing CMS programs, we are working with measure developers to ensure existing eCQMs are converted to FHIR and that new eCQMs are also natively developed in FHIR. We also stated we are considering a requirement that all measures proposed for addition to CMS programs be specified in FHIR.

\248\ Summaries are available and more information on the most recent Connectathon is available at: https://confluence.hl7.org/spaces/FHIR/pages/281218287/2025+-+01+Clinical+Reasoning.

Additional information and updates regarding eCQMs and the dQM transition can be found on the Electronic Clinical Quality Improvement (eCQI) Resource Center website, available at: https://ecqi.healthit.gov/dqm?qt-tabs_dqm=dqm-strategic-roadmap. We continue to explore potential applications of the FHIR standard to the reporting and use of different types of quality measurement data.

We sought feedback on the following questions:

Are there specific eCQMs or elements of existing eCQMs that you anticipate presenting particular challenges in specifying in FHIR?

Are there gaps in the QI-Core IG that are likely to impact our ability to effectively specify current CMS eCQMs in FHIR?

What supplementary activities would encourage additional engagement in FHIR testing activities (such as Connectathons) that support the development of current and future IGs to advance adoption and use of FHIR-based eCQMs? b. Data Standardization for Quality Measurement and Reporting

We are continuing to collaborate with ONC as it develops a certification approach to enable reporting of FHIR-based eCQMs using technology certified under the ONC Health IT Certification Program. This approach aims to repurpose and harmonize existing FHIR requirements in the ONC Health IT Certification Program whenever possible.\249\ It also aims to incorporate industry-developed standards for the exchange of quality measurement data using FHIR.

\249\ See 45 CFR 170.315(g)(10)--Standardized API for patient and population services FHIR certification in the ONC Health IT Certification program.

In this section we discussed the standards and other artifacts which CMS and ONC are evaluating to serve as the basis for new health IT certification criteria supporting FHIR-based quality measurement and reporting. New health IT certification criteria for quality measurement and reporting could include requirements for certified health IT modules to support the consistent capture and exchange of quality data using FHIR APIs. New criteria could also support standardized reporting rules to ensure successful submission of quality measure data for the Hospital IQR Program, the Hospital OQR Program, and the Medicare Promoting Interoperability Program.

A key artifact we are reviewing as part of this approach is the QI- Core IG, which defines a set of FHIR profiles within a common logic model for clinical quality measurement and clinical decision support intended for use for multiple use cases across domains.\250\ As described previously, this IG is used to represent the data elements necessary to support current eCQMs.

\250\ https://hl7.org/fhir/us/qicore/index.html.

The QI-Core IG builds on the HL7 FHIR[supreg] US Core IG (US Core IG) which is currently referenced under the ONC Health IT Certification Program and implements the USCDI in FHIR. The US Core IG is incorporated in the “Standardized API for patient and population services” health IT certification criterion \251\ and is widely implemented across certified health IT systems. Accordingly, we anticipate that developers implementing the QI-Core IG will be able to leverage existing work from implementing the US Core IG. QI-Core is expected to evolve over time to reflect subsequent versions of the US Core IG. For example, QI-Core 6.0 builds upon US Core version 6.1.0, which provides consensus-based capabilities aligned with USCDI version 3 (v3) data elements for FHIR APIs. In the HTI-1 final rule (89 FR 1196), ASTP/ONC finalized the expiration of USCDI v1 on January 1, 2026, and adopted USCDI v3 as the new baseline version of USCDI after USCDI v1 expires.

\251\ 45 CFR 170.315(g)(10).

We also anticipate alignment between the QI-Core IG and the USCDI+ Quality data element list, which incorporates additional data elements beyond USCDI. We have collaborated with ASTP/ONC around the development of USCDI+ Quality as an extension to USCDI to improve healthcare interoperability across quality programs, establishing a consistent baseline of harmonized data elements for a wide range of quality measurement use cases.\252\ Specifically for CMS programs, USCDI+ Quality includes the data elements to support program-specific measures.\253\

\252\ https://www.healthit.gov/topic/interoperability/uscdi-plus.

\253\ For more information about the USCDI+ Quality data element list please visit https://uscdiplus.healthit.gov/.

We are also considering the Data Exchange for Quality Measures (DEQM) IG \254\ as part of the framework supporting the transition to FHIR-based eCQMs, in particular for supporting FHIR-based reporting to CMS. The DEQM IG provides a framework that defines conformance profiles and guidance to enable the exchange of quality information and enable FHIR-based quality measure reporting. It is based upon other related work in the FHIR and quality measure realm, including the US Core IG, the Healthcare Effectiveness Data and Information Set (HEDIS) IG, and Quality Reporting Document Architecture (QRDA) Category I and III reporting specifications. We are considering the use of the DEQM IG with quality measures specified in accordance with QI-Core.

\254\ https://build.fhir.org/ig/HL7/davinci-deqm/.

To facilitate the exchange of significant volumes of data to support quality measurement, we are also evaluating the use of HL7 FHIR [supreg] Bulk Data, both on its own \255\ or through the DEQM IG.\256\ The existing Bulk Data Access IG defines a standardized, FHIR-based approach for exporting bulk data from a FHIR server to an authenticated and authorized client. ASTP/ONC has adopted the Bulk Data Access IG STU 1, version 1.0.0, published on August 22, 2019 (hereafter referred to as version 1), and has incorporated it into the ONC Health IT Certification Program.\257\ The Bulk Data Access IG has recently seen

considerable revisions and enhancements over version 1 from the HL7 standards community. A new version of the Bulk Data Access IG, planned to be balloted in 2025, is expected to introduce new features such as the capacity to organize output by patient and criteria-based cohort creation, which could significantly enhance the quality reporting use case for the IG.\258\ The HL7 community will also continue to prepare additional enhancements to the Bulk Data Access IG throughout 2025, with the Argonaut Project announcing Bulk Import as a 2025 project.\259\ Bulk Import is already being used by HRSA in their UDS+ IG,\260\ and has the potential to enhance the quality reporting use case more broadly. It defines a standardized mechanism for data submitters to upload or submit their Bulk FHIR data to a receiving system when they have their Bulk FHIR data ready to submit, rather than having to reactively respond to a Bulk FHIR export request initiated by a receiving system.

\255\ https://hl7.org/fhir/uv/bulkdata/.

\256\ https://hl7.org/fhir/us/davinci-deqm/OperationDefinition-bulk-submit-data.html.

\257\ ONC has adopted the Bulk Data Access IG, version 1, in 45 CFR 170.215, and has incorporated this IG into the ONC Health IT Certification Program as part of the “Standardized API for patient and population services” certification criterion in 45 CFR 170.215(g)(10).

\258\ See Argonaut Bulk Optimize project: https://confluence.hl7.org/spaces/AP/pages/227213555/Bulk+Optimize.

\259\ https://confluence.hl7.org/spaces/AP/pages/325453837/Bulk+Import.

\260\ https://www.fhir.org/guides/hrsa/uds-plus/OperationDefinition-import.html.

We sought feedback on the following questions:

Can you share any experiences or challenges reviewing, implementing, or testing the QI-Core, DEQM, or Bulk FHIR standards, including any experiences or challenges unique to Bulk FHIR Import versus Bulk FHIR Export?

Are there any deficiencies or gaps in the DEQM IG that must be addressed before it can potentially be used for reporting to CMS on eCQMs using FHIR APIs?

Are there additional baseline requirements or capabilities that need to be considered before FHIR-based eCQMs could be reported to CMS using Bulk FHIR? c. Timeline Under Consideration for FHIR-Based eCQM Reporting

As we noted in the FY 2023 IPPS/LTCH PPS final rule (87 FR 49183), we are considering proposing a transition period during which healthcare providers may report using either QDM- or FHIR-based eCQMs. This period would provide time for quality program participants, health IT developers, and CMS to engage in learning to optimize systems and processes. During this period, participants would still be required to report on the number of eCQMs finalized for an applicable reporting program, but program participants would be able to choose to submit either QDM-based or FHIR-based eCQMs to meet respective reporting requirements. For instance, program participants who are implementing updated certified health IT and gaining experience with FHIR-based eCQMs could continue submitting QRDA files to meet program requirements, while those who are ready to report FHIR-based eCQMs would be able to do so, for a specified period. For the purposes of this RFI, we referred to this concept as the “reporting options” period.

We acknowledged that participants in the identified CMS programs may proceed with updating certified health IT and implementing dQMs at different speeds. Hence, we are considering the reporting options period in order to provide additional time for providers to make the transition, in advance of any future proposal to require FHIR-based reporting. We are considering at least a two-year reporting options period before any future proposal to require mandatory reporting. Note that any updates to specific program requirements related to providing data for quality measurement and reporting would be addressed through future notice-and-comment rulemaking, as necessary.

We sought feedback on the following questions:

Would a minimum of 24 months from the effective date of a FHIR-based eCQM reporting option using ONC Health IT Certification Program criteria to support quality program submission provide sufficient time for implementation (including measure specification review, certified health IT updates, workflow changes, training, and testing)?

What resources or guidance could CMS provide to assist with the transition to submission of FHIR-based eCQM data?

What, if any, challenges do you anticipate with the reporting timeline of FHIR-based eCQMs (beginning with at least a two- year reporting options period before any future proposal to require FHIR-based reporting)?

What resources, guidance, or other support can we provide to encourage and facilitate the early adoption and reporting of FHIR- based eCQMs during the reporting options period? d. Measure Development and Reporting Tools

We develop and maintain tools and resources to assist measure developers in the different stages of the Measure Lifecycle.\261\ The Measure Authoring Development Integrated Environment (MADiE) is a free software tool that supports the eCQM development and testing process through dynamic authoring and testing within a single application.\262\ MADiE supports QI-Core profile-informed authoring, testing, and verification of the behavior of FHIR-based eCQMs.\263\ We encourage measure developers to continue using this environment for the development of FHIR-based eCQMs.

\261\ https://mmshub.cms.gov/cms-tools.

\262\ https://www.emeasuretool.cms.gov/.

\263\ Ibid.

In the FY 2023 IPPS/LTCH PPS final rule (87 FR 49183), we described plans to modernize programmatic data receiving systems through a unified CMS FHIR receiving system that would provide a single point of data receipt for quality reporting programs. We may also consider separate FHIR receiving systems for some programs initially as the shift to FHIR across CMS programs will be incremental. CMS will provide information on the form and manner for reporting for each program in respective notice-and-comment rulemaking, as necessary. Our vision remains to ultimately develop and implement a single point of data receipt via a unified CMS FHIR receiving system.

In the CMS Digital Quality Measurement Strategic Roadmap, we noted the development of a FHIR-based measure calculation tool (MCT).\264\ After further consideration and testing, we have decided not to advance the MCT as previously described.

\264\ https://ecqi.healthit.gov/dqm?qt-tabs_dqm=dqm-strategic-roadmap.

We sought feedback on the following question:

What capabilities would be most useful for CMS to support in a FHIR-based eCQM reporting model?

What, if any, additional concerns should CMS take into consideration when developing FHIR-based reporting requirements for systems receiving quality data? e. Additional FHIR Transition Activities for ACOs

While this RFI focused on the Hospital IQR Program, the Hospital OQR Program, and the Medicare Promoting Interoperability Program, we also sought similar feedback in the CY 2026 PFS proposed rule for MIPS (90 FR 32685). In the CY 2026 PFS proposed rule we sought feedback on how the dQM transition and use of FHIR-based approaches to quality reporting would impact eligible clinicians participating in MIPS as well as in ACOs. ACOs have

encountered challenges with aggregating, deduplicating, and matching quality data necessary to report using the eCQM and MIPS Clinical Quality Measure (CQM) collection types, as ACOs may bring together healthcare providers using disparate EHR systems from which data must be extracted and aggregated. In that RFI, we sought feedback on how the transition to FHIR-based reporting of eCQMs could help to mitigate these challenges.

We received several comments on the topics in section X.B.2. of the preamble of this final rule. We provide a summary of comments received.

Comment: Many commenters supported the transition to FHIR-based eCQMs to improve data standardization and collection. Several commenters stated that this transition would allow digital quality reporting to be less burdensome on providers, patients, and payers and lead to more accurate results. A few commenters added that the dQM transition would achieve broader interoperability goals and support timely insights that drive patient outcomes.

Many commenters shared overarching challenges they believe may impact the dQM transition. A few commenters noted the need for clear FHIR versioning policies, backward compatibility, and for adequate notice for transitions between standards. A few commenters additionally noted challenges with specifying QRDA-based eCQMs in FHIR due to inconsistent measure specifications, measure logic complexity, data elements not routinely captured in structured EHR fields, and disparity in how EHRs store and utilize data in comparison to how QI-Core expects data to be stored. The lack of EHR functionality to trigger electronic reporting notifications, the timing of diagnosis data entered in the system, and secondary capabilities such as secure authentication and connections between FHIR systems were also noted as potential challenges by a few commenters.

Several commenters mentioned challenges from their experiences reviewing, implementing, or testing QI-Core, DEQM, or Bulk FHIR standards. Some of the challenges shared include what they believe are misalignment of several QI-Core profiles and US Core profiles. A few commenters with FHIR Bulk Export experience indicated that it improves the ability to extract large-scale patient data, but challenges remain with EHR implementations that limit the number of patient records placed per query. Several commenters recommended CMS work with HL7, Argonaut, and the FHIR community to align to a limited and common standard for Bulk Import, offer enhanced mapping guidance, and provide implementation examples.

Many commenters provided feedback on the FHIR-based eCQM transition timeline--in support, against, and in support with recommendations. Several commenters expressed support for the potential 24-month timeline from effective date to the start of the reporting options period. However, many commenters expressed concerns around the 24-month timeline, stating that it is not sufficient. Commenters offered recommendations, including a longer timeframe that would allow for technical assistance and resources to be integrated, resolve any troubleshooting delays, and permit testing and validation prior to full implementation.

Many commenters provided feedback on tools to support quality data reporting. Several commenters recommended CMS provide the ability for providers to track their performance through real-time feedback (on elements such as measure calculations, errors, and data quality) and provider-facing EHR dashboards to compare CMS results with their internal systems. In addition to Connectathons, several commenters suggested CMS provide testing tools to health IT developers and eligible hospitals and CAHs, fund pilots, and use education and outreach opportunities to engage a cross section of hospitals in real- world testing. Several commenters also recommended the provision of incentives or scoring bonuses for early adopters, for pilot projects, and for technical assistance for small and rural hospitals to help support the dQM transition.

Response: We thank commenters for their feedback. While we will not be responding to specific comments submitted in response to this RFI in this final rule, we intend to use this information to inform future dQM transition work and potential future rulemaking in our efforts toward a patient-centric digital health ecosystem. 3. Approach to FHIR Patient Assessment Reporting in the IPFQR Program

Section 4125(b) of the Consolidated Appropriations Act of 2023 (CAA, 2023) (Pub. L. 117-328, December 29, 2022) \265\ amended section 1886(s)(4) of the Act by adding a new subparagraph (E), which requires an inpatient psychiatric facility (IPF) participating in the IPFQR Program to collect and submit specified standardized patient assessment data using a new standardized patient assessment instrument, for rate year 2028 and each subsequent year.

\265\ https://www.congress.gov/117/plaws/publ328/PLAW-117publ328.pdf.

As noted in the RFI \266\ in the FY 2025 IPF Prospective Payment System (PPS)-Rate Update proposed rule, achieving interoperability is an essential part of our goal to facilitate safe and secure data sharing, access, and utilization of electronic health information to enhance decision-making and create a more efficient healthcare system (89 FR 23201). We also stated that we are considering ways to ensure that the IPF Patient Assessment Instrument (IPF-PAI) can be represented using FHIR standards (89 FR 23201). As part of that RFI, we requested and received input on topics including: Whether Standardized Patient Assessment Data Elements already in use in the CMS Data Element Library (DEL) \267\ are appropriate and clinically relevant for the IPF setting, use of CMS reporting systems, and other interoperability- related considerations (89 FR 23201). In the FY 2025 IPF PPS final rule, we acknowledged a recommendation to align the IPF-PAI with USCDI and several commenters noted IPFs did not receive funding to adopt CEHRT, suggesting we consider how the implementation of the IPF-PAI would affect providers without EHRs (89 FR 64646).

\266\ “Patient Assessment Instrument Under IPFQR Program (IPF PAI) to Improve the Accuracy of PPS” (89 FR 23200 through 23204).

\267\ https://del.cms.gov/DELWeb/pubHome.

We are considering opportunities to advance FHIR-based reporting of patient assessment data for the IPF-PAI mandated by the CAA, 2023. In the FY 2026 IPPS/LTCH PPS proposed rule (90 FR 18326), the questions in this section sought to gain an understanding of the current adoption and use of EHRs, other health IT, and data standards supporting interoperability (such as FHIR and USCDI) within IPFs. We also aimed to identify the extent of technology adoption beyond certified health IT and EHRs and sought a better understanding of how FHIR-standardized data can be generated, used, and shared through other technologies, without use of EHRs. Our objective was to explore how IPFs typically integrate technologies with varying complexity into existing systems and how this affects IPF workflows. We sought to identify the challenges or opportunities that may arise during this integration, and determine the support needed to complete and submit the IPF-PAIs in ways that protect and enhance care delivery. This insight will help inform the technologies we may consider for

use with the IPF-PAI and quality data reporting.

We sought feedback on the current state of health IT use, including EHRs, in IPFs:

To what extent does your IPF use health IT systems to maintain and exchange patient records?

If your facility has transitioned to using electronic records in whole or in part, what types of health IT does your IPF use to maintain electronic patient records? Are these health IT systems certified under the ONC Health IT Certification Program? Does your facility use EHRs or other health IT products or systems that are not certified under the ONC Health IT Certification Program? If so, do these systems exchange data using standards and implementation specifications adopted by HHS? \268\ Please specify.

\268\ For instance, see standards adopted by ONC on behalf of HHS in 45 CFR part 170, subpart B.

Does your IPF submit patient data to CMS directly from your health IT system, without the assistance of a third-party intermediary? If a third-party intermediary is used to report data, what type of intermediary service is used? How does your facility currently exchange health information with other healthcare providers or systems, specifically between IPFs and other provider types or with public health agencies? What challenges do you face with electronic exchange of health information?

Are there any challenges with your current electronic devices (for example, tablets, smartphones, computers) that hinder your ability to easily exchange information across health IT systems? Please describe any specific issues you encounter.

Does limited internet or lack of internet connectivity impact your ability to exchange data with other healthcare providers, including community-based care services, or your ability to submit patient data to CMS?

What steps does your IPF take to ensure compliance with security and patient privacy requirements such as the requirements of the regulations promulgated under the Health Insurance Portability and Accountability Act (HIPAA) and related regulations?

Does your IPF refer to the SAFER Guides (see newly revised versions published in January 2025 at https://www.healthit.gov/topic/safety/safer-guides) \269\ to self-assess EHR safety practices?

\269\ The SAFER Guides are an evidence-based set of recommendations in the form of nine stand-alone, subject-oriented chapters that present the health IT community, including eligible hospitals and CAHs that use health IT, with best practice recommendations to improve the safety and safe use of EHRs. See https://www.healthit.gov/topic/safety/safer-guides.

What challenges or barriers does your IPF encounter when submitting quality measure data to CMS as part of the IPFQR Program? Please identify any factors that hinder successful data submission. What opportunities or factors could improve your facility's successful data submission to CMS?

What types of technical assistance, guidance, workforce training resources, and other resources would help IPFs to successfully implement FHIR-based technologies for submitting the IPF-PAI to CMS? What strategies can CMS, HHS, or other Federal partners take to ensure that technical assistance is both comprehensive and user-friendly? How could Quality Improvement Organizations (QIOs) or other entities enhance this support?

Is your facility using technology that utilizes APIs based on the FHIR standard to enable electronic data sharing? If so, with whom are you sharing data using the FHIR standard and for what purpose(s)? For example, have you used FHIR APIs to share data with public health agencies? Does your facility use any Substitutable Medical Applications and Reusable Technologies (SMART) on FHIR \270\ applications? If so, are the SMART on FHIR applications integrated with your EHR or other health IT?

\270\ https://smarthealthit.org/.

What benefits or challenges have you experienced with implementing technology that uses FHIR-based APIs? How can adopting technology that uses FHIR-based APIs to facilitate the reporting of patient assessment data impact provider workflows? What impact, if any, does adopting this technology have on quality of care?

Does your facility have any experience using technology that shares electronic health information using one or more versions of the USCDI standard?

Would your IPF and vendors or both be interested in participating in testing to explore options for transmission of assessments, for example, testing methods to transmit assessments that incorporate FHIR-enabled data to CMS?

What other information should we consider to facilitate successful adoption and integration of FHIR-based technologies and standardized data for patient assessment instruments like the IPF-PAI? We invite any feedback, suggestions, best practices, or success stories related to the implementation of these technologies.

We received several comments on these topics. The following is a summary of the comments received from both the FY 2026 IPPS/LTCH PPS proposed rule (90 FR 18326 through 18327) and the FY 2026 IPF PPS proposed rule (90 FR 18520 through 90 FR 18523), where this RFI was also included.

Comment: Many commenters expressed support for CMS' intent to transition to the FHIR-based standard in IPFQR, particularly for the IPF-PAI. A few commenters noted the opportunity for a FHIR-based standard to improve care coordination, enable actionable insights, and integrate structured data into EHRs. A few commenters highlighted the potential for FHIR to modernize behavioral health data reporting, enhance discharge planning, and enable meaningful performance measurement.

Many commenters asserted that there are challenges that may hinder interoperability efforts in IPFs. Commenters specifically described the following challenges: Inconsistent state laws governing data sharing and outdated provider directories, expense and complexity caused by non-standard reporting requirements, internet connectivity issues (particularly in rural areas), lack of ability for some IPFs to accept direct messaging, and outdated systems, particularly in stand-alone IPFs. A few commenters noted the high cost and burden of implementing FHIR-based technologies for facilities without certified EHRs.

A few commenters described variability in EHR adoption and infrastructure readiness across IPF facilities. A few commenters reported adopting EHRs capable of utilizing USCDI, with one commenter indicating that most of their members have or are currently implementing EHRs that support both USCDI and FHIR. Several commenters noted that while adoption continues to improve, they expressed concern about the low adoption rate of certified EHRs in IPFs compared to other healthcare settings. A few commenters urged CMS to provide financial incentives and technical assistance to support rural and resource- constrained IPF facilities in transitioning to FHIR-based systems. A few commenters specifically highlighted IPFs' exclusion from the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 \271\ as a cause for many IPFs having outdated systems that are incapable of interoperable data exchange and urged

CMS to provide equitable support for IPFs. Lastly, a few commenters noted that many freestanding IPFs rely on non-EHR vendors for data submission, which further complicates their ability to transition to FHIR-based reporting.

\271\ The Heath Information Technology for Economic and Clinical Health (HITECH) Act of 2009, part of the American Recovery and Reinvestment Act of 2009, Title XIII of Division A and Title IV of Division B of Public Law 111-5.

A few commenters provided recommendations to support the dQM transition in IPFs. Recommendations to CMS included: Updating USCDI standards to incorporate specific FHIR-based data elements, providing consistent reporting processes to reduce provider burden, encouraging collaboration with health IT vendors, testing FHIR-enabled data submission methods, ensuring solutions reflect the unique needs of IPFs, and allowing 18 to 24 months for FHIR API development and testing.

Response: We thank commenters for their feedback. While we will not be responding to specific comments submitted in response to this RFI in this final rule, we intend to use this information to inform future dQM transition work and potential future rulemaking in our efforts toward a patient-centric digital health ecosystem. 4. General Solicitation of Comments

In conjunction with the previous questions, we also sought input on the following:

Specific to FHIR-based quality reporting, are there any additional factors, or considerations to account for, that may help foster data harmonization and reduce reporting burden across entities?

The Trusted Exchange Framework and Common AgreementTM (TEFCATM) framework supports nationwide health information exchange by connecting health information networks (HINs) across the country.\272\ Additionally, TEFCA facilitates FHIR exchange by requiring Qualified HINs (QHINs) to perform patient discovery for those querying for data and providing data holders with FHIR endpoints to enable point-to-point exchange via FHIR APIs. How could this initiative potentially support exchange of FHIR-based quality measures and patient assessment submissions consistent with the FHIR Roadmap (available here: https://rce.sequoiaproject.org/three-year-fhir-roadmap-for-tefca/)? How might TEFCA enable the use of patient assessment data for secondary uses such as treatment and research?

\272\ For more information about TEFCA, see https://www.healthit.gov/topic/interoperability/policy/trusted-exchange-framework-and-common-agreement-tefca.

We received several comments on these topics. We provide a summary of comments received.

Comment: Commenters provided feedback on additional considerations that may foster data harmonization and reduce reporting burden. A commenter suggested CMS minimize the frequency and magnitude of changes to quality measures. Another commenter suggested reporting for multiple quality programs via one FHIR-based submission system.

Commenters also provided feedback on how the QHINs can support data exchange in CMS quality programs. Many commenters supported CMS' use of the TEFCA framework for quality measure and patient assessment submission as they believe it would allow for the following: Ease of provider and payer submission of quality data to CMS, more consistent and wider data exchange, and easier exchange of data. A few commenters provided existing barriers and opportunities for TEFCA including the need for the development of additional use cases to support submission of quality measure and patient assessment data.

Response: We thank commenters for their feedback. While we will not be responding to specific comments submitted in response to this RFI in this final rule, we intend to use this information to inform future dQM transition work and potential future rulemaking in our efforts toward a patient-centric digital health ecosystem.

The Hospital IQR Program is a pay-for-reporting program intended to measure the quality of hospital inpatient services, improve the quality of care provided to Medicare beneficiaries, and facilitate public transparency. Section 1886(b)(3)(B)(viii) of the Social Security Act (the Act) states that subsection (d) hospitals participating in the Hospital IQR Program that do not submit data required for measures selected with respect to such a year, in the form and manner required by the Secretary, will incur a 2.0 percentage point reduction to their annual payment update for the applicable fiscal year. We refer readers to our previous final rules for detailed discussions of the history of the Hospital IQR Program, including statutory history, and for the measures we have previously adopted for the Hospital IQR Program measure set.\273\ We also refer readers to 42 Code of Federal Regulations (CFR) 412.140 for the Hospital IQR Program regulations. We note that we are discontinuing the practice of retaining all subsections of the preamble every year and have thus omitted subsections where there are no proposed changes.

\273\ These rules are: the FY 2010 IPPS/LTCH PPS final rule (74 FR 43860 through 43861); the FY 2011 IPPS/LTCH PPS final rule (75 FR 50180 through 50181); the FY 2012 IPPS/LTCH PPS final rule (76 FR 51605 through 61653); the FY 2013 IPPS/LTCH PPS final rule (77 FR 53503 through 53555); the FY 2014 IPPS/LTCH PPS final rule (78 FR 50775 through 50837); the FY 2015 IPPS/LTCH PPS final rule (79 FR 50217 through 50249); the FY 2016 IPPS/LTCH PPS final rule (80 FR 49660 through 49692); the FY 2017 IPPS/LTCH PPS final rule (81 FR 57148 through 57150); the FY 2018 IPPS/LTCH PPS final rule (82 FR 38326 through 38328 and 82 FR 38348); the FY 2019 IPPS/LTCH PPS final rule (83 FR 41538 through 41609); the FY 2020 IPPS/LTCH PPS final rule (84 FR 42448 through 42509); the FY 2021 IPPS/LTCH PPS final rule (85 FR 58926 through 58959); the FY 2022 IPPS/LTCH PPS final rule (86 FR 45360 through 45426); the FY 2023 IPPS/LTCH PPS final rule (87 FR 49190 through 49310); the FY 2024 IPPS/LTCH PPS final rule (88 FR 59144 through 59203); and the FY 2025 IPPS/LTCH PPS final rule (89 FR 69515 through 69577).

2. Considerations in Expanding and Updating Quality Measures (a) Measure Concepts Under Consideration for Future Years in the Hospital IQR Program-Request for Information (RFI): Well-Being and Nutrition

In the FY 2026 IPPS/LTCH PPS proposed rule (90 FR 18328), we sought input on measure concepts of well-being and nutrition for future years in the Hospital IQR Program. We invited comments on tools and measures that assess overall health, happiness, and life satisfaction, including emotional well-being, social connectedness, purpose, and fulfillment, that fall into concepts of well-being. We additionally sought comments on tools and measures that assess optimal nutrition and preventive care in the Hospital IQR Program (90 FR 18328).

We received public comments on these RFIs. The following is a summary of the comments we received: 1. Well-Being and Nutrition

Comments: Many commenters expressed concerns about the applicability of well-being and nutrition measures in the hospital acute care setting, due to their observation that care in this environment is focused on resolving acute conditions as opposed to addressing emotional health, social connections, and food access. These commenters stated that measures related to well-being and nutrition are better suited for outpatient or primary care settings.

Many commenters expressed concern that implementing measures related to well-being and nutrition in hospitals,

particularly in rural or resource-limited settings, may be administratively burdensome and would hold hospitals accountable for factors outside their control. Some commenters were also concerned that measures of well-being and nutrition would be difficult to implement in hospitals, while others stated that assessing well-being during hospital stays may yield unreliable data due to the stress and disruption inherent in inpatient care. Some commenters recommended the use of standardized tools and existing data sources, such as electronic health records (EHRs), to simplify administration and integration into clinical workflows. Commenters encouraged engagement with providers, patients, and caregivers to ensure that new domains reflect both clinical relevance and patient experience. Some commenters recommended pilot testing in diverse settings and populations to ensure reliability, practicality, and applicability of new measures before full implementation.

Many commenters supported the utilization of the Malnutrition Care Score (MCS) electronic clinical quality measure (eCQM), noting it plays a critical role in identifying and addressing malnutrition in hospital settings. Some commenters supported making the MCS eCQM mandatory and recommended continuing to focus on this measure's performance. A few commenters did not support adopting additional nutrition measures, stating that the MCS eCQM already addresses nutritional concerns.

Many commenters supported the inclusion of evidence-based and actionable nutrition measures, noting that hospitals play a vital role in identifying and addressing nutrition needs during inpatient stays. Some commenters emphasized the importance of aligning nutrition measures with clinical workflows and addressing both food insecurity and diet quality.

Commenters noted that barriers to nutrition and well-being, such as food insecurity and social isolation, should be addressed through targeted interventions and community partnerships. Some commenters stressed the need to address resource gaps through federally funded programs that impact nutrition and well-being while others recommended incentivizing hospitals to partner with community organizations to expand access to nutrition services, including medically tailored meals and food pharmacies. Commenters emphasized the importance of ensuring continuity of care through discharge planning and community referrals. To support long-term health outcomes, commenters recommended expanding hospital-based measures to include post-discharge follow-up and integration with community resources.

Commenters recommended developing patient-centered measures that address the full spectrum of well-being, including emotional, social, and physical health. Commenters also recommended incorporating measures that assess care transitions, patient activation, and personalized goals to support pathways to well-being. Commenters specifically recommended developing outcome-based measures that reflect meaningful improvements in patient health and quality of life.

Commenters recommended aligning any future well-being and nutrition measures with existing social determinants of health (SDOH) screening tools and identified food insecurity screening as a foundational tool for addressing nutrition and well-being. Many commenters expressed concern over CMS's proposal to remove SDOH measures, arguing that these screenings provide critical insights into patient needs and support holistic care delivery.

Response: We thank all the commenters for responding to this RFI. While we are not responding to specific comments in response to the RFI in this final rule, we will take this feedback into consideration for our future measure development efforts for the Hospital IQR Program. (b) Background

We refer readers to the FY 2019 IPPS/LTCH PPS final rule (83 FR 41147 through 41148), in which we describe the Meaningful Measures Framework. In 2021, we launched Meaningful Measures 2.0 to promote innovation and modernization of all aspects of quality, addressing a wide variety of settings, interested parties, and measure requirements.\274\

\274\ Centers for Medicare & Medicaid Services. (2025). Meaningful Measures 2.0: Moving from Measure Reduction to Modernization. Available at: https://www.cms.gov/meaningful-measures-20-moving-measure-reduction-modernization.

There are statutory requirements that the Secretary of HHS make public certain quality and efficiency measures that the Secretary is considering for adoption through rulemaking under Medicare.\275\ To comply with those requirements, the Consensus-Based Entity (CBE), currently Battelle, convenes the Partnership for Quality Measurement (PQM), which is comprised of clinicians, patients, measure experts, and health information technology specialists, to participate in the pre- rulemaking process and the measure endorsement process. We refer readers to the FY 2025 IPPS/LTCH PPS final rule and the PQM website \276\ for a more detailed discussion on the updated pre-rulemaking measure reviews (PRMR) process (89 FR 69457 through 69459).

\275\ See section 1890A(a)(2) of the Social Security Act (42 U.S.C. 1395aaa-1(a)(2)).

\276\ Battelle, Partnership for Quality website. Available at: https://p4qm.org/.