Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems; Quality Reporting Programs; Overall Hospital Quality Star Rating; Hospital Price Transparency; and Notice of Closure of a Teaching Hospital and Opportunity To Apply for Available Slots

In the August 2, 2007 ASC final rule with comment period (72 FR 42493), we established our policy to base ASC relative payment weights and payment rates under the revised ASC payment system on APC groups and the OPPS relative payment weights. Consistent with that policy and the requirement at section 1833(i)(2)(D)(ii) of the Act that the revised payment system be implemented so that it would be budget neutral, the initial ASC conversion factor (CY 2008) was calculated so that estimated total Medicare payments under the revised ASC payment system in the first year would be budget neutral to estimated total Medicare payments under the prior (CY 2007) ASC payment system (the ASC conversion factor is multiplied by the relative payment weights calculated for many ASC services in order to establish payment rates). That is, application of the ASC conversion factor was designed to result in aggregate Medicare expenditures under the revised ASC payment system in CY 2008 being equal to aggregate Medicare expenditures that would have occurred in CY 2008 in the absence of the revised system, taking into consideration the cap on ASC payments in CY 2007, as required under section 1833(i)(2)(E) of the Act (72 FR 42522). We adopted a policy to make the system budget neutral in subsequent calendar years (72 FR 42532 through 42533; Sec. 416.171(e)).

In the CY 2008 OPPS/ASC final rule with comment period (72 FR 66857 through 66858), we set out a step-by-step illustration of the final budget neutrality adjustment calculation based on the methodology finalized in the August 2, 2007 ASC final rule (72 FR 42521 through 42531) and as applied to updated data available for the CY 2008 OPPS/ ASC final rule with comment period. The application of that methodology to the data available for the CY 2008 OPPS/ASC final rule with comment period resulted in a budget neutrality adjustment of 0.65.

For CY 2008, we adopted the OPPS relative payment weights as the ASC relative payment weights for most services and, consistent with the final policy, we calculated the CY 2008 ASC payment rates by multiplying the ASC relative payment weights by the final CY 2008 ASC conversion factor of $41.401. For covered office-based surgical procedures, covered ancillary radiology services (excluding covered ancillary radiology services involving certain nuclear medicine procedures or involving the use of contrast agents, as discussed in section XIII.D.2. of the CY 2023 OPPS/ASC proposed rule (87 FR 44715 through 44716)), and certain diagnostic tests within the medicine range that are covered ancillary services, the established policy is to set the payment rate at the lower of the PFS unadjusted nonfacility PE RVU- based amount or the amount calculated using the ASC standard ratesetting methodology. Further, as discussed in the CY 2008 OPPS/ASC final rule with comment period (72 FR 66841 through 66843), we also adopted alternative ratesetting methodologies for specific types of services (for example, device-intensive procedures).

As discussed in the August 2, 2007 ASC final rule with comment period (72 FR 42517 through 42518) and as codified at Sec. 416.172(c) of the regulations, the revised ASC payment system accounts for geographic wage variation when calculating individual ASC payments by applying the pre-floor and pre-reclassified IPPS hospital wage indexes to the labor-related share, which is 50 percent of the ASC payment amount based on a GAO report of ASC costs using 2004 survey data. Beginning in CY 2008, CMS accounted for geographic wage variation in labor costs when calculating individual ASC payments by applying the pre-floor and pre-reclassified hospital wage index values that CMS calculates for payment under the IPPS, using updated Core Based Statistical Areas (CBSAs) issued by OMB in June 2003.

The reclassification provision in section 1886(d)(10) of the Act is specific to acute care hospitals. We believe that using the most recently available pre-floor and pre-reclassified IPPS hospital wage indexes result in the most appropriate adjustment to the labor portion of ASC costs. We continue to believe that the pre-floor, pre- reclassified hospital wage indexes, which are updated yearly and are used by several other Medicare payment systems, appropriately account for geographic variation in labor costs for ASCs (89 FR 23424). Therefore, the wage index for an ASC is the pre-floor and pre- reclassified hospital wage index for the fiscal year under the IPPS of the CBSA that maps to the CBSA where the ASC is located.

On July 21, 2023, OMB issued OMB Bulletin No. 23-01, which provided the delineations of all Metropolitan Statistical Areas, Metropolitan Divisions, Micropolitan Statistical Areas, Combined Statistical Areas, and New England City and Town Areas in the U.S. and Puerto Rico based on the standards published on July 16, 2021, in the Federal Register (86 FR 37770) and 2020 Census Bureau data. (A copy of this bulletin may be obtained at https://www.whitehouse.gov/wp-content/uploads/2023/07/OMB-Bulletin-23-01.pdf.) As discussed in the FY 2025 IPPS/LTCH PPS final rule with comment period (89 FR 69253 through 69266), we finalized our proposal to use the new CBSAs delineations issued by OMB in OMB Bulletin 23-01 for the IPPS hospital wage index beginning in CY 2025. Therefore, because the ASC wage indexes for the calendar year are

the pre-floor and pre-reclassified IPPS hospital wage indexes for the fiscal year, in the CY 2025 OPPS/ASC final rule with comment period (89 FR 94362 through 94363) we finalized our proposal to incorporate the new OMB delineations into CY 2025 ASC wage indexes. We believe that using the revised delineations based on OMB Bulletin No. 23-01 will increase the integrity of the ASC wage index system by creating a more accurate representation of current geographic variations in wage levels. In addition to adopting the revised delineations based on OMB Bulletin No. 23-01, we also finalized our proposal to limit year-to- year ASC wage index value changes to no more than a 5-percent decrease, similar to the policy of other Medicare payment systems under Parts A and B. This 5-percent cap, implemented in a budget neutral manner through the wage index scalar, mitigates any large negative impacts of adopting the new delineations and prevents large year-to-year declines in wage index values as a means to reduce volatility in Medicare payments.

The proposed CY 2026 ASC wage indexes reflect the OMB labor market area delineations (including the revisions to the OMB labor market delineations discussed previously, as set forth in OMB Bulletin No. 23- 01). We note that, in certain instances, there might be urban or rural areas for which there is no IPPS hospital that has wage index data that could be used to set the wage index for that area. When all of the areas contiguous to the urban CBSA of interest are rural and there is no IPPS hospital that has wage index data that could be used to set the wage index for that area, our policy has been to determine the ASC wage index by calculating the average of all wage indexes for urban areas in the State (75 FR 72058 through 72059). For example, for CY 2026, we propose to apply a proxy wage index based on this methodology to ASCs located in CBSA 35 (Rural North Dakota). In other situations, where there are no IPPS hospitals located in a relevant labor market area, we apply our current policy of calculating an urban or rural area's wage index by calculating the average of the wage indexes for CBSAs (or metropolitan divisions where applicable) that are contiguous to the area with no wage index. For example, for CY 2026, we proposed that we continue to apply a proxy wage index based on this methodology to ASCs located in CBSA 25980 (Hinesville, GA). Further, the proposed CY 2026 ASC wage index includes our policy finalized in the CY 2025 OPPS/ASC final rule with comment period that limits wage index changes to decrease by no more than 5 percent from the final CY 2025 ASC wage index value. As we discussed in the April 2025 Update to the Ambulatory Surgical Center Payment System (Change Request 14017), to limit wage index changes by no more than 5 percent from the final CY 2025 ASC wage index, some counties may require a transition CBSA before being fully reflected in the OMB labor market delineations as set forth in OMB Bulletin No. 23-01.

We received public comments on these proposals. The following is a summary of the comments we received and our responses.

Comment: A few commenters recommended that we apply OPPS geographic reclassifications and wage index floor policies to ASCs to further harmonize payment systems and mitigate the impact of inadequate wage indices on rural ASCs, noting that hospitals can seek geographic reclassifications and receive wage index floors of 1.0 in frontier States while ASCs are excluded from these protections, despite competing in the same labor markets. The commenters highlighted specific inequities such as in South Dakota, where hospitals receive a wage index floor of 1.0 while ASCs face a much lower rural wage index of 0.8203, creating serious implications for ASCs' ability to recruit and retain staff in areas already facing workforce shortages. Both organizations emphasized that applying these wage index policies to ASCs would advance CMS's goal of aligning outpatient payment systems and ensure that beneficiaries in rural and frontier areas retain access to safe, high-quality surgical care.

Response: We appreciate the concerns the commenter has raised. The reclassification provision in section 1886(d)(10) of the Act is specific to acute care hospitals. We believe that using the most recently available pre-floor and pre-reclassified IPPS hospital wage indexes result in the most appropriate adjustment to the labor portion of ASC costs. However, we are sensitive to payment disparities the commenter raises between the OPPS and ASC payment system and will continue to monitor this issue and consider the commenter's recommendation in future rulemaking.

After consideration of public comments we received, we are finalizing our proposal to use the most recently available pre-floor and pre-reclassified IPPS hospital wage indexes to the labor-related share to create the final CY 2026 ASC wage indexes and to limit wage index decreases by no more than 5 percent from the final CY 2025 ASC wage index for a particular CBSA. The final CY 2026 ASC wage indexes reflect the OMB labor market area delineations (including the revisions to the OMB labor market delineations discussed previously, as set forth in OMB Bulletin No. 23-01) unless the county is otherwise in a transition CBSA. Additionally, based on the absence of IPPS hospitals, we are also finalizing our proposal to apply a proxy wage index based to ASCs located in CBSA 25980 (Hinesville, GA) and in CBSA 35 (Rural North Dakota). 2. Calculation of the ASC Payment Rates a. Updating the ASC Relative Payment Weights for CY 2026 and Future Years

We update the ASC relative payment weights each year using the national OPPS relative payment weights (and PFS nonfacility PE RVU- based amounts, as applicable) for that same calendar year and uniformly scale the ASC relative payment weights for each update year to make them budget neutral (72 FR 42533). The OPPS relative payment weights are scaled to maintain budget neutrality for the OPPS. We then scale the OPPS relative payment weights again to establish the ASC relative payment weights. To accomplish this, we hold estimated total ASC payment levels constant between calendar years for purposes of maintaining budget neutrality in the ASC payment system. That is, we apply the weight scalar to ensure that projected expenditures from the updated ASC payment weights in the ASC payment system are equal to what would be the current expenditures based on the scaled ASC payment weights. In this way, we ensure budget neutrality and that the only changes to total payments to ASCs result from increases or decreases in the ASC payment update factor.

As discussed in section II.A.1.a. of this final rule with comment period, we are using the CY 2024 claims data to be consistent with the OPPS claims data for this final rule with comment period. Consistent with our established policy, we proposed to scale the CY 2026 relative payment weights for ASCs according to the following method. Holding ASC utilization, the ASC conversion factor, and the mix of services constant from CY 2024, we proposed to compare the estimated total payment using the CY 2025 ASC relative payment weights with the estimated total payment using the CY 2026 ASC relative payment weights to

take into account the changes in the OPPS relative payment weights between CY 2025 and CY 2026.

In consideration of our policy to provide a higher ASC payment rate with ASC complexity adjustment codes for certain primary procedures when performed with add-on packaged services, we incorporated estimated total spending and estimated utilization for these codes in our budget neutrality calculation for CYs 2023 and 2024. For the CY 2026 OPPS/ASC proposed rule, our proposed ASC complexity adjustment codes for CY 2026 did not impact the ASC weight scalar. Similarly, for this final rule with comment period, our estimated change in ASC spending related to our final ASC complexity adjustment codes for CY 2026 did not impact the ASC weight scalar.

Additionally, as discussed in section XIII.E. of the CY 2025 OPPS/ ASC final rule with comment period (89 FR 94342 through 94361), section 4135(a) and (b) of the CAA, 2023, titled “Access to Non-Opioid Treatments for Pain Relief”, amended sections 1833(t)(16) and 1833(i) of the Act, respectively, to provide for temporary separate payments for non-opioid treatments for pain relief. As discussed in further detail in section XIII.E. of the CY 2025 OPPS/ASC final rule with comment period, for qualifying non-opioid products, we finalized applying an 18 percent payment limitation on the volume weighted payment average of the top 5 services associated with the use of the qualifying non-opioid product. In CY 2024, four of these qualifying nonopioid products were separately payable without the 18 percent payment limitation--HCPCS Codes C9089 (Bupivacaine implant, 1 mg), J0666 (Inj, bupivacaine liposome), J1096 (Dexametha opth insert 0.1 mg), and J1097 (Phenylep ketorolac opth soln). Therefore, to maintain budget neutrality, we estimated the total anticipated reduction in ASC spending for these qualifying non-opioid products for CY 2025 as a result of the 18 percent payment limitation required by section 4135 of the CAA, 2023. Based on the updated 18 percent payment limitations and CY 2024 utilization, we estimated that the proposed CY 2026 payment limitations will not impact the ASC weight scalar. Similarly, based on the updated 18 percent payment limitations and CY 2024 utilization for this final rule with comment period, we estimate that the final CY 2026 payment limitations will not impact the ASC weight scalar.

In section XIII.C.2.b. of this final rule with comment period, we discuss our proposal to unpackage and pay separately for groups of skin substitute products under the ASC payment system beginning January 1, 2026. Currently, these products are packaged into payment for the primary covered surgical procedures. To maintain budget neutrality under the OPPS, the reduction in any APC's relative weights from the loss of skin substitute costs in the APC's geometric mean cost will be offset by an increase in the OPPS weight scalar. To maintain budget neutrality, this increase in the OPPS weight scalar will be offset by a reduction in estimated new OPPS payment for skin substitute APC groups.

Since we request ASCs not to report packaged items and services on ASC claims, we are unable to perform a similar adjustment and determine existing utilization of skin substitute products from ASC claims. To resolve this limitation but maintain budget neutrality within the ASC payment system, we multiplied the change in the geometric mean costs of covered surgical skin procedures in the ASC setting from unpackaging skin substitute products by the utilization of such skin procedures in the ASC setting to approximate the estimated skin substitute payments in the ASC setting. Based on existing surgical procedure utilization and our estimated utilization of skin substitute products in the ASC setting, our estimated separate payments for skin substitutes in the ASC setting did not impact the ASC weight scalar.

We proposed to use the ratio of estimated CY 2025 to estimated CY 2026 total payments (the weight scalar) to scale the ASC relative payment weights for CY 2026. The proposed CY 2026 ASC weight scalar was 0.872. The CY 2026 OPPS/ASC proposed rule inadvertently stated the proposed CY 2026 ASC weight scalar was 0.842 (90 FR 33752 and 90 FR 33846). The ASC payment system payment rates that were displayed in Addendum AA, BB, and FF to the CY 2026 OPPS/ASC proposed rule used the correct proposed ASC weight scalar, 0.872, in the proposed payment rate calculations.

As discussed further in the CY 2025 OPPS/ASC final rule with comment period (89 FR 94363 through 94364), we have historically displayed this figure rounded to the nearest ten thousandth; however, we believe this level of specificity is unnecessarily burdensome for an ASC payment system that is less than one-tenth the size of the OPPS (in which the weight scalar is rounded to the nearest ten-thousandth). Consistent with historical practice, we proposed to scale, using this method (with an ASC weight scalar rounded to the nearest thousandth), the ASC relative payment weights of covered surgical procedures, covered ancillary radiology services, and certain diagnostic tests within the medicine range of CPT codes, which are covered ancillary services for which the ASC payment rates are based on OPPS relative payment weights.

We proposed that we would not scale ASC payment for separately payable covered ancillary services that have a predetermined national payment amount (that is, their national ASC payment amounts are not based on OPPS relative payment weights), such as drugs and biologicals that are separately paid or services that are contractor-priced or paid at reasonable cost in ASCs. Any service with a predetermined national payment amount, which includes the device portion of device-intensive procedures, would be included in the ASC budget neutrality comparison, but scaling of the ASC relative payment weights would not apply to those services or the portion of those services. The ASC payment weights for those services without predetermined national payment amounts would be scaled to eliminate any difference in the total payment between the current year and the update year.

However, as discussed in sections V.B.8.i. and XIII.C.4. of the CY 2025 OPPS/ASC proposed rule, we proposed that the OPPS payment rates used for ratesetting under the ASC payment system for CY 2026 and subsequent years would not incorporate the prospective offset to the OPPS conversion factor, as a result of the 340B remedy offset. Historically, the ASC payment system has generally adopted the OPPS conversion factor used for determining the OPPS payment rates and determining the device portions for device-intensive procedures under the ASC payment system.

We estimated that a 2 percent reduction in the OPPS conversion factor would otherwise reduce ASC payments for device-intensive procedures by approximately one percent; the non-device portions for all covered surgical procedures would otherwise be increased to offset reduction to device portions for device-intensive procedures. For CY 2026, we estimated the reduction to device portions from a 2 percent prospective offset would have reduced proposed CY 2026 ASC expenditures for device-intensive procedures by approximately $42 million and would have otherwise increased the ASC weight scalar by 0.1 percent to offset such reduction.

For any given year's ratesetting, we typically use the most recent full calendar year of claims data to model

budget neutrality adjustments. We proposed to use the CY 2024 claims data to model our budget neutrality adjustment for CY 2026.

We received public comments on these proposals. The following is a summary of the comments we received and our responses.

Comment: Many commenters reiterated their longstanding recommendation that CMS discontinue the ASC weight scalar, stating that the secondary rescaling process applied to maintain budget neutrality has created an inappropriate and growing payment disparity between ASCs and HOPDs, with ASC reimbursement rates now averaging 50 percent less than HOPD rates for the same procedures despite no evidence of increased differences in capital and operating costs between settings. The commenters noted that this antiquated cost containment mechanism penalizes migration to lower-cost ASC settings and threatens outpatient access to care, with ASC relative weights decreasing by an average of 7 percent each year since 2010 and the proposed 2026 scalar representing the largest projected cut to ASC weights since payment system alignment in 2008. The commenters recommended that we either eliminate the ASC weight scalar or alternatively combine OPPS and ASC utilization to establish a single weight scalar that would improve payment system alignment and more accurately scale for outpatient volume across both sites of service.

Response: We thank the commenters for their input. We disagree that the ASC weight scalar has impeded beneficiary access to outpatient surgical procedures in an ASC setting. In fact, utilization data demonstrates the opposite trend. While the ASC weight scalar has generally declined each year to maintain budget neutrality in the payment system on a year-to-year basis, the data shows that ASC market share of commonly-performed outpatient surgical procedures has steadily increased. For example, CPT code 66984 (Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification); without endoscopic cyclophotocoagulation), which has been the most commonly-performed surgical procedure in an ASC setting, was reported 73.4 percent of the time in an ASC in CY 2014 when comparing the ASC, HOPD, and physician office settings. This procedure was reported 16.7 percent of the time in a HOPD in CY 2014. For CY 2024, we estimate the share of ASC utilization of CPT code 66984 increased and was reported 81.5 percent of the time in an ASC setting while it declined to 9.2 percent of the time in the HOPD setting. The increase in ASC utilization share across the three outpatient settings and corresponding decline in HOPD utilization share over a 10-year period suggests that the budget neutrality adjustment, and any increase in payment disparity between the OPPS and ASC payment system, does not itself create access to care issues. Therefore, while we will continue to look for changes to our payment methodologies that might improve access to care for Medicare beneficiaries by improving payment accuracies and encourage greater efficiencies in care, we are not accepting the commenters' recommendation to discontinue the ASC weight scalar for CY 2026.

Comment: Many commenters expressed a strong concern with the proposed 4.7 percent reduction in payment for CPT code 66984. Commenters stated that the proposed payment would not keep up with inflation and would have a significant negative financial impact on ASCs that perform such procedures.

Response: After reviewing our OPPS/ASC ratesetting programs, we identified an issue that incorrectly calculated the geometric mean cost for procedures that use intraocular lenses. Specifically, our ratesetting programs inadvertently did not import the HCPCS codes that describe intraocular lens devices and disregarded all intraocular lens costs as not related to the OPPS or ASC payment system. Therefore, such IOL costs had not been packaged into the costs of the primary procedure. After correcting this issue, we observed a 7.3 percent increase in the geometric mean cost of CPT code 66984 as well as a 6.5 percent increase in the geometric mean cost of CPT code 66982 (Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (e.g., iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage; without endoscopic cyclophotocoagulation). Since the Level 1 Intraocular APC is largely influenced by the cost of CPT code 66984, we have seen a similarly large increase from our proposed national unadjusted ASC payment rate from $1,156.71. For final CY 2026 surgical procedure payment rates under the ASC payment system, we refer readers Addendum AA of this final rule with comment period.

Comment: A commenter expressed concern about a growing national trend of reduced ASC access for retina surgery, noting that a majority of retina specialists in a recently-performed survey report difficulty accessing sufficient OR time for emergent cases such as retinal detachment repair, with many having their ASC surgical block time reduced or eliminated due to inadequate facility reimbursement that results in significant financial losses for procedures like retinal detachment repair (CPT code 67108 (Repair of retinal detachment; with vitrectomy, any method, including, when performed, air or gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of subretinal fluid, scleral buckling, and/or removal of lens by same technique)) and complex retinal detachment repair (CPT code 67113 (Repair of complex retinal detachment (e.g., proliferative vitreoretinopathy, stage c-1 or greater, diabetic traction retinal detachment, retinopathy of prematurity, retinal tear of greater than 90 degrees), with vitrectomy and membrane peeling, including, when performed, air, gas, or silicone oil tamponade, cryotherapy, endolaser photocoagulation, drainage of subretinal fluid, scleral buckling, and/ or removal of lens)). The commenter emphasized that facilities cannot afford to allocate adequate time to meet patient demand when losing several hundred dollars per case, leading to ASCs limiting retina cases or suspending the service entirely, ultimately moving cases to higher- cost settings contrary to CMS's goal of providing care in the most cost-effective setting.

Response: We appreciate the concerns the commenter has raised and will continue to monitor the payment adequacy of retina detachment procedures and other surgical procedures in the Intraocular Procedures APC clinical family going forward.

Comment: Multiple commenters requested that CMS adjust the ASC payment for CPT code 64590 (insertion or replacement of peripheral neurostimulator pulse generator) from the proposed $16,502.60 to $18,330.98 to maintain consistency with historical methodology where ASC payments typically represent 110 percent-113 percent of the device offset, rather than the proposed 102 percent. The commenters also requested that CMS limit the proposed 16.1 percent payment reduction, stating that such a dramatic decrease will halt patient access to neurostimulation therapies in

ASC facilities and goes against site neutrality goals. Some commenters suggested any payment change, particularly for device-intensive procedures, should be capped at no more than 10 percent in any given year, consistent with the IPPS.

Response: We are aware of the reduction in the OPPS and ASC payment rates for CPT code 64590 but believe our APC assignment changes represent an improvement in our payment for high-cost neurostimulator- related procedures. We note that with the reassignment of CPT code 61885 to APC 5465 Level 5 Neurostimulator and Related Procedures, 95 percent of the claims for APC 5464 Level 4 Neurostimulator and Related Procedures contain CPT code 64590 as the primary procedure. Therefore, the proposed geometric mean cost and payment rate of APC 5464 is almost entirely based on the geometric mean cost of CPT code 64590. For this reason, we do not believe it would be appropriate to limit the payment rate decline for CPT code 64590 and are not accepting the commenters' recommendation.

Comment: A commenter recommended a cap on year-to-year reductions, limiting payment decreases, especially for device-intensive procedures in the ASC payment system, to no more than 10 percent.

Response: We did not propose such a policy in our CY 2026 OPPS/ASC proposed rule. We appreciate the recommendation and may take this comment into consideration in future rulemaking.

After consideration of public comments we received, we are finalizing our proposal to use scaled OPPS relative weights to establish ASC relative payment weights and to use the ratio of CY 2025 to CY 2026 total payments (the weight scalar) to scale the ASC relative payment weights for CY 2026. The final CY 2026 ASC weight scalar is 0.872. Consistent with historical practice, we are finalizing our proposal to scale the ASC relative payment weights of covered surgical procedures, covered ancillary radiology services, and certain diagnostic tests within the medicine range of CPT codes, which are covered ancillary services for which the ASC payment rates are based on OPPS relative payment weights. b. Updating the ASC Conversion Factor

Under the OPPS, we typically apply a budget neutrality adjustment for provider-level changes, most notably a change in the wage index values for the upcoming year, to the conversion factor. Consistent with our final ASC payment policy, for the CY 2017 ASC payment system and subsequent years, in the CY 2017 OPPS/ASC final rule with comment period (81 FR 79751 through 79753), we finalized our policy to calculate and apply a budget neutrality adjustment to the ASC conversion factor for supplier-level changes in wage index values for the upcoming year, just as the OPPS wage index budget neutrality adjustment is calculated and applied to the OPPS conversion factor.

For CY 2026, we calculated the proposed adjustment for the ASC payment system by using the most recent CY 2024 claims data available and estimating the difference in total payment that would be created by introducing the proposed CY 2026 ASC wage indexes. Specifically, holding CY 2024 ASC utilization, service-mix, and the proposed CY 2026 national payment rates after application of the weight scalar constant, we calculated the total adjusted payment using the CY 2025 ASC wage indexes and the total adjusted payment using the proposed CY 2026 ASC wage indexes which included the 5-percent cap on wage index declines. We used the 50 percent labor-related share for both total adjusted payment calculations. We then compared the total adjusted payment calculated with the CY 2025 ASC wage indexes to the total adjusted payment calculated with the proposed CY 2026 ASC wage indexes and applied the resulting ratio of 0.9999 (the proposed CY 2026 ASC wage index budget neutrality adjustment) to the CY 2025 ASC conversion factor to calculate the proposed CY 2026 ASC conversion factor.

Section 1833(i)(2)(D)(v) of the Act requires that the ASC conversion factor be reduced by a productivity adjustment in each calendar year. Section 1886(b)(3)(B)(xi)(II) of the Act defines the productivity adjustment to be equal to the 10-year moving average of changes in annual economy-wide private nonfarm business multifactor productivity (MFP). We finalized the methodology for calculating the productivity adjustment in the CY 2011 PFS final rule with comment period (75 FR 73394 through 73396) and revised it in the CY 2012 PFS final rule with comment period (76 FR 73300 through 73301) and the CY 2016 OPPS/ASC final rule with comment period (80 FR 70500 through 70501). The proposed productivity adjustment for CY 2026 was projected to be 0.8 percentage point, as published in the FY 2026 IPPS/LTCH PPS proposed rule (90 FR 18266) based on IGI's 2024 fourth quarter forecast.

Section 1833(i)(2)(C)(i) of the Act requires that, if the Secretary has not updated amounts established under the revised ASC payment system in a calendar year, the payment amounts shall be increased by the percentage increase in the Consumer Price Index for all urban consumers (CPI-U), U.S. city average, as estimated by the Secretary for the 12-month period ending with the midpoint of the year involved. The statute does not mandate the adoption of any particular update mechanism, but it requires the payment amounts to be increased by the CPI-U in the absence of any update. Because the Secretary updates the ASC payment amounts annually, we adopted a policy, which we codified at Sec. 416.171(a)(2)(ii)), to update the ASC conversion factor using the CPI-U for CY 2010 and subsequent calendar years.

In the CY 2019 OPPS/ASC final rule with comment period (83 FR 59075 through 59080), we finalized a policy to apply the hospital market basket update (which is the inpatient hospital market basket percentage increase reduced by the productivity adjustment) to ASC payment system rates for an interim period of 5 years (CY 2019 through CY 2023), during which we would assess whether there was a migration of the performance of procedures from the hospital setting to the ASC setting as a result of the use of a hospital market basket update, as well as whether there were any unintended consequences, such as less than expected migration of the performance of procedures from the hospital setting to the ASC setting. At that time, the most recently available full year of claims data to assess the expected migration applying the productivity-adjusted hospital market basket update during the interim period was within the period from CY 2019 through CY 2022. However, the impact of the COVID-19 PHE on health care utilization, CY 2020 in particular, was tremendously profound, particularly for elective surgeries, because many beneficiaries avoided healthcare settings, when possible, to avoid possible infection from the SARS-CoV-2 virus. As a result, it was nearly impossible to disentangle the effects from the COVID-19 PHE in our analysis of whether the higher update factor for the ASC payment system caused increased migration to the ASC setting. To analyze whether procedures migrated from the hospital setting to the ASC setting, we needed to use claims data from a period during which the COVID-19 PHE had less of an impact on health care utilization. Therefore, for CY 2024, we finalized our proposal to extend the 5-year interim period an additional 2 years through CY 2024 and

CY 2025. We believed hospital outpatient and ASC utilization data from CYs 2023 and 2024 would enable us to more accurately analyze whether the application of the hospital market basket update to the ASC payment system had an effect on the migration of services from the hospital setting to the ASC setting. We revised our regulations at Sec. 416.171(a)(2)(iii), (iv), (vi), (vii), and (viii) which establish the annual update to the ASC conversion factor, to reflect this 2-year extension.

For the CY 2026 OPPS/ASC proposed rule, we proposed to extend our utilization of the hospital market basket update factor in the ASC payment system for one additional year, through CY 2026, as we continue to review and evaluate hospital outpatient and ASC utilization data, as well as the migration of surgical procedures between settings. In conjunction with our proposal, we are revising our regulations at Sec. 416.171(a)(2)(iii), (iv), (vi), (vii), and (viii), which establish the annual update to the ASC conversion factor, the 2.0 percentage point reduction for ASCs that fail to meet the standards for reporting ASC quality measures, and the productivity adjustment, to reflect this one year extension.

We received public comments on these proposals. The following is a summary of the comments we received and our responses.

Comment: Multiple commenters supported our continued use of the hospital market basket as the annual update mechanism for ASC payments through CY 2026, with several organizations noting that this policy helps align cost and resource calculations between hospital outpatient departments and ambulatory surgery centers and supports migration of services to lower-cost settings. Many of these commenters recommended we permanently update the ASC payment system with the productivity- adjusted hospital market basket update factor. However, a major hospital industry organization opposed our proposal and recommended that CMS work expeditiously with ASC interested parties to develop a minimally burdensome way to collect ASC-specific cost data that could be used to calculate an appropriate update mechanism, stating that hospitals and ASCs have different costs and serve different patients. The commenters noted that while the hospital market basket update is an improvement over previous methods, evidence indicates it may not accurately reflect ASCs' actual cost structure, and MedPAC has recommended since 2010 that CMS collect ASC cost data to develop an ASC-specific market basket.

Response: We appreciate the feedback from commenters. We did not propose to collect ASC-specific cost data in our CY 2026 OPPS/ASC proposed rule but may take this comment into consideration in future rulemaking. We agree with commenters that providing the same annual update mechanism under the OPPS and ASC payment system can support the migration of services to the lower-cost ASC setting. We are finalizing our proposal to apply the productivity-adjusted hospital market basket update to the ASC payment system for CY 2026. 2. CY 2026 Final ASC Conversion Factor

For CY 2026, we are finalizing our proposal to utilize inpatient hospital market basket percentage increase of 3.3 percent reduced by the productivity adjustment of 0.7 percentage point, resulting in a final hospital market basket update of 2.6 percent for ASCs meeting the quality reporting requirements. Therefore, we are finalizing a 2.6 percent hospital market basket update factor to the CY 2025 ASC conversion factor for ASCs meeting the quality reporting requirements to determine the CY 2026 ASC payment amounts. The ASCQR Program affected payment rates beginning in CY 2014 and, under this program, there is a 2.0 percentage point reduction to the hospital market basket update factor for ASCs that fail to meet the ASCQR Program requirements. We refer readers to section XIV.E. of the CY 2019 OPPS/ ASC final rule with comment period (83 FR 59138 through 59139) and section XIV.E. of the CY 2026 OPPS/ASC proposed rule for a detailed discussion of our policies regarding payment reduction for ASCs that fail to meet ASCQR Program requirements.

For CY 2026, we are adjusting the CY 2025 ASC conversion factor ($54.895) by a wage index budget neutrality factor of 1.0000 in addition to the productivity-adjusted hospital market basket update of 2.6 percent, discussed previously, which results in a final CY 2026 ASC conversion factor of $56.322 for ASCs meeting quality reporting requirements. For ASCs not meeting quality reporting requirements, we are adjusting the CY 2025 ASC conversion factor ($54.895) by the wage index budget neutrality factor of 01.0000 in addition to the reduced productivity-adjusted hospital market basket update of 0.6 percent, discussed above, which results in a final CY 2026 ASC conversion factor of $55.224 for ASCs not meeting the quality reporting requirements. 3. Display of the Final CY 2026 ASC Payment Rates

Addenda AA and BB to this final rule with comment period (which are available on the CMS website) display the final ASC payment rates for CY 2026 for covered surgical procedures and covered ancillary services, respectively. The final payment rates included in Addenda AA and BB to this final rule with comment period reflect the full ASC payment update and not the reduced payment update used to calculate payment rates for ASCs not meeting the quality reporting requirements under the ASCQR Program.

These Addenda contain several types of information related to the proposed CY 2026 payment rates. Specifically, in Addendum AA, a “Y” in the column titled “To be Subject to Multiple Procedure Discounting” indicates that the surgical procedure would be subject to the multiple procedure payment reduction policy. As discussed in the CY 2008 OPPS/ASC final rule with comment period (72 FR 66829 through 66830), most covered surgical procedures are subject to a 50 percent reduction in the ASC payment for the lower-paying procedure when more than one procedure is performed in a single operative session.

The values displayed in the column titled “Final CY 2026 Payment Weight” are the final relative payment weights for each of the listed services for CY 2026. The final relative payment weights for all covered surgical procedures and covered ancillary services where the ASC payment rates are based on OPPS relative payment weights were scaled for budget neutrality. Therefore, scaling was not applied to the device portion of the device-intensive procedures; services that are paid at the PFS nonfacility PE RVU-based amount; separately payable covered ancillary services that have a predetermined national payment amount, such as drugs and biologicals and brachytherapy sources that are separately paid under the OPPS; or services that are contractor- priced or paid at reasonable cost in ASCs. This includes separate payment for non-opioid pain management drugs.

To derive the final CY 2026 payment rate displayed in the “Final CY 2026 Payment Rate” column, each ASC payment weight in the “Final CY 2026 Payment Weight” column was multiplied by the final CY 2026 conversion factor. The conversion factor includes a budget neutrality adjustment for changes in the wage index values and the annual update as reduced by the

productivity adjustment. The final CY 2026 ASC conversion factor uses the final CY 2026 productivity-adjusted hospital market basket update factor of 2.6 percent (which is equal to the inpatient hospital market basket percentage increase of 3.3 percent reduced by the productivity adjustment of 0.7 percentage point).

Comment: A commenter requested that we remove the Multiple Procedure Payment Reduction (MPPR) assignment from CPT code 64596 (insertion of neurostimulator electrode array, peripheral nerve) and reassign it from “Y” to “N” status in ASC Addendum AA for CY 2026, stating that the current multi-procedure discount results in inequitable payment access since bilateral implantation or multiple nerve targeting requires separate StimRouter devices with individual incision and tunneling procedures. The commenter noted that CPT code 64596 is an outlier compared to other percutaneous implantation codes (64555, 64575, 64590) that do not have MPPR assignment, and emphasized that the clinical need for multiple integrated neurostimulators is similar to other peripheral nerve stimulation devices where each implant requires additional work and separate device costs. The commenter also noted confusion among providers since StimRouter was previously reimbursed under CPT 64555 (which has no multi-procedure discount) prior to the creation of CPT 64596 in January 2024.

Response: We do not agree that CPT code 64596 is an outlier in assigning the MPPR status to “Y” in that many other surgical procedures with significant device costs in the Neurostimulator and Related Procedures APC clinical family are also discounted under the MPPR policy, such as CPT code 64583 (Revision or replacement of hypoglossal nerve neurostimulator array and distal respiratory sensor electrode or electrode array, including connection to existing pulse generator). However, we appreciate the concerns the commenter has raised with respect to the impacts of our MPPR policy on access to surgical procedures with significant device costs. We will continue to monitor the concerns the commenter has raised and may take the commenter's recommendation into consideration in future rulemaking.

In Addendum BB, there are no relative payment weights displayed in the “Final CY 2026 Payment Weight” column for items and services with predetermined national payment amounts, such as separately payable drugs and biologicals. The “Final CY 2026 Payment” column displays the final CY 2026 national unadjusted ASC payment rates for all items and services. The final CY 2026 ASC payment rates listed in Addendum BB for separately payable drugs and biologicals are based on the most recently available data used for payment in physicians' offices. For CY 2021, we finalized adding a new column to ASC Addendum BB titled “Drug Pass-Through Expiration during Calendar Year” where we flag through the use of an asterisk each drug for which pass-through payment is expiring during the calendar year (that is, on a date other than December 31st).

Addendum EE to this final rule with comment period provides the HCPCS codes and short descriptors for surgical procedures that are to be excluded from payment in ASCs for CY 2026.

Addendum FF to this final rule with comment period displays the OPPS payment rate (based on the standard ratesetting methodology), the APC device offset percentage, the device offset percentage for determining device-intensive status (based on the standard ratesetting methodology), and the device portion of the ASC payment rate for CY 2026 for covered surgical procedures.

XIV. Cross-Program Measures for the Hospital Outpatient Quality Reporting (OQR), Rural Emergency Hospital Quality Reporting (REHQR), and Ambulatory Surgical Center Quality Reporting (ASCQR) Programs

We refer readers to sections XV., XVI., and XVII. of this final rule with comment period for program-specific background information, including the statutory authorities and previously finalized and newly proposed measure sets, for the Hospital Outpatient Quality Reporting (OQR), Rural Emergency Hospital Quality Reporting (REHQR), and Ambulatory Surgical Center Quality Reporting (ASCQR) Programs, respectively.

B. Measure Concepts Under Consideration for Future Years in the Hospital OQR, REHQR, and ASCQR Programs--Request for Information (RFI): Well-Being and Nutrition

In the CY 2026 OPPS/ASC proposed rule (90 FR 33754), we sought input on well-being and nutrition measures for consideration in future rulemaking for the Hospital OQR, REHQR, and ASCQR Programs. Well-being is a comprehensive approach to disease prevention and health promotion, as it integrates mental and physical health while emphasizing preventative care to proactively address potential health issues.\252\ This comprehensive approach emphasizes person-centered care by promoting the well-being of patients and family members. We sought comments on tools and measures that assess overall health, happiness, and satisfaction in life, which could include aspects of emotional well-being, social connections, purpose, and fulfillment. We also requested input and comments on the applicability of tools and constructs that assess the integration of complementary and integrative health, skill building, and self-care.

\252\ Centers for Disease Control and Prevention. (May 2024). About Emotional Well-Being. Available at https://www.cdc.gov/emotional-well-being/about/#cdc_behavioral_basics_types-health-benefits. Accessed: April 30, 2025.

We also sought comments on tools and measures that assess optimal nutrition and preventive care in the Hospital OQR, REHQR, and ASCQR Programs. Assessments for nutritional status may include strategies, guidelines, and practices that promote healthy eating habits and ensure individuals receive the necessary nutrients for maintaining health, growth, and overall well-being. Such assessments may also include aspects of health that support or mediate nutritional status, such as physical activity and sleep. In this context, preventive care plays a vital role by proactively addressing factors that may lead to poor nutritional status or related health issues. These efforts not only support optimal nutrition but also work to prevent conditions that could otherwise hinder an individual's health and nutritional needs.

Comment: Many commenters supported the inclusion of well-being and nutrition measures in the Hospital OQR, REHQR, and ASCQR Programs. Many commenters emphasized that including evidence-based, actionable metrics on these topics in quality reporting programs is essential for managing chronic illness, improving patient outcomes, and advancing health equity. Several commenters encouraged CMS to adopt malnutrition quality measures, such as the Malnutrition Care Score (MCS, formerly known as the Global Malnutrition Composite Score) currently used in the Hospital Inpatient Quality Reporting (IQR) program, for the Hospital OQR, REHQR, and ASCQR programs. A few commenters emphasized the importance of implementing measures that use validated, flexible, and interdisciplinary tools, such as the Patient-Reported Outcomes Measurement Information System (PROMIS), World Health Organization Well-Being Index (WHO-5), Patient Health Questionnaire-9

(PHQ-9), Canadian Occupational Performance Measure (COPM), Occupational Self-Assessment (OSA), and Self-Management Ability Scale (SMAS), that capture individualized outcomes including participation, resilience, and quality of life.253 254 255 256 257 258 Other commenters recommended Functional Communication Measures (FCMs) for swallowing to ensure adequate nutrition, hydration, and recovery.\259\ A few commenters recommended incorporating measures that assess care transitions, patient activation, and personalized goals to support pathways to well-being. A few commenters expressed the importance of integrating evidence-based measures that target the aging population and incorporating protective factors such as food access, community safety, financial security, and health literacy. Other commenters encouraged developing new measures that address the topic of maternal recovery in the outpatient setting, as well as measures that recognize specific interventions such as Medical Nutrition Therapy, food insecurity screenings, and chronic care interventions.

\253\ Health Measures. (March 2023). PROMIS. Available at https://www.healthmeasures.net/explore-measurement-systems/promis.

\254\ World Health Organization (October 2024). The World Health Organization-Five Well-Being Index (WHO-5). Available at https://www.who.int/publications/m/item/WHO-UCN-MSD-MHE-2024.01.

\255\ American Psychological Association. Patient Health Questionnanire-9 (PHQ-9). Available at https://www.apa.org/depression-guideline/patient-health-questionnaire.pdf.

\256\ COPM. (2025). The COPM is an individualized, client- centered outcome measure. Available at https://www.thecopm.ca.

\257\ Shirely Ryan Ability Lab. (April 2018). Occupational Self- Assessment. Available at https://www.sralab.org/rehabilitation-measures/occupational-self-assessment.

\258\ Mapi Research Trust. (2012). Self-Management Ability Scale-Short Form (SMAS-S). Available at https://eprovide.mapi-trust.org/instruments/self-management-ability-scale-short-form.

\259\ American Speech-Language-Hearing Association. (2020). Functional Communication Measures (FCMs). Available at https://www.asha.org/siteassets/noms/slp-noms-functional-communication-measures.pdf?srsltid=AfmBOoqymclX2j2Mt7aSFrul0T_PdYL1oNzRZAuzzYO1SBp9mHNe5r0i.

A few commenters urged CMS to consider the applicability of any well-being or nutrition measures to the outpatient setting, noting that facilities should not be held accountable for factors beyond their control, such as lack of access to healthy foods. Many commenters expressed concern that implementing measures related to well-being and nutrition in healthcare facilities, particularly in rural or resource- limited settings, may be administratively burdensome. A few commenters stated that, although ASCs play a vital role in delivering surgical and procedural care, the short-term, episodic nature of ASC services is not optimal for addressing broader well-being or nutritional needs, which require longitudinal interventions and follow-up beyond the ASC setting. A few commenters encouraged CMS to engage with primary care providers, patients, and caregivers to ensure that new domains reflect both clinical relevance and patient experience. A few commenters urged CMS to ensure adequate reimbursement for nutrition care measures that reflects true costs and supports equitable patient access.

Many commenters expressed concern over the proposal to remove SDOH measures, arguing that these screenings provide critical insights into patient needs and support holistic care delivery. Some of these commenters recommended aligning any future well-being and nutrition measures with existing social determinants of health screening tools and identified food insecurity screening as a foundational tool for addressing nutrition and well-being. A few commenters emphasized the importance of aligning nutrition measures with clinical workflows and addressing both food insecurity and diet quality.

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

A few 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. A few commenters recommended pilot testing in diverse settings and populations to ensure reliability, practicality, and applicability of new measures before full implementation. A commenter suggested that new measures related to well-being and nutrition should be electronic clinical quality measures (eCQMs) to align submission formats across CMS quality reporting programs. A commenter urged CMS to leverage the Gravity Project's United States Core Data for Interoperability (USCDI) and Fast Healthcare Interoperability Resources[supreg] (FHIR[supreg]) standards to improve interoperability and integrate community-based supports.260 261

\260\ Office of Disease Prevention and Health Promotion. United States Core Data for Interoperability. Available at https://odphp.health.gov/foodismedicine/federal-resource-hub/united-states-core-data-interoperability.

\261\ eCQI Resource Center. (June, 2025). FHIR--Fast Healthcare Interoperability Resources. Available at https://ecqi.healthit.gov/fhir/about.

Response: We thank the commenters for their input. While we are not responding to specific comments in response to the RFI in this final rule with comment period, we will take this feedback into consideration for our future measure development efforts for the Hospital OQR, REHQR, and ASCQR Programs.

1. Removal of the COVID-19 Vaccination Coverage Among Healthcare Personnel (HCP) Measure From the Hospital OQR and ASCQR Programs Beginning With the CY 2024 Reporting Period/CY 2026 Payment Determination

We refer readers to the CY 2022 OPPS/ASC final rule with comment period where we adopted the COVID-19 Vaccination Coverage Among HCP measure into the Hospital OQR and ASCQR Programs (86 FR 63824 through 63833 and 86 FR 63875 through 63883, respectively) and the CY 2024 OPPS/ASC final rule with comment period where we modified the COVID-19 Vaccination Coverage Among HCP measure to account for updated vaccine guidance (88 FR 81963 through 81968 and 88 FR 82013 through 82017, respectively).

In the CY 2026 OPPS/ASC proposed rule (90 FR 33754 through 33755), for the Hospital OQR and ASCQR Programs, we proposed to remove the COVID-19 Vaccination Coverage Among HCP measure beginning with the CY 2024 reporting period/CY 2026 payment determination under removal Factor 8, as the costs associated with the measure outweigh the benefit of its continued use in the program (42 CFR 419.46(i)(3)(i)(H) and 416.320(c)(2)(viii), respectively). Reporting on this measure currently requires reporting data on COVID-19 Vaccination Coverage

Among HCP for at least 1 week every month. This requires healthcare facilities to track current vaccination status for all employees, licensed independent practitioners, adult students/trainers and volunteers, and other contract personnel and log in to the National Healthcare Safety Network (NHSN) system to report the data monthly, either manually in NHSN or by uploading a comma-separated value (CSV) file.\262\ The estimated burden of collecting this information annually across all 3,200 hospitals in the Hospital OQR Program is between $1,446,400 and $1,687,680. Across the 4,590 ASCs in the ASCQR Program, the estimated annual burden is between $2,074,680 and $2,420,766. We refer readers to section XXIII. of this final rule with comment period for more details on this estimated burden calculation.

\262\ Centers for Disease Control and Prevention. (2025). Weekly COVID-19 Vaccination Module for Healthcare Personnel. Available at https://www.cdc.gov/nhsn/pdfs/hps/covidvax/2025-hcp-combined-protocol-508.pdf. Accessed: April 30, 2025.

When we first adopted the COVID-19 Vaccination Coverage Among HCP measure for the Hospital OQR and ASCQR Programs, the U.S. was in the midst of a Public Health Emergency (PHE) that incurred millions of cases and over 718,000 COVID-19 deaths (86 FR 63825 and 86 FR 63875 through 63876, respectively). While preventing the spread of COVID-19 remains a public health goal, the PHE ended on May 11, 2023.\263\ In addition, the death rate due to COVID-19 in the U.S. has decreased since the adoption of this measure.\264\ In August 2021, when this measure was being proposed, the U.S. was averaging over 6,000 deaths related to COVID-19 per week.\265\ In April 2023, the last full month of the PHE, weekly number of deaths attributed to COVID-19 averaged around 1,300.\266\ With the end of the PHE and the decrease in COVID-19 deaths, we believe the continued costs and burden to healthcare facilities of tracking and monthly reporting on this measure outweigh the benefit of continued information collection on COVID-19 vaccination coverage among HCP. As it may be costly for hospitals and ASCs to continue to report on the COVID-19 Vaccination Coverage Among HCP measure, removal of this measure will allow for the Hospital OQR and ASCQR Programs to focus on other clinical goals.

\263\ U.S. Department of Health and Human Services. (2023). COVID-19 Public Health Emergency. Available at https://www.hhs.gov/coronavirus/covid-19-public-health-emergency/index.html. Accessed: April 30, 2025.

\264\ Centers for Disease Control and Prevention. (2025). COVID Data Tracker. Available at https://covid.cdc.gov/covid-data-tracker/#trends_totaldeaths_select_00. Accessed: April 30, 2025.

\265\ Centers for Disease Control and Prevention. (2025). COVID Data Tracker. Available at https://covid.cdc.gov/covid-data-tracker/#trends_weeklydeaths_select_00. Accessed: April 30, 2025.

\266\ Centers for Disease Control and Prevention. (2025). COVID Data Tracker. Available at https://covid.cdc.gov/covid-data-tracker/#trends_weeklydeaths_select_00. Accessed: April 30, 2025.

We stated that if this proposal is finalized, hospitals and ASCs that do not report their CY 2024 reporting period data for the COVID-19 Vaccination Coverage Among HCP measure to CMS would not be considered noncompliant with the measure for their CY 2026 payment determination (that is, hospitals and ASCs that do not report CY 2024 reporting period data would not be penalized for CY 2026 payments due to this measure). Any COVID-19 Vaccination Coverage Among HCP measure data received by CMS would not be used for public reporting or payment purposes.

We also stated that if this proposal is not finalized, hospitals and ASCs that do not report their CY 2024 reporting data for the COVID- 19 Vaccination Coverage Among HCP measure to CMS would be considered noncompliant with the measure for their CY 2026 payment determination and would receive a letter of noncompliance. Payment adjustments would apply to CY 2026 payment determination for fee-for-service claims as previously finalized.

We invited public comments on these proposals.

Comment: Many commenters supported the removal of the COVID-19 Vaccination Coverage Among HCP measure and agreed that the burden imposed by tracking COVID-19 vaccination among healthcare personnel outweighs the benefits of its continued use in the Hospital OQR and ASCQR Programs. Many commenters supported removal of this measure because it requires near-continuous monitoring of each employee's vaccination status due to changing vaccination definitions. Commenters asserted that the labor and resource intensiveness of collecting and reporting data for this measure requires significant staff time and resources that are diverted from other clinical priorities, such as direct patient care. Many commenters agreed that this measure no longer aligns with an urgent public health priority or provides meaningful or actionable data for quality improvement. Commenters stated that the measure has become outdated, especially since the COVID-19 PHE declaration ended in May 2023.

Response: We thank commenters for their support.

Comment: Several commenters did not agree with removing this measure, asserting that the benefits of maintaining vaccination data for public health surveillance and promoting vaccine uptake outweigh the costs of tracking vaccination coverage. Commenters stated that systematic reporting of healthcare personnel vaccination rates is essential for monitoring and responding to future infectious disease outbreaks in healthcare settings. Instead of removal, these commenters recommended modifying the measure to reduce administrative burden so that preparedness remains a priority. Commenters expressed concern that removing the measure could reduce institutional accountability and preparedness, ultimately resulting in higher costs associated with preventable infections.

Several commenters asserted that vaccination is a critical strategy to minimize preventable harm and maintain safe healthcare environments, and that removing the measure would contradict the healthcare industry's obligation to uphold high standards of care and infection prevention. Some commenters were concerned that removing this measure could reduce attention to vaccination programs, potentially compromising healthcare system resilience. Commenters stated that removing this measure could lead to decreased vaccination rates among healthcare personnel, thereby increasing the risk of hospital-acquired infections and compromising patient safety for vulnerable patient populations, such as those who are immunocompromised, undergoing cancer treatment, or pregnant. A few commenters stated that vaccination of healthcare personnel is particularly important in ASC settings where many patients are undergoing cardiovascular, oncological, or mediport placement procedures.

Response: We acknowledge commenter concerns about patient safety, protecting vulnerable populations, and maintaining public health surveillance and readiness. We agree that patient safety practices and high-quality healthcare for all patients are a priority, and we expect participating hospitals and ASCs to support safe practices that protect patients from infections and other preventable harm. The removal of the COVID-19 Vaccination Coverage Among HCP measure is not intended to interfere with infection control practices, but rather to alleviate the burden associated with data collection

and reporting on a monthly cadence now that the PHE has ended. We note that hospitals and ASCs are not restricted from tracking HCP vaccinations that are appropriate for the setting of care and the population served.

Comment: A few commenters expressed concerns about the proposed applicability date for removing the COVID-19 Vaccination Coverage Among HCP measure, which is the CY 2026 payment determination. Commenters stated that hospitals and ASCs have already invested significant resources to complete the process of submitting CY 2024 quality data used for CY 2026 payment determination. These commenters discouraged the proposal to remove measures applicable to past reporting periods, especially for relatively new measures, as it creates confusion and burden among hospitals and ASCs.

Response: We understand commenters' concern regarding the timing around removal of these measures and the confusion and burden this may impose on hospitals and ASCs that have already submitted CY 2024 quality data. However, because we have determined that the cost of reporting on these measures outweighs the benefits of retaining them in the program, it would place an undue burden on hospitals and ASCs to continue requiring reporting on these measures for an additional year. We note that hospitals and ASCs that do not report their CY 2024 reporting period data for the COVID-19 Vaccination Coverage Among HCP measure to CMS will not be considered noncompliant with the measure for purposes of their CY 2026 payment determination (that is, hospitals and ASCs that do not report CY 2024 reporting period data will not be penalized for CY 2026 payments due to this measure). Any COVID-19 Vaccination Coverage Among HCP measure data received by CMS will not be used for public reporting or payment purposes.

After consideration of the comments received, we are finalizing our proposal to remove the COVID-19 Vaccination Coverage Among HCP measure from the Hospital OQR and ASCQR Programs beginning with the CY 2024 reporting period/CY 2026 payment determination. 2. Removal of the Hospital Commitment to Health Equity (HCHE) Measure From the Hospital OQR and REHQR Programs and the Facility Commitment to Health Equity (FCHE) Measure From the ASCQR Program Beginning With the CY 2025 Reporting Period/CY 2027 Payment or Program Determination

We refer readers to the CY 2025 OPPS/ASC final rule with comment period where we adopted the Hospital Commitment to Health Equity (hereafter referred to as HCHE) measure into the Hospital OQR and REHQR Programs and the Facility Commitment to Health Equity (hereafter referred to as FCHE) measure into the ASCQR Program (89 FR 94368 through 94381).

In the CY 2026 OPPS/ASC proposed rule (90 FR 33755 through 33756), for the Hospital OQR, REHQR, and ASCQR Programs, we proposed to remove the HCHE and FCHE measures beginning with the CY 2025 reporting period/ CY 2027 payment or program determination under removal Factor 8, as the costs associated with achieving a high score on the measure outweigh the benefit of its continued use in the program (Sec. Sec. 419.46(i)(3)(i)(H), 419.95(e)(3)(i)(H), and 416.320(c)(2)(viii), respectively).

When adopted, we intended the collection of data described in the five domains of these measures to provide hospital, REH, and ASC leadership with meaningful and actionable health data to drive quality improvements to eliminate health disparities. We have a renewed focus on measurable clinical outcomes and direct patient care. The HCHE and FCHE measures are structural measures which do not directly assess these areas of interest. Further, based on the feedback received from hospitals, REHs, and ASCs, the burden of collecting these measures may outweigh the benefits. Removal of these measures will alleviate an estimated annual burden of approximately 533 hours, at a cost of $22,518, across all participating hospitals (89 FR 94523); 6 hours, at a cost of $332, across all participating REHs (89 FR 94530); and 746 hours, at a cost of $41,313 across all participating ASCs (89 FR 94534).

An important goal of the Hospital OQR, REHQR, and ASCQR Programs is to move forward in the least burdensome manner possible while maintaining a parsimonious set of meaningful quality measures and continuing to incentivize improvement in the quality of care provided to patients. Removing these measures from the Hospital OQR, REHQR and ASCQR Programs serves this goal. Our priority is to re-focus on measurable clinical outcomes as well as identifying quality measures on topics of prevention, nutrition, and well-being. As such we refer readers to “Measure Concepts under Consideration for Future Years in the Hospital OQR, REHQR, and ASCQR Programs--Request for Information (RFI): Well-Being and Nutrition” in section XIV.B. of this final rule with comment period.

We acknowledge that some hospitals, REHs, and ASCs may have expended resources to implement some or all of the activities described in the HCHE and FCHE measures attestation statements to be able to attest “yes” for measure reporting purposes.

We stated that if this proposal is finalized, hospitals, REHs, and ASCs that do not report their CY 2025 reporting period data for the HCHE or FHCE measure to CMS would not be considered noncompliant with the measure for purposes of their CY 2027 payment or program determination (that is, hospitals, REHs, or ASCs that do not report CY 2025 reporting period data would not be penalized for CY 2027 payments due to this measure, if applicable). Any HCHE or FCHE measure data received by CMS would not be used for public reporting or payment purposes.

We also stated that if this proposal is not finalized, hospitals, REHs, or ASCs that do not report their CY 2025 reporting data for the HCHE or FCHE measures to CMS would be considered noncompliant with the measure for their CY 2027 payment or program determination and would receive a letter of noncompliance. Payment adjustments would apply to CY 2027 payment determination fee-for-service (FFS) claims as previously finalized in the Hospital OQR and ASCQR Programs.

We invited public comments on this proposal.

Comment: Many commenters supported the removal of the HCHE measure from the Hospital OQR and REHQR Programs, and the FCHE measure from the ASCQR Program. Several commenters supported the removal as part of broader efforts to streamline quality reporting programs and reduce regulatory burden. They agreed that eliminating measures like HCHE and FCHE would allow facilities to redirect resources toward higher- priority initiatives and patient care, focusing on more tangible interventions and measurable outcomes rather than attestation-based requirements. A commenter stated that the measure duplicates efforts already met through existing standards, such as The Joint Commission's National Patient Safety Goal NPSG.16.01.01--Improve Health

Care Equity. This commenter encouraged CMS to align measures with existing standards.

Many commenters expressed concerns about structural measures, emphasizing their concerns about administrative burden and the limited impact of these measures on improving patient outcomes. These commenters stated that the burden of reporting these measures outweighs the benefits, highlighting challenges in implementation such as a lack of infrastructure, training, and staff capacity to collect and act on the data meaningfully. Several commenters stated these challenges were particularly acute for small and rural facilities, including single- specialty ASCs.

Many commenters stated that the FCHE measure does not reflect the structure of ASCs to provide short-term, episodic care, and ASCs generally do not have the infrastructure nor the resources to meet the requirements of those measures, such as EHR technology. A commenter asserted that the cost of implementation was higher than the CMS estimate for ASCs.

Many commenters supported the removal of these measures as they expressed the measure was not appropriately tailored to the outpatient hospital, ASC, and REH settings. A few commenters supported the removal due to their lack of consensus-based entity (CBE) endorsement, measure testing, and validity. A few commenters expressed concern about the measure scoring methodology, specifically, the complexity of the reporting requirements and the actionability of the data.

Response: We thank the commenters for their support. We agree that the removal of this measure will reduce the administrative burden and the challenges related to implementation in the ASC setting. We note that both the HCHE and FCHE measures went through the rigorous measure development lifecycle outlined at the CMS Measures Management System website,\267\ which includes measure testing and reliability analysis. For the Hospital OQR Program and ASCQR Program, we note that section 1833(t)(17) of the Act does not require that each measure adopted for these programs be CBE-endorsed. For the REHQR Program, section 1861(kkk)(7)(C)(i) of the Act generally requires that quality measures specified by the Secretary for the REHQR Program be endorsed by a CBE; however, section 1861(kkk)(7)(C)(ii) of the Act provides an exception to the general CBE-endorsement requirement, stating that in the case of a specified area or medical topic determined appropriate by the Secretary for which a measure has not been endorsed by the entity with a contract under section 1890(a) of the Act, the Secretary may specify a measure that is not endorsed as long as due consideration is given to measures that have been endorsed or adopted by a consensus organization identified by the Secretary. We reviewed CBE-endorsed measures and were unable to identify any other CBE-endorsed measures on this topic, and therefore we believe the exception in section 1861(kkk)(7)(C)(ii) of the Act applies for purposes of this measure for the REHQR Program.

\267\ Centers for Medicare & Medicaid Services (2024, December). Blueprint Measure Lifecycle. Measures Management System. Available at https://mmshub.cms.gov/blueprint-measure-lifecycle-overview.

Comment: A few commenters supported the removal of these measures and stated they remain committed to ensuring quality care for all patients and investing in culturally responsive care models.

Response: We appreciate commenters' support and commitment to maintaining quality care for all patients. Despite removal of these measures, facilities will still be able to collect data that is important to their patient care initiatives and reflects the unique needs of their specific patient population.

Comment: Many commenters opposed the removal of the HCHE measure from the Hospital OQR and REHQR Programs, and the FCHE measure from the ASCQR Program, emphasizing the critical role these measures play in advancing health equity and addressing disparities in care delivery. These commenters stated that the measures provide structured accountability for facility leadership to prioritize equity work, collect data on social determinants of health, and implement quality improvement initiatives.

Several commenters asserted that removing the measure would signal a retreat from CMS' stated goals of reducing disparities and improving care for vulnerable populations, including those with severe mental illness, racial and ethnic minorities, rural populations, those with low socioeconomic status, and dual eligible beneficiaries. A commenter stated that removing the HCHE and FCHE measures from the respective programs contradicts the goals of the Make America Healthy Again initiative.

Response: We acknowledge the commenters' concerns. We agree that holding facilities accountable for high-quality healthcare delivery to all beneficiaries is important and remains a priority for the Hospital OQR, REHQR, and ASCQR Programs. We remain focused on identifying measures that balance feasibility, burden, and impact, while aligning with shifting administration priorities as the health system continues to evolve. We are identifying ways to reduce provider reporting burden, while continuing to hold facilities accountable for measurable clinical health outcomes and patient safety. We appreciate the commenters' support for the Make America Healthy Again initiative and will review suggestions received on the new measure RFI in section XIV.B. of this final rule with comment period as we consider relevant measures to introduce in the future.

Comment: Many commenters stated that removal of the measure could result in decreased quality of care, reduce transparency and accountability, and exacerbate gaps in care quality, ultimately resulting in worsened health outcomes and higher costs. Several commenters cited examples of persistent disparities in care, including maternal mortality rates across the population and differences between urban and rural health outcomes. A few commenters asserted removal of this measure would widen the existing gap between medical and behavioral health institutions, emphasizing that addressing social needs such as food insecurity, housing instability, and transportation barriers is essential for improving health outcomes, particularly chronic diseases, and reducing preventable hospital admissions.

Response: We acknowledge commenters' concerns and considered the potential impact on patient outcomes and health disparities when deciding to remove this measure. We urge facilities to continue to incorporate industry standards that may address challenges that could impact safe, high-quality healthcare delivery. Despite removal of these measures, facilities will still be able to collect data that is important to their patient care initiatives and reflects the unique needs of their specific patient population.

Comment: Several commenters stated that the benefits of this measure, which is reducing the costs associated with health inequities, outweigh CMS' estimated burden of implementing the HCHE and FCHE measures. A few commenters stated that structural measures incur a low reporting burden, as facilities do not incur financial penalties so long as they report complete and accurate data. A commenter stated that CMS should prioritize the benefits for Medicare beneficiaries and taxpayers, with

burden to providers as a secondary consideration.

Response: We appreciate commenters' input regarding the burden associated with reporting on the HCHE and FCHE measures. We agree with commenters that the reporting burden associated with structural measures is typically small; however, we believe that costs are multi- faceted and include administrative costs to facilities, maintaining information collection systems, and analyzing reported data. At this time, we remain focused on identifying outcome measures that balance feasibility, burden, and impact, while aligning with administration priorities. We are identifying ways to reduce provider reporting burden, while continuing to hold facilities accountable for measurable clinical health outcomes and patient safety. We have considered both the benefits and the burden of these measures, and determined the multi-faceted costs associated with the measures outweigh the benefits of continued use in the program.

Comment: A few commenters stated that facilities have already incurred the burden to create programs to support the HCHE and FCHE measures and have already invested resources in collecting and submitting data for the CY 2025 reporting period. These commenters stated that CMS should delay the removal of the measures so as to not erode the substantial efforts already underway. A commenter expressed concerns about the proposed effective date for the removal of the FCHE measures, which is the CY 2027 payment determination.

Response: We acknowledge commenters' concern regarding the timing around measure removal and the costs of preparing to report on the measures. However, because we have determined that the cost of reporting on this measure outweighs the benefits of retaining it in the program, we are removing these measures at the earliest feasible reporting period of CY 2025, for which the submission period has not yet opened and the deadline would not be until in May 2026. This negates the need for hospitals and ASCs to expend additional resources on reporting a measure for which we have determined that the costs outweigh the benefits.

Comment: Several commenters recommended refining the HCHE and FCHE measures rather than removing them entirely. A few commenters suggested modifications to reduce administrative burden while preserving the measure's intent and improving value. A few commenters proposed adjustments to scoring methodologies, reporting frequency, or voluntary submission to make the measure more feasible for facilities to implement. A few commenters expressed concerns about removing structural measures as clinical-based measures do not incentivize actionable change at the systemic level, citing “measure gaming”, or demonstrating improvements on measures that are disconnected from true improvements in patient care, as a reason to maintain these measures. A few commenters encouraged CMS to explore alternative mechanisms for tracking equity-related efforts and integrating social needs into care delivery, such as voluntary documentation of Z-codes.

Response: We thank the commenters for their recommendations and will consider them as we evaluate any potential future measures on this subject. We note that structural measures, such as the HCHE and FCHE measures, evaluate a hospital or facility's capacity, systems, and processes to deliver high quality care, whereas outcome measures assess the impact of health care services or interventions on patients.\268\ We are focused on identifying ways to reduce provider reporting burden while continuing to hold hospitals and facilities accountable for measurable clinical outcomes and patient safety. Hospitals and facilities are encouraged to continue to engage in activities to close gaps in care and collect data that is important to their patient care initiatives and reflect the needs of their patient population regardless of whether it is required for the Hospital OQR, REHQR, and ASCQR Programs.

\268\ Agency for Healthcare Research and Quality. (Oct 2025) Types of Health Care Quality Measures. Available at https://www.ahrq.gov/talkingquality/measures/types.html.

After consideration of the comments received, we are finalizing our proposal to remove the HCHE measure from the Hospital OQR and REHQR Programs, and the FCHE measure from the ASCQR Program beginning with the CY 2025 reporting period/CY 2027 payment determination. 3. Removal of Two Social Drivers of Health Measures From the Hospital OQR, REHQR, and ASCQR Programs Beginning With the CY 2025 Reporting Period

In the CY 2026 OPPS/ASC proposed rule (90 FR 33756), we proposed to remove two social drivers of health (SDOH) process measures from the Hospital OQR, REHQR, and ASCQR Programs beginning with the CY 2025 reporting period: Screening for Social Drivers of Health (adopted at 89 FR 94381 through 94398) and Screen Positive Rate for Social Drivers of Health (adopted at 89 FR 94398 through 94403), for which the CY 2025 reporting period would be voluntary, and mandatory reporting would begin with the CY 2026 reporting period/CY 2028 payment or program determination.

We proposed to remove the SDOH measures beginning with the CY 2025 reporting period under removal Factor 8 as the costs associated with the measure outweigh the benefit of its continued use in these programs (Sec. Sec. 419.46(i)(3)(i)(H), 419.95(e)(3)(i)(H), and 416.320(c)(2)(viii), respectively). We heard from some hospitals, REHs, and ASCs concerned with the costs and resources associated with screening patients via manual processes, manually storing such data, training staff, and altering workflows for these measures. In the CY 2025 OPPS/ASC final rule with comment period, we estimated a total annual burden of 6,878,055 hours at a cost of $168,460,032 in the Hospital OQR Program (89 FR 94523 and 94524), 12,984 hours at a cost of $318,163 in the REHQR Program (89 FR 94530 and 94531), and 711,479 hours at a cost of $17,447,164 in the ASCQR Program (89 FR 94534 and 94535), to screen all admitted patients in accordance with the Screening for SDOH measure specifications and report the measure data to CMS. For the Screen Positive Rate for SDOH measure, we estimated a total annual burden of 533 hours at a cost of $29,518 in the Hospital OQR Program (89 FR 94524), 6 hours at a cost of $332 in the REHQR Program (89 FR 94531 and 94532), and 746 hours at a cost of $41,313 in the ASCQR Program (89 FR 94535), to report the measure data. We noted that the HQR system calculates the rate for these two measures, and that hospitals, REHs, and ASCs' responsibility is to report the aggregate number of patients screened, the aggregate number of patients that screened positive, and their total patient population.

We discussed in the CY 2026 OPPS/ASC proposed rule that the costs of the continued use of these measures in the Hospital OQR, REHQR, and ASCQR Programs outweigh the benefits to facilities and patients. Removal of these measures would alleviate the burden on hospitals, REHs, and ASCs to manually screen each patient and submit data each reporting cycle, allowing hospitals, REHs, and ASCs to focus resources on measurable clinical outcomes and direct patient care. This would also remove the patient burden associated with repeated SDOH screenings across multiple healthcare facilities. We refer readers to “Measure Concepts under

Consideration for Future Years in the Hospital OQR, REHQR, and ASCQR Programs-Request for Information (RFI): Well-Being and Nutrition” in section XIV.B. of this final rule with comment period for more information regarding our areas of focus for new measures. We acknowledged that some hospitals, ASCs and REHs may have expended resources to implement SDOH screenings, however, facilities that had already implemented such screenings prior to adoption of the measures would not have expended similar resources. The objectives of the Hospital OQR, REHQR, and ASCQR Programs continue to incentivize the improvement of care quality and health outcomes for all patients through transparency and use of appropriate quality measures.

We invited public comments on this proposal.

Comment: Many commenters supported removing the Screening for SDOH and Screen Positive Rate for SDOH measures. These commenters emphasized that the measures require significant resources for data collection, which could distract hospitals, REHs, and ASCs from focusing on direct patient outcomes and other quality improvement initiatives. Many commenters supported removal of these measures because the measures do not show whether facilities are addressing the specific risk factors impacting patients in response to screenings and patients have expressed frustration resulting from duplicative screenings across healthcare settings.

Response: We thank the commenters for their support.

Comment: Several commenters supported removal due to a lack of testing, appropriate tailoring to the outpatient hospital, ASC, and REH settings, and CBE endorsement. Many commenters supported removal of the FCHE measure as ASCs do not provide longitudinal care, and it is therefore unreasonable to expect them to comprehensively address SDOH. A few commenters expressed that ASCs generally do not have the infrastructure nor the resources to meet the requirements of those measures, such as social workers on staff or knowledge of resources in a patient's own community as many patients travel for ASC care.

Response: We note that the two SDOH measures went through the rigorous measure development lifecycle outlined at the CMS Measures Management System website \269\ which includes measure testing and reliability analysis. For the Hospital OQR Program and ASCQR Program, we note that section 1833(t)(17) of the Act does not require that each measure adopted for these programs is CBE-endorsed. For the REHQR Program, section 1861(kkk)(7)(C)(i) of the Act generally requires that quality measures specified by the Secretary for the REHQR Program be endorsed by a CBE; however, section 1861(kkk)(7)(C)(ii) of the Act provides an exception to the general CBE-endorsement requirement, stating that in the case of a specified area or medical topic determined appropriate by the Secretary for which a measure has not been endorsed by the entity with a contract under section 1890(a) of the Act, the Secretary may specify a measure that is not endorsed as long as due consideration is given to measures that have been endorsed or adopted by a consensus organization identified by the Secretary. We reviewed CBE-endorsed measures and were unable to identify any other CBE-endorsed measures on this topic, and therefore we believe the exception in section 1861(kkk)(7)(C)(ii) of the Act applies for purposes of this measure for the REHQR Program.

\269\ Centers for Medicare & Medicaid Services (2024, December). Blueprint Measure Lifecycle. Measures Management System. Available at https://mmshub.cms.gov/blueprint-measure-lifecycle-overview.

Comment: A few commenters supported the removal of the measure and stated they remain committed to health equity and to operationalizing SDOH screening and intervention in the best manner for their facilities. These commenters mentioned experiencing declined readmissions and emergency department use through connecting patients to community-based services, but that the burden of reporting is significant, so they will continue referring patients voluntarily.

Response: We appreciate commenters' support and commitment to maintaining quality care for all patients.

Comment: Many commenters did not support CMS' proposal to remove the two SDOH measures from the Hospital OQR, REHQR, and ASCQR Programs. Many commenters described how SDOH significantly impacts health outcomes and the types of care and services patients may require in healthcare facilities. These commenters stated that screening for SDOH is fundamental to patient-centered care, including clinical outcomes, treatment adherence, and reducing preventable healthcare utilization (for example, emergency department visits and readmissions). A commenter stated that these SDOH measures intended to create a systematic structure and standardized measurement to support patients with complex needs across all settings, and their removal adds difficulty in scaling care transitions and integrating social care into clinical workflows. Another commenter asserted that ASCs are well- positioned for SDOH screening by serving as a strategic starting point for scaling upstream driver initiatives across the continuum of care.

Response: We acknowledge commenters' concerns and encourage hospitals, REHs, and ASCs to continue to close identified gaps in patient care. Removing these measures from the Hospital OQR, REHQR, and ASCQR Programs does not prevent facilities from measuring and addressing patients' social needs, as clinically appropriate. Further, these SDOH measures are only reported in aggregate and do not measure the extent to which providers are ultimately connecting patients with resources or services and whether patients are benefiting from these screenings.

Comment: Many commenters disagreed that removal of the SDOH measures would reduce burden. Many of these commenters stated that the ultimate cost savings arising from SDOH screening through improved chronic disease management and prevention of avoidable hospitalizations. A few commenters also asserted that facilities have already incurred the cost to set up the systems to collect this data, and that removal now would have minor impacts on costs. Several commenters stated that eliminating these measures without a transition plan could disrupt established care practices, undermine quality, harm partnerships with community-based organizations, and present ethical challenges. A commenter stated that the public deserves to know which facilities are taking a prevention-driven approach to health care.

Response: We thank commenters for their feedback. As previously mentioned, removal of these measures does not prevent hospitals and ASCs from measuring and addressing patients' social needs as clinically appropriate. We acknowledge that hospitals and ASCs may have expended resources to implement SDOH screenings; however, removing these measures at this time will alleviate additional burden with regard to data collection and submission requirements, especially with screening patients via manual processes and other manual collection and data storage mechanisms. We encourage hospitals and facilities to transition in a manner that aligns with existing workflows, operational practices, and community partnerships.

Comment: Several commenters suggested that CMS retain these measures and conduct listening sessions or publish an RFI to gather interested

parties' feedback to address burden. Several commenters requested that CMS allow for voluntary reporting of the SDOH measures or pause the measures to avoid disrupting ongoing efforts to collect social risk data. A few commenters suggested a period of confidential reporting to facilitate iterative improvement. A few commenters expressed the importance of identifying and documenting Z codes and noted the importance of SDOH-related screening for capturing applicable Z codes. A few commenters suggested stratifying performance reports based on SDOH-associated ICD-10 diagnoses or patient demographics. A commenter advised CMS to develop a claims-based approach to measure health disparities.

A few commenters recommended maintaining the current SDOH measures and developing an additional measure to encourage facilities to connect patients to community resources. Some commenters encouraged alignment with other initiatives, such as the National Committee for Quality Assurance's (NCQA's) Healthcare Effectiveness Data and Information Set (HEDIS) Social Needs Screening and Interventions (SNS-E) measure, Health Level 7 Gravity Project, and United States Core Data for Interoperability. Some commenters requested that CMS provide technical assistance in integrating screening into workflows and connecting patients with social needs to resources. A commenter recommended an incentive program for community-based organizations that face funding challenges in supporting an influx of demand as a result of SDOH screening.

Response: We appreciate the commenters' concerns and feedback regarding the importance of collecting SDOH data from patients and acknowledge that some patients may face challenges following discharge that may be related to SDOH. We recognize that some clinicians may find value in obtaining SDOH information as part of clinical decision making, such as discharge planning and patient care, and acknowledge feedback from some commenters stating that they value collecting this information. We agree that healthcare outcomes may be different for those experiencing unstable housing or food insecurity. Facilities may find ways to address these concerns in their workflow because they recognize the importance of these items and the removal of the SDOH measure requirements should not, in any way, preclude hospitals, REHs, or ASCs from collecting and using this information.

Comment: Many commenters stated that the SDOH measures align with CMS' broader goals, including ensuring high-quality healthcare for all patients and implementing the Make America Healthy Again initiative. In response to the request for comment, “Measure Concepts under Consideration for Future Years in the Hospital OQR, REHQR, and ASCQR Programs-Request for Information (RFI): Well-Being and Nutrition,” several commenters urged CMS to keep the SDOH measures and invest resources into improving the applicability and actionability of these measures as a way to improve well-being and nutrition.

Response: We appreciate commenters' support for the goals of the Make America Healthy Again initiative and the constructive role that quality measures can play in ensuring quality healthcare for all. Because we have determined that the cost of reporting on these measures outweighs the benefits of retaining them in these programs, it would place an undue burden on hospitals and ASCs to require reporting on these measures as we explore alternative approaches to implementing measures related to well-being and nutrition. We will consider the feedback commenters provided in future policymaking.

After consideration of the comments we received, we are finalizing our proposal to remove the Screening for Social Drivers of Health and Screen Positive Rate for Social Drivers of Health measures from the Hospital OQR, REHQR, and ASCQR Programs beginning with the CY 2025 reporting period.

Under our current Extraordinary Circumstances Exception (ECE) regulations, we have granted exceptions to data submission deadlines and requirements for the Hospital OQR, REHQR, and ASCQR Programs in the event of extraordinary circumstances beyond the control of a hospital, REH, or ASC (42 CFR 419.46(e), 419.95(g), 416.310(d), respectively). Extraordinary circumstances may include, but are not limited to, natural disasters or systemic problems with data collection systems.\270\ We refer readers to the CY 2022 OPPS/ASC final rule with comment period (86 FR 63873), the CY 2024 OPPS/ASC final rule with comment period (88 FR 82076), and the CY 2018 OPPS/ASC final rule with comment period (82 FR 52614 through 52614) for further background about the ECE policies for the Hospital OQR, REHQR, and ASCQR Programs, respectively. We also refer readers to the QualityNet website for program-specific requirements for submitting an ECE request.\271\

\270\ Centers for Medicare & Medicaid Services. (May 2024). Quality Program Extraordinary Circumstances Exceptions (ECE) Request Form. QualityNet. Available at https://qualitynet.cms.gov/files/677e843f50ed8df7419f60e1?filename=HQR_ECE_Req_Form_CY_2025.pdf. Accessed: April 30, 2025.

\271\ Centers for Medicare & Medicaid Services. Hospital OQR Program Extraordinary Circumstances Exceptions (ECE) Policy: https://qualitynet.cms.gov/outpatient/oqr/participation%23tab2#tab2; REHQR Program Extraordinary Circumstances Exceptions (ECE) Policy: https://qualitynet.cms.gov/reh/rehqr/participation#tab2; and ASCQR Program Extraordinary Circumstances Exceptions (ECE) Policy: https://qualitynet.cms.gov/asc/ascqr/participation%23tab3#tab2. Accessed: April 30, 2025.

Our ECE policy provides flexibility for Hospital OQR, REHQR, and ASCQR Program participants toward meeting program requirements in the event of an extraordinary circumstance. For instance, we recognize that, in circumstances where a full exception is not applicable, it is beneficial for a hospital, REH, or ASC to report data later than the reporting deadline. Delayed reporting authorized under our ECE policy allows temporary relief for a hospital, REH, or ASC experiencing an extraordinary circumstance while preserving the benefits of data reporting, such as transparency and informed decision-making for beneficiaries and providers alike.

2. Update to the Extraordinary Circumstances Exception (ECE) Policy for the Hospital OQR, REHQR, and ASCQR Programs

In the CY 2026 OPPS/ASC proposed rule (90 FR 33756 through 33757), we proposed to update the current Hospital OQR, REHQR, and ASCQR Program ECE policies codified at 42 CFR 419.46(e); 419.95(g); and 416.310(d), respectively, to include extensions of time as a form of relief and to further clarify the policy. Specifically, we proposed updating the regulations at Sec. Sec. 419.46(e)(1), 419.95(g)(1), and 416.310(d)(1) to state that CMS may grant an ECE with respect to reporting requirements in the event of an extraordinary circumstance-- defined as an event beyond the control of a hospital, REH, or ASC (for example, a natural or man-made disaster such as a hurricane, tornado, earthquake, terrorist attack, or bombing)--that affected the ability of the hospital, REH, or ASC to comply with one or more applicable

reporting requirements with respect to a calendar year.

We proposed that the steps for requesting or granting an ECE would remain the same as the current ECE process, detailed by CMS at the QualityNet website or a successor website.\272\ However, at Sec. Sec. 419.46(e)(2)(i), 419.95(g)(2)(i), and 416.310(d)(2)(i), we proposed that a hospital, REH, or ASC, respectively, may request an ECE within 30 calendar days of the date that the extraordinary circumstance occurred. Our current policy allows a request within 90 days; this change was proposed toward aligning the Hospital OQR, REHQR, and ASCQR policy with CMS systems implementation requirements across all quality reporting programs. Under this proposed policy, we clarified that CMS would retain the authority to grant an ECE as a form of relief at any time after the extraordinary circumstance has occurred. For the Hospital OQR, REHQR, and ASCQR Programs, at Sec. Sec. 419.46(e)(2)(ii), 419.95(g)(2)(ii), and 416.310(d)(2)(ii), respectively, we proposed that CMS would notify the requestor with a decision in writing. If CMS grants an ECE to the hospital, REH, or ASC, the written decision will specify whether the hospital, REH, or ASC is exempted from one or more reporting requirements or whether CMS has granted the hospital, REH, or ASC an extension of time to comply with one or more reporting requirements.

\272\ Centers for Medicare & Medicaid Services. Hospital OQR Program Extraordinary Circumstances Exceptions (ECE) Policy https://qualitynet.cms.gov/outpatient/oqr/participation%23tab2#tab2; REHQR Program Extraordinary Circumstances Exceptions (ECE) Policy: https://qualitynet.cms.gov/reh/rehqr/participation#tab2; and ASCQR Program Extraordinary Circumstances Exceptions (ECE) Policy: https://qualitynet.cms.gov/asc/ascqr/participation%23tab3#tab2. Accessed: April 30, 2025.

Additionally, at Sec. Sec. 419.46(e)(3), 419.95(g)(3), and 416.310(d)(3), we proposed that we may grant an ECE to one or more hospitals, REHs, or ASCs that have not requested an ECE if we determine that: a systemic problem with a CMS data collection system directly impacted the ability of the hospital, REH, or ASC to comply with a quality data reporting requirement, or that an extraordinary circumstance has affected an entire region or locale. We further proposed that, as is the case under our current policy, any ECE granted would specify whether the affected hospitals, REHs, or ASCs are exempted from one or more reporting requirements or whether CMS has granted the hospital, REH, or ASC an extension of time to comply with one or more reporting requirements.

We invited public comments on these proposals.

Comment: Many commenters expressed support for CMS' proposals to update and codify the ECE policy across hospital, REH, and ASC quality programs. Many commenters appreciated CMS' efforts to codify its authority to grant reporting deadline extensions or exceptions in response to extraordinary circumstances, recognizing this flexibility as critical for hospitals, REHs, and ASCs facing natural disasters or other emergencies. A few commenters specifically supported the proposal to update and codify CMS' ability to grant ECEs to hospitals, REHs, and ASCs even if those facilities have not requested an exception. A commenter supported the proposal to allow hospitals, REHs, and ASCs 30 days to submit an ECE request.

Response: We thank the commenters for their support.

Comment: Several commenters cautioned CMS to avoid defaulting to extensions in cases where broader relief is warranted and ensure reporting extensions are not disproportionately utilized in place of exceptions. A few commenters also urged CMS to recognize that a mere extension is not always sufficient, as the reliability and integrity of data collected during extraordinary events may be compromised. A few commenters urged CMS to provide details on how the determination of an exception versus an extension will be made to ensure transparency. A commenter stated this transparency would allow hospitals to better prepare for response times and required resources based on whether they are likely to receive an exemption or an extension. A commenter requested that CMS consider granting full exceptions for cyberattacks, specifically, due to the amount of time that the systems would be offline.

Response: We appreciate commenters' concerns regarding the use of extensions for ECE requests. We note that we do not intend to replace exceptions with extensions and acknowledge that extensions are not always appropriate or operationally feasible. We will determine whether to grant an exception versus an extension using the same evaluation approach currently used in ECE determinations, on a case-by-case basis, based on the specific circumstances affecting the hospital, REH, or ASC, including circumstances impacting the operational feasibility of an extension.

Comment: Many commenters did not support the reduced timeframe for hospitals to request an ECE from the current 90-day period to 30 days following an extraordinary circumstance. A few commenters stated that the proposed 30-day window is insufficient for hospitals, REHs, or ASCs to respond to a crisis, assess the impact on data collection and systems, and submit a request for an exception. A few commenters mentioned previously experienced and potential future situations, such as severe flooding and ransomware attacks, where hospitals, REHs, and ASCs would be fully engaged in patient care and operational recovery, leaving little capacity to prioritize administrative tasks like ECE requests. A few commenters expressed concern that the reduced timeframe encourages hospitals, REHs, or ASCs to divert critical staff at a time they are needed most and would force them to prioritize paperwork over patient care, undermining the goals of the CMS quality reporting and value programs. A few commenters requested that CMS review ECE submissions to assess the feasibility for facilities to meet a 30-day response deadline and disclose its justification for reducing the window.

Many commenters urged CMS to retain the current 90-day window but would support 60 days to align with the IPPS and IPF PPS final rules. A few commenters requested CMS retain the 90-day window, despite alignment with the IPPS and IPF PPS final rules; these commenters stated that even 90 days can be an insufficient period of time due to the impacts of extraordinary circumstances on infrastructure and operations.

Response: We appreciate commenters' feedback regarding concerns about reducing the timeframe for hospitals, REHs, and ASCs to submit an ECE request. Due to concerns regarding a hospital's, REH's, or ASC's ability to assess the impact on quality data submissions and complete the necessary ECE request form within 30 days of the extraordinary circumstance, we are modifying the timeframe to allow for 60 days to submit an ECE request. We believe this timeframe will provide sufficient time for hospitals, REHs, and ASCs to assess the impact on quality reporting without disrupting operational and care needs. The 60-day period will also align with the same policy finalized for hospital inpatient providers and inpatient psychiatric facilities (IPF) in the FY 2026 IPPS/LTCH PPS final rule (90 FR 37026) and the FY 2026 IPF PPS final rule (90 FR 37661), respectively.

Comment: A commenter did not support the proposal that CMS may grant an ECE to one or more hospitals, REHs, or ASCs that have not requested

an ECE. This commenter expressed concern that granting wholesale exceptions for entire regions or locales is not in the best interest of beneficiaries or the general public who depend on access to quality reporting to assess the safety and quality of the care delivered. Another commenter expressed concern that less publicized extraordinary circumstances will not prompt CMS to issue an ECE without request, and that the process to submit an ECE request via the HQR portal, email, or secure fax may be unavailable if an emergency event severely disrupts operations for months.

Response: We appreciate commenters' concerns regarding our proposal to grant ECEs to hospitals, REHs, and ASCs that have not requested an ECE but were subject to an extraordinary circumstance affecting their region or locale. While we understand the value of quality reporting data to the public, we believe that granting ECEs during certain circumstances where entire regions or locales may be experiencing a collective disruption in normal operations would alleviate some of the immediate administrative burden of submitting an ECE request. In such cases, we would decide whether facilities are excepted from one or more reporting requirements or granted an extension of time so that we can ensure transparent reporting of reliable data. If a facility is not automatically granted an ECE due to an extraordinary circumstance, we encourage the hospital, REH, or ASC to follow the same approach currently used to submit an ECE request. We believe the modified 60-day timeframe will provide sufficient time for a facility to submit an ECE request without further disrupting operations. The 60-day period will also align with the same policy finalized for the Hospital IQR Program and IPFQR Program in the FY 2026 IPPS/LTCH PPS final rule (90 FR 37026) and the FY 2026 IPF PPS final rule (90 FR 37661), respectively.

After consideration of the public comments, we are finalizing our ECE proposals as proposed, except for the proposed 30-day deadline. In lieu of the 30-day deadline, we are finalizing an ECE request deadline of 60 days following an extraordinary circumstance. We are making conforming amendments to our regulation text at Sec. Sec. 419.46(e), 419.95(g), and 416.310(d) for the Hospital OQR, REHQR, and ASCQR Programs, respectively, to reflect these policy changes.

In the CY 2026 OPPS/ASC proposed rule (90 FR 33757), we proposed to adopt the Emergency Care Access & Timeliness electronic clinical quality measure (eCQM) beginning, with voluntary reporting for the CY 2027 reporting period followed by mandatory reporting beginning with the CY 2028 reporting period/CY 2030 payment determination. In addition, we proposed to remove the Median Time from Emergency Department (ED) Arrival to ED Departure for Discharged ED Patients (Median Time for Discharged ED Patients) measure and the Left Without Being Seen measure, beginning with the CY 2028 reporting period/CY 2030 payment determination, if the Emergency Care Access & Timeliness eCQM is adopted into the program. We also proposed to modify the Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Hospital Level--Outpatient) measure (Excessive Radiation eCQM) from mandatory reporting to voluntary reporting, beginning with the CY 2027 reporting period.

We refer readers to section XIV.C. of this final rule with comment period, Cross-Program Measures, where we discuss the removal of the following Hospital OQR Program measures: (1) COVID-19 Vaccination Coverage Among Healthcare Personnel (HCP) measure beginning with the CY 2024 reporting period/CY 2026 payment determination; (2) Hospital Commitment to Health Equity (HCHE) measure beginning with the CY 2025 reporting period/CY 2027 payment determination; (3) Screening for Social Drivers of Health (SDOH) measure beginning with the CY 2025 reporting period; and (4) Screen Positive Rate for SDOH measure beginning with the CY 2025 reporting period. 1. Adoption of the Emergency Care Access & Timeliness eCQM Beginning With Voluntary Reporting for the CY 2027 Reporting Period Followed by Mandatory Reporting Beginning With the CY 2028 Reporting Period/CY 2030 Payment Determination a. Background

Occupancy and boarding rates in U.S. emergency departments (EDs) continue to worsen and exceed pre-pandemic levels.\273\ ED boarding, defined as holding a patient in the ED after the patient is admitted or placed into observation status at a hospital, often occurs due to shortages of inpatient beds and staff and contributes to ED crowding, leading to safety risks for patients and stressful working conditions for healthcare personnel.\274\ A recent report from the Agency for Healthcare Research and Quality (AHRQ) characterized patient ED boarding as a growing public health crisis and engaged interested parties to address the strain on the U.S. healthcare system.\275\

\273\ Moore, C. & Heckmann R. (2025). Hospital Boarding In The ED: Federal, State, And Other Approaches. Health Affairs Forefront. Available at https://www.healthaffairs.org/content/forefront/hospital-boarding-ed-federal-state-and-other-approaches. Accessed: April 30, 2025.

\274\ Moore, C. & Heckmann R. (2025). Hospital Boarding In The ED: Federal, State, And Other Approaches. Health Affairs Forefront. Available at https://www.healthaffairs.org/content/forefront/hospital-boarding-ed-federal-state-and-other-approaches. Accessed: April 30, 2025.

\275\ Agency for Healthcare Research and Quality. (2025). Technical Report: AHRQ Summit To Address Emergency Department Boarding. Available at https://www.ahrq.gov/sites/default/files/wysiwyg/topics/ed-boarding-summit-report.pdf. Accessed: April 30, 2025.

Recent studies indicate that delays in the timeliness of ED care are associated

with patient harm.276 277 Long ED wait times are also one of the most cited reasons for patients leaving an ED without being evaluated by a clinician.\278\ Increased ED length of stay (LOS) is also a strong predictor of poor timeliness of care and is significantly impacted by ED boarding. One study found that for every patient boarded, the median ED LOS for all admitted patients increased by at least 12 minutes.\279\ Furthermore, ED boarding and crowding have been associated with poor patient outcomes, such as increased mortality,\280\ delays in needed care,\281\ and negative patient and staff experiences.282 283 For instance, evidence shows that ED crowding can harm patients with sepsis by delaying administration of lifesaving intravenous (IV) fluids and antibiotics.\284\

\276\ Gaieski, D.F., Agarwal, A.K., Mikkelsen, M.E., Drumheller, B., Cham Sante, S., Shofer, F.S., Goyal, M., & Pines, J.M. (2017). The impact of ED crowding on early interventions and mortality in patients with severe sepsis. The American Journal of Emergency Medicine, 35(7), 953-960. Available at https://doi.org/10.1016/j.ajem.2017.01.061. Accessed: April 30, 2025.

\277\ Laam L.A., Wary A.A., Strony R.S., Fitzpatrick M.H., & Kraus C.K. (2021). Quantifying the impact of patient boarding on emergency department length of stay: All admitted patients are negatively affected by boarding. Journal of American College Emergency Physicians, 2(2):e12401. Available at https://doi.org/10.1002/emp2.12401. Accessed: April 30, 2025.

\278\ Janke, A.T., Melnick, E.R., & Venkatesh, A.K. (2022). Monthly Rates of Patients Who Left Before Accessing Care in US Emergency Departments, 2017-2021. JAMA, 5(9), e2233708. Available at https://doi.org/10.1001/jamanetworkopen.2022.33708. Accessed: April 30, 2025.

\279\ Laam L.A., Wary A.A., Strony R.S., Fitzpatrick M.H., & Kraus C.K. (2021). Quantifying the impact of patient boarding on emergency department length of stay: All admitted patients are negatively affected by boarding. Journal of American College Emergency Physicians, 2(2):e12401. Available at https://doi.org/10.1002/emp2.12401. Accessed: April 30, 2025.

\280\ Hsuan, C., Segel, J.E., Hsia, R.Y., Wang, Y., & Rogowski, J. (2023). Association of emergency department crowding with inpatient outcomes. Health Services Research, 58(4), 828-843. Available at https://doi.org/10.1111/1475-6773.14076. Accessed: April 30, 2025.

\281\ Gaieski, D.F., Agarwal, A.K., Mikkelsen, M.E., Drumheller, B., Cham Sante, S., Shofer, F.S., Goyal, M., & Pines, J.M. (2017). The impact of ED crowding on early interventions and mortality in patients with severe sepsis. The American Journal of Emergency Medicine, 35(7), 953-960. Available at https://doi.org/10.1016/j.ajem.2017.01.061. Accessed: April 30, 2025.

\282\ Reznek, M.A., Larkin, C.M., Scheulen, J.J., Harbertson, C.A., & Michael, S.S. (2021). Operational factors associated with emergency department patient satisfaction: Analysis of the Academy of Administrators of Emergency Medicine/Association of Academic Chairs of Emergency Medicine national survey. Academic Emergency Medicine: Official Journal of the Society for Academic Emergency Medicine, 28(7), 753-760. Available at https://doi.org/10.1111/acem.14278. Accessed: April 30, 2025.

\283\ Loke, D.E., Green, K.A., Wessling, E.G., Stulpin, E.T., & Fant, A.L. (2023). Clinicians' Insights on Emergency Department Boarding: An Explanatory Mixed Methods Study Evaluating Patient Care and Clinician Well-Being. Joint Commission Journal on Quality and Patient Safety, 49(12), 663-670. Available at https://doi.org/10.1016/j.jcjq.2023.06.017. Accessed: April 30, 2025.

\284\ Gaieski, D.F., Agarwal, A.K., Mikkelsen, M.E., Drumheller, B., Cham Sante, S., Shofer, F.S., Goyal, M., & Pines, J.M. (2017). The impact of ED crowding on early interventions and mortality in patients with severe sepsis. The American Journal of Emergency Medicine, 35(7), 953-960. Available at https://doi.org/10.1016/j.ajem.2017.01.061. Accessed: April 30, 2025.

Due to growing concerns about the quality and timeliness of care in the ED, as well as the burden associated with two chart-abstracted ED measures adopted in the Hospital OQR Program measure set, the Median Time for Discharged ED Patients measure and the Left Without Being Seen measure, CMS assessed additional ways to support efforts that reduce patient harm and improve outcomes for patients requiring emergency care. b. Measure Overview

The Emergency Care Access & Timeliness eCQM \285\ is specified for the hospital setting and calculates the proportion of four outcome metrics that quantify access to and timeliness of care in an ED setting against specified thresholds, including: (1) patient wait time--1 hour; (2) whether the patient left the ED without being evaluated; (3) patient boarding time in the ED (as defined by a Decision to Admit (order) to ED departure for admitted patients)--4 hours; and (4) patient ED LOS (time from ED arrival to ED physical departure, as defined by the ED departure timestamp)--8 hours. The Emergency Care Access & Timeliness eCQM provides HOPDs with data for each of these individual numerator components, which are described in greater detail in section XV.B.1.c. of this final rule with comment period.

\285\ The Emergency Care Access and Timeliness eCQM was previously named the Emergency Care Capacity and Quality (ECCQ) eCQM. The name of the measure has been updated to better reflect the purpose of the measure based on feedback from the Pre-Rulemaking Measure Review (PRMR) Hospital Recommendation Group Meeting on January 16, 2025. Available at https://p4qm.org/sites/default/files/2025-02/PRMR-Hospital-Recommendation-Group-Meeting-Summary.pdf. Accessed: April 30, 2025.

The numerator components of the Emergency Care Access & Timeliness eCQM overlap with the patient population and measure specifications of two chart-abstracted measures in the Hospital OQR Program: (1) the Median Time for Discharged ED Patients measure, and (2) the Left Without Being Seen measure. The Median Time for Discharged ED Patients measure assesses the time patients spent in the ED before being sent home, also known as ED throughput. The Left Without Being Seen measure assesses the percentage of patients who leave the ED without being evaluated by a physician/advanced practice nurse/physician's assistant (physician/APN/PA). Numerator component (2) overlaps with the Left Without Being Seen patient population, and numerator component (4) overlaps with the Median Time for Discharged ED Patients measure. In addition to capturing the same data elements as the Median Time for Discharged ED Patients and Left Without Being Seen measures, the Emergency Care Access & Timeliness eCQM measures boarding time in the ED, numerator component (3), and time from arrival to placement in a treatment room, numerator component (1), which are not currently captured by any other measure in the Hospital OQR Program measure set.\286\

\286\ Partnership for Quality Measurement. Emergency Care Capacity and Quality. Available at https://p4qm.org/measures/4625e. Accessed: April 30, 2025.

In the CY 2026 OPPS/ASC proposed rule (90 FR 33757 through 33762), we proposed that removal of two chart-abstracted measures in conjunction with the proposed adoption of the Emergency Care Access & Timeliness eCQM would reduce HOPD burden by requiring the reporting of one digital quality measure instead of two chart-abstracted measures. While the Median Time for Discharged ED Patients and the Left Without Being Seen measures require manual intervention to retrieve data from clinical documentation, the Emergency Care Access & Timeliness eCQM allows for automated extraction of patient-level data directly from the electronic health record (EHR). In the proposed rule (90 FR 33758), we acknowledged that updating EHRs with new measures requires some initial investment from hospitals, but in the long-term it would automate timely collection of more granular quality information. We referred readers to the eCQI Resource Center for general eCQM implementation guidance at https://ecqi.healthit.gov/oqr/ecqm-resources. We also refer readers to section XV.B.2. of this final rule with comment period for more information on these removals of the chart-abstracted measures.

For more information about the testing, feasibility, scientific acceptability, meaningfulness, and validity of the Emergency Care Access & Timeliness eCQM, we refer readers to https://p4qm.org/measures/4625e.