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

The measure denominator includes all ED encounters associated with patients of all ages, for all-payers, during a 12-month period of performance. Patients can have multiple encounters during a period of performance, and each encounter is eligible to contribute to the calculation of the measure.\287\

\287\ For proposed measure specifications, we refer readers to the eCQI Resource Center at https://ecqi.healthit.gov/ecqm/hosp-outpt/2027/cms1244v1, or the CMS QualityNet Hospital OQR Program website at https://qualitynet.cms.gov/outpatient.

The measure numerator includes any ED encounter in the denominator where the patient experiences any one of the following: (1) the patient waited longer than 1 hour after arrival to the ED to be placed in a treatment room or dedicated treatment area that allows for audiovisual privacy during history-taking and physical examination; (2) the patient left the ED without being evaluated; (3) the patient boarded in the ED for longer than 4 hours; and (4) the patient had an ED LOS of longer than 8 hours.\288\ An encounter is considered part of the numerator if it includes any one of the four numerator events, with events not being mutually exclusive and each contributing only once to the numerator. ED encounters with ED observation stays \289\ are excluded from components (3) and (4) but are included in the denominator. Patients who have a “decision to admit” after an ED observation stay remain excluded from criteria (3) calculations.\290\

\288\ For proposed measure specifications, we refer readers to the eCQI Resource Center at https://ecqi.healthit.gov/ecqm/hosp-outpt/2027/cms1244v1, or the CMS QualityNet Hospital OQR Program website at https://qualitynet.cms.gov/outpatient.

\289\ ED observations stays are defined as an observation encounter where the patient remains physically in an area under control of the ED and under the care of an ED clinician inclusive of observation in a hospital bed. Partnership for Quality Measurement. Emergency Care Capacity and Quality. Available at https://p4qm.org/measures/4625e. Accessed: April 30, 2025.

\290\ Specific codes required to calculate the numerator are outlined in the value set data dictionary and eCQM package (Quality Data Model--QDM output). Please refer to the “Measure Calculation” Section for information: https://p4qm.org/measures/4625e. Accessed: April 30, 2025.

These four outcomes were selected based on published literature demonstrating that each numerator component is associated with patient harm,\291\ as well as input from clinical experts including ED experts and statistical and methodological experts and a Technical Expert Panel (TEP) that was convened by the measure developer.\292\ A Patient and Family Engagement (PFE) Work Group provided feedback on experiences with emergency care, noting long wait times to be seen by a provider, long wait times to be transferred, and gaps in the discharge processes.

\291\ Partnership for Quality Measurement. Emergency Care Capacity and Quality. Available at https://p4qm.org/measures/4625e. Accessed: April 30, 2025.

\292\ Partnership for Quality Measurement. Emergency Care Capacity and Quality. Available at https://p4qm.org/measures/4625e. Accessed: April 30, 2025.

The numerator thresholds were developed according to evidence and consensus-based clinical guidelines for ED time thresholds, including guidelines developed by The Joint Commission (TJC), the American College of Emergency Physicians (ACEP), and the Emergency Department Benchmarking Alliance as well as input from a TEP, literature reviews, and environmental scans. For example, the 4-hour threshold for numerator component (3), boarding time, was developed according to recommendations from TJC and ACEP.293 294

\293\ The Joint Commission. (2012). Patient Flow through the Emergency Department. Available at https://www.jointcommission.org/en-us/standards/r3-report/r3-report-4. Accessed: April 30, 2025.

\294\ American College of Emergency Physicians. (2024). Emergency Department Boarding and Crowding. Available at https://www.acep.org/administration/crowding--boarding. Accessed: April 30, 2025.

Measure testing for the Emergency Care Access & Timeliness eCQM was conducted by the measure developer across 32 hospital-based EDs, representing a diverse mix of geographic regions, rurality, hospital size, teaching status, trauma level, and EHR vendors, demonstrating that the measure is reliable, valid, and feasible for all required data elements.\295\ Measure testing results showed a wide range in overall scores, and across all strata, indicating variation in performance and implying room for quality improvement.\296\

\295\ Partnership for Quality Measurement. Emergency Care Capacity and Quality. Available at https://p4qm.org/measures/4625e. Accessed: April 30, 2025.

\296\ Partnership for Quality Measurement. Emergency Care Capacity and Quality. Available at https://p4qm.org/measures/4625e. Accessed: April 30, 2025.

The measure score is first calculated at the individual ED level as the proportion of ED encounters where any one of the four outcomes occurred. Raw measure scores are then standardized by ED case volume using z-scores. The z-score, or standard score, indicates how many standard deviations a data point is from the mean of a normal distribution. It is calculated by subtracting the mean from a data point, then dividing the result by the standard deviation. For the Emergency Care Access & Timeliness eCQM, a volume-adjusted z-score shows how an ED's performance compares to the average for similar- volume EDs, addressing differences in patient population in HOPDs and ensuring fair “like to like” comparisons between EDs of similar size. ED volume strata are defined in volume bands of 20,000 ED visits, and each ED is assigned to only one volume stratum. For CMS Certification Numbers (CCNs) with more than one ED, volume-adjusted z-scores are then combined as a weighted average for that CCN.\297\

\297\ For proposed measure specifications, we refer readers to the CMS QualityNet Hospital OQR Program website at https://qualitynet.cms.gov/outpatient.

The results of the Emergency Care Access & Timeliness eCQM are stratified into four groups, two by age (18 years and older, and under 18 years) and two by mental health diagnoses (with, and without).\298\ The stratification of results by age and mental health diagnosis, as well as standardization of measure performance scores by volume, is sufficient to account for differences between hospitals without further need for risk adjustment.

\298\ The principal diagnosis (first listed diagnosis at ED discharge) will be used to define strata inclusion. For this measure's purpose, mental health diagnoses do not include substance use disorder diagnoses. Mental health refers to mental health diagnoses, life stressors and crises, and stress-related physical symptoms.

For more detail on the measure specifications, we referred readers to the CMS QualityNet Hospital OQR Program website at https://qualitynet.cms.gov/outpatient, which also takes readers to the electronic specifications available at the eCQI Resource Center: https://ecqi.healthit.gov/ecqm/hosp-outpt/2027/cms1244v1. d. Pre-Rulemaking Measure Review (PRMR)

As required under section 1890A of the Act, the Secretary must establish and follow a pre-rulemaking process for selection of quality and efficiency measures, including for the Hospital OQR Program. The pre-rulemaking process, which we refer to as the Pre-Rulemaking Measure Review (PRMR), includes a review of measures published on the publicly available “Measures Under Consideration List” (MUC List) by one of several committees convened by the consensus-based entity (CBE), with which we contract in accordance with section 1890 of the Act, for the purpose of providing interested parties input to the Secretary on the selection of quality and efficiency

measures under consideration for use in certain Medicare quality programs, including the Hospital OQR Program. We refer readers to the CY 2025 OPPS/ASC final rule with comment period (89 FR 94372) for details on the PRMR process, including the voting procedures used to reach consensus on measure recommendations. We described in the CY 2026 OPPS/ASC proposed rule that the PRMR Hospital Recommendation Group met on January 15 and 16, 2025, to review measures included by the Secretary on the publicly available 2024 MUC List, including the Emergency Care Access & Timeliness eCQM (MUC2024-075), and provided additional recommendations on the potential use of this measure.\299\

\299\ Partnership for Quality Measurement. (2025). 2024-2025 Pre-Rulemaking Measure Review (PRMR) Recommendation Group Final Meeting Summary: Hospital Committee. Available at https://p4qm.org/sites/default/files/2025-02/PRMR-Hospital-Recommendation-Group-Meeting-Summary.pdf. Accessed: April 30, 2025.

The voting results of the PRMR Hospital Recommendation Group for the proposed Emergency Care Access & Timeliness eCQM within the Hospital OQR Program were: 10 members recommended adopting the measure into the Hospital OQR Program; 10 members recommended adoption with conditions; 7 members voted not to recommend the measure for adoption. No voting category reached 75 percent or greater, including the combination of the recommend and the recommend with conditions categories and thus, the Hospital Recommendation Group did not reach consensus.\300\

\300\ Partnership for Quality Measurement. (2025). 2024-2025 Pre-Rulemaking Measure Review (PRMR) Recommendation Group Final Meeting Summary: Hospital Committee. Available at https://p4qm.org/sites/default/files/2025-02/PRMR-Hospital-Recommendation-Group-Meeting-Summary.pdf. Accessed: April 30, 2025.

The PRMR Hospital Recommendation Group noted in their deliberations that the measure will provide important insights into ED wait times which impact experience of care. The Group expressed concern that this measure may cause an increase in cost of care due to patients being transferred from the ED to observation.\301\ While we acknowledged that patients transferred from the ED to observation may result in increased short-term costs due to additional monitoring and extended stays, the measure is designed to address significant issues surrounding the access to timely care which have been proven to reduce long-term costs.\302\ Hospital Recommendation Group members also expressed concern about the lack of CBE endorsement. We noted that we submitted the Emergency Care Access & Timeliness eCQM for CBE endorsement for review in the Fall 2024 cycle and the CBE endorsed the measure with conditions on February 12, 2025.\303\

\301\ Partnership for Quality Measurement. (2025). 2024-2025 Pre-Rulemaking Measure Review (PRMR) Recommendation Group Final Meeting Summary: Hospital Committee. Available at https://p4qm.org/sites/default/files/2025-02/PRMR-Hospital-Recommendation-Group-Meeting-Summary.pdf. Accessed: April 30, 2025.

\302\ Dyas, S.R., Greenfield, E., Messimer, S., Thotakura, S., Gholston, S., Doughty, T., Hays, M., Ivey, R., Spalding, J., & Phillips, R. (2015). Process-Improvement Cost Model for the Emergency Department. Journal of Healthcare Management, 60(6): 442- 57. Available at https://doi.org/10.1097/00115514-201511000-00011. Accessed: April 30, 2025.

\303\ Partnership for Quality Measurement. (2024). 2024 Pre- Rulemaking Measure Review Preliminary Assessment. Available at https://p4qm.org/sites/default/files/2024-12/PRMR-PA-MUC2024-075.pdf. Accessed: April 30, 2025.

The Hospital Recommendation Group discussed conditions specific to the Hospital OQR Program, including changing the name of the measure to better reflect the measure's focus.\304\ We agreed with this feedback and changed the name of the measure from the Emergency Care Capacity and Quality eCQM to Emergency Care Access & Timeliness eCQM. Group members also recommended refraining from including the Emergency Care Access & Timeliness eCQM in Overall Hospital Quality Star Ratings (Star Ratings) due to the possible duplication of data with existing measures. We noted that we proposed to remove two existing measures in the Hospital OQR Program, the Median Time for Discharged ED Patients and the Left Without Being Seen measures, to avoid duplicative data collection and reporting. We also noted that the Emergency Care Access & Timeliness measure would only be included in the Star Ratings calculation after the existing measures are removed. We refer readers to section XV.B.2. of this final rule with comment period for more information on the removal of the Median Time for Discharged ED Patients and the Left Without Being Seen measures.

\304\ Partnership for Quality Measurement. (2025). 2024-2025 Pre-Rulemaking Measure Review (PRMR) Recommendation Group Final Meeting Summary: Hospital Committee. Available at https://p4qm.org/sites/default/files/2025-02/PRMR-Hospital-Recommendation-Group-Meeting-Summary.pdf. Accessed: April 30, 2025.

The Hospital Recommendation Group also recommended revising the measure specifications to create separate measure components and explore alternative measures for patient boarding time and patient ED LOS. We acknowledged the Hospital Recommendation Group's concerns and noted that multiple TEPs and interested parties supported the inclusion of more than one numerator component as a strategy for internally balancing the measure and that the time thresholds for patient boarding time and ED LOS are based on more than a decade of consensus work. Lastly, Group members recommended stratifying the measure by factors such as care type, region, and hospital or trauma level designation. We emphasized that the approach to stratification by age and mental health diagnosis, as well as volume standardization of the measure performance scores, is sufficient to account for differences between hospitals without further need for additional stratification.\305\

\305\ Partnership for Quality Measurement. (2025). 2024-2025 Pre-Rulemaking Measure Review (PRMR) Recommendation Group Final Meeting Summary: Hospital Committee. Available at https://p4qm.org/sites/default/files/2025-02/PRMR-Hospital-Recommendation-Group-Meeting-Summary.pdf. Accessed: April 30, 2025.

The Emergency Care Access & Timeliness eCQM is specified in a standard electronic format, utilizing data extracted electronically from EHRs, with all data coming from defined fields in electronic sources. We noted in the CY 2026 OPPS/ASC proposed rule that eCQMs allow for retrieval of data directly from an EHR, reducing administrative burden on hospitals and minimizing errors due to manual abstraction of data.\307\

\307\ Centers for Medicare & Medicaid Services. (2023). Electronic Clinical Quality Measures (eCQMs) Specification, Testing, Standards, Tools, and Community. Available at https://mmshub.cms.gov/sites/default/files/eCQM-Specifications-Testing-Standards-Tools-Community.pdf. Accessed: April 30, 2025.

We proposed to adopt 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. We stated we believe this would provide HOPDs sufficient time to test and integrate the eCQM into existing clinical workflows. Additionally, limiting voluntary reporting to 1 year prioritizes addressing long ED wait times and ED boarding as well as removing two chart-abstracted measures from the Hospital OQR Program measure set to reduce HOPD burden. We refer readers to section XV.C.2. of this final rule with comment period for additional information on the Emergency Care Access & Timeliness eCQM form, manner, and timing of data submission and reporting requirements.

We refer readers to section XVI.B.1. of this final rule with comment period where we discuss the adoption of a similar measure for the Rural Emergency Hospital Quality Reporting Program.

We invited public comments on this proposal. The following is a summary of the comments we received and our responses.

Comment: Many commenters supported the adoption of the Emergency Care Access & Timeliness eCQM as proposed. These commenters emphasized the importance of measuring emergency room wait times, particularly boarding times. Many commenters stated that ED boarding is a public health emergency and national security and preparedness issue, as it endangers patient outcomes and contributes to ambulance diversion, adverse events, preventable errors, reduced patient satisfaction, ED violence, staff burnout, and higher health care costs. Many commenters stated that boarding reflects broader health system dysfunction and that valid and reliable measurement is essential to identifying, diagnosing, and pursuing strategies that can solve this issue. A few commenters supported CMS for moving to reinstate a boarding-related measure into its quality reporting programs following the previous removal of several measures related to this topic.

Response: We thank commenters for their support. We agree that measurement is essential to addressing the complex issue of ED boarding.

Comment: Several commenters supported the timeline for adoption of the Emergency Care Access & Timeliness eCQM into the Hospital OQR Program, believing the transition from voluntary reporting to mandatory reporting to be appropriate for a new eCQM. These commenters supported the transition for existing ED efficiency measures to the new Emergency Care Access & Timeliness eCQM and urged CMS to finalize the timeline as proposed.

Response: We thank the commenters for their support. The timeline for 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, was developed to balance the immediacy of the ED boarding crisis while providing HOPDs sufficient time to test and integrate the eCQM into existing clinical workflows in preparation for reporting the measure. HOPDs would have approximately 25 months from the publication of this final rule with comment period until the start of the mandatory reporting period in January 2028, and approximately 3.5 years from the publication of this final rule with comment period until the submission deadline for the CY 2028 data in May 2029, to implement any workflow modifications or organizational updates necessary to successfully report on the measure.

Comment: Several commenters recommended publicly reporting the four individual numerator components as well as the overall measure score for the Emergency Care Access & Timeliness eCQM. Several commenters noted that data for the individual numerator components would provide more granular insights and improve hospitals' ability to target specific areas for improvement. A few commenters opposed the use of a composite measure, noting that it would mask performance on the four distinct numerator components.

Response: We agree with commenters that performance data for the four numerator components provides meaningful and actionable information for hospitals, patients, and other members of the public. If the Emergency Care Access & Timeliness eCQM is adopted into the Hospital OQR Program, we would publicly report the overall measure score and rates for the four numerator components once the measure becomes mandatory.

We note that the overall score for the Emergency Care Access & Timeliness eCQM represents the proportion of ED encounters in the denominator where the patient experiences at least one of the four numerator events: (1) the patient waited longer than 1 hour after arrival to the ED to be placed in a treatment room or dedicated treatment area that allows for audiovisual privacy during history- taking and physical examination; (2) the patient left the ED without being evaluated; (3) the patient boarded in the ED for longer than 4 hours; and (4) the patient had an ED LOS of longer than 8 hours.\308\ We also note that the four numerator component rates are not blended or combined to obtain the overall score. That is, for each numerator component, the denominator includes all ED encounters associated with patients of all ages, for all-payers, during a 12-month period of performance, and the numerator includes the ED encounters in the denominator that met the criteria for the designated numerator event.

\308\ For measure specifications, we refer readers to the eCQI Resource Center at https://ecqi.healthit.gov/ecqm/hosp-outpt/2027/cms1244v1, or the CMS QualityNet Hospital OQR Program website at https://qualitynet.cms.gov/outpatient.

Comment: A few commenters requested clarification on how encounters that meet more than one numerator criteria would be included in the measure calculations. A commenter requested clarification on double counting, benchmarking, and reporting for patients with behavioral health needs.

Response: As specified, if a single ED encounter meets the criteria for more than one numerator event, the encounter would be included in each of the applicable component scores and once in the overall summary score regardless of how many numerator events it met. Because the overall measure score represents the proportion of ED visits where any component outcome occurred, the Emergency Care

Access & Timeliness eCQM avoids overlap and double counting that can skew measure results. For the request for clarification on the benchmarks for this measure, we believe the commenter is referring to the numerator thresholds. As discussed in the CY 2026 OPPS/ASC proposed rule, these thresholds were developed according to evidence and consensus-based clinical guidelines for ED time thresholds, including those from The Joint Commission (TJC) and the American College of Emergency Physicians (ACEP). For the request for clarification on reporting for patients with behavioral health needs, we reiterate that we will stratify the data for each of the numerator components and the overall summary score into four groups, two by age (18 years and older, and under 18 years) and two by mental health diagnoses (with, and without).\309\

\309\ The principal diagnosis (first listed diagnosis at ED discharge) will be used to define strata inclusion. For this measure's purpose, mental health diagnoses do not include substance use disorder diagnoses. Mental health refers to mental health diagnoses, life stressors and crises, and stress-related physical symptoms.

Comment: A few commenters requested clarification of what constitutes a “treatment room or dedicated treatment area” in the first numerator component, with a commenter stating that some hospitals may interpret this strictly as a dedicated room, while others might consider curtained dividers as meeting the definition. A few commenters requested that CMS consider revising the language to focus on the initiation of treatment, regardless of where it occurs, to accommodate diverse ED layouts and workflows.

Response: We note that measure numerator component (1) does not specify a physical location; it evaluates whether the patient waited longer than 1 hour after arrival to the ED to be placed in a treatment room or dedicated treatment area that allows for audiovisual privacy during history-taking and physical examination. Based on this description, multiple settings, including both curtained dividers and a dedicated room, would qualify if there is audiovisual privacy. Spaces that do not provide both visual privacy and audio privacy sufficient to ensure patient dignity, confidentiality, and quality of care during history-taking and physical examination would not qualify. We believe this approach allows for flexibility so that diverse ED layouts and workflows can be accommodated when hospitals implement the measure while also ensuring that patients' privacy is respected.

Comment: A few commenters requested that CMS consider either defining exclusion criteria for complex ED encounters (for example, specialized care pathways, specialty consultations, forensic patients, or patients requiring advanced imaging) or adding exclusionary language for each of the numerator components. Another commenter requested exclusion criteria for multi-casualty events. According to commenters, these exclusions are necessary to avoid misclassifying high-quality, comprehensive care provided in a single ED visit as poor performance.

Response: Regarding commenters' requests for exclusion criteria, we note that the measure methodology, including consideration of potential exclusions, was informed by extensive literature review, empiric analyses, and feedback from the TEP, PFE Work Group, and the public comment period held during measure development. The measure does not have exclusions beyond observation stays for numerator component (3) and (4) because the numerator events included in the measure are considered access failures regardless of patient complexity or surge scenarios. We believe that excluding patients from the measure would violate its intent to ensure timely access to emergency care for all patients. As described below, we do not anticipate zero scores for all numerator components on every patient, and we believe the hospital comparison logic (such as using standardized z-scores to adjust for ED volume) adequately accounts for differences in performance among hospitals. We will monitor the measure during implementation to determine whether any additional exclusions are appropriate for measure incorporation in future re-specification.

We agree that some patients are clinically complex and require specialized, time-intensive services in the ED, and note that this was considered during measure development. We do not expect hospitals to achieve zero scores for all numerator components. We also note that the Hospital OQR Program is a pay-for-reporting program that penalizes hospitals for not submitting data rather than for performance on the measure. However, collecting and publicly reporting these data will allow for comparisons between hospitals that serve similar communities and support the development of targeted quality improvement strategies.

Comment: A few commenters noted that for small, rural hospitals, delays in the ability to transfer patients are frequently out of their control. A few commenters sought clarification on whether the measure includes transfer patients, with a commenter noting a distinction between patients who are transferred to another facility and patients being admitted to the same facility or discharged home.

Response: We recognize the complexity and interdependence of multiple systems when it comes to attribution of transfer cases. The decision to include transfer patients in the Emergency Care Access & Timeliness eCQM was carefully considered during measure development, particularly through input from the TEP. Capturing transfers in the measure numerator ensures that it is the responsibility of the transferring ED to proactively build processes that maintain care coordination to ensure timely transfer, which patients from the PFE Work Group expressed was important to them. Additionally, we believe including transfers in the numerator limits the incentive to inappropriately transfer patients to other facilities due to ED overcrowding.

In response to commenters' requests for clarification on whether the measure includes transfer patients, we clarify that transfer patients are included and assessed against all numerator criteria. To the extent that transfer patient encounters meet the threshold for each numerator component, they would be included in the measure. During measure testing, the proportion of total encounters with a final disposition of transfer was 2 percent. Therefore, we believe the inclusion of transfers will not have a significant impact on the reliability or validity of the measure.

We note that the two versions of the Emergency Care Access & Timeliness eCQM proposed for the Hospital OQR and REHQR Programs differ in numerator component (3), boarding. The Hospital OQR Program version of the measure captures inpatient boarding time, defined as the time from Decision to Admit (order) to ED departure. The REHQR Program version of the measure captures transfer boarding time in the ED because REHs do not provide inpatient services. We refer readers to section XVI.B.1 of this final rule with comment period for more information on the Emergency Care Access & Timeliness eCQM proposed for the REHQR Program.

We understand commenters' concerns that small and rural hospitals may face factors outside their control when transferring patients and note that we do not expect hospitals will achieve zero scores for all numerator components. However, collecting and publicly reporting these data is an important step towards addressing ED overcrowding

and barriers to access, which all parties involved during the measure development process agreed is critical.

Comment: Several commenters recommended refinements to the time thresholds established for the numerator components of the Emergency Care Access & Timeliness eCQM. A few commenters suggested using these timing thresholds as absolute maximum limits rather than as mean or median targets. A few commenters recommended that future performance targets should move towards shorter time periods as the quality gap closes. These commenters expressed concern about boarding times for high-risk groups, such as patients admitted to intensive care units and adults aged 65 and older. Another commenter expressed concern about the strain experienced by hospitals serving the most high-risk patients and recommended against setting targets hospitals may not be able to achieve. A few commenters stated that CMS had not provided clinical data to support the timing thresholds in the measure specifications. A few commenters noted that during peak seasonal spikes in patient volume, particularly during the winter months when influenza and COVID- 19 surges occur, it would be unrealistic for hospitals to consistently meet the timing thresholds.

Response: We note that the timing thresholds for each numerator component are maximum limits rather than mean or median targets. These timing thresholds were developed according to evidence-based clinical guidelines, including those developed by The Joint Commission, American College of Emergency Physicians, and the Emergency Department Benchmarking Alliance,310 311 as well as from input from a TEP, literature reviews, and environmental scans. We acknowledge commenters' concerns that the timing thresholds may be challenging for hospitals serving high-risk patient populations to meet. During measure development, the developer considered ways to address high-risk groups based on risk factor categories, including age, mental health diagnosis, comorbidity, complexity, race, and income.\312\ The measure's approach, involving stratification by age and mental health diagnosis and volume standardization to address case mix differences across EDs, is intended to account for differences between hospitals without requiring additional risk adjustment.

\310\ The Joint Commission. (2012). Patient Flow through the Emergency Department. Available at https://www.jointcommission.org/en-us/standards/r3-report/r3-report-4. Accessed: April 30, 2025.

\311\ American College of Emergency Physicians. (2024). Emergency Department Boarding and Crowding. Available at https://www.acep.org/administration/crowding-boarding. Accessed: April 30, 2025.

\312\ For more information about the risk factors considered by the measure developer, we refer readers to the Risk Factor Conceptual Model available at https://p4qm.org/sites/default/files/2025-10/4625e-ECAT-Risk-Factor-Conceptual-Model.pdf.

We acknowledge that ED volumes fluctuate by seasonal trends. To account for these variations, a full calendar year was selected as the measure's performance period, to allow time to capture seasonal variations in the reported outcomes and allow hospitals and health systems sufficient time to analyze data and implement quality improvement efforts. During the public comment period held during measurement development, commenters strongly agreed with this approach and appreciated its alignment with other CMS reporting periods.\313\ While we acknowledge that certain seasons could experience peak volumes, we proposed to require hospitals to report all four calendar quarters (one full calendar year) of data beginning with the CY 2028 reporting period/CY 2030 payment determination (90 FR 33766). The measure would be reported annually, not seasonally, for public reporting purposes. Furthermore, we do not expect the measure rate to be zero.

\313\ Yale New Haven Health Services Corporation. (April 2024). Public Comment Summary. Available at https://mmshub.cms.gov/sites/default/files/ECCQFinalSpreadsheetofPublicComments04152024.xlsx. Accessed: October 28, 2025.

We also note that hospitals should prepare for predictable volume increases, including ensuring sufficient staffing, as part of emergency preparedness, and note that the measure can help hospitals monitor the adequacy of their staffing plans for anticipated surges. We will consider recommendations regarding the appropriateness of the timing thresholds as part of our measure monitoring and evaluation program.

Comment: A few commenters recommended that CMS assign more weight to numerator component (3) (that is, the patient boarded in the ED for longer than 4 hours), to reflect its importance and the likelihood that it may affect other ED outcomes. A few commenters stated that applying volume standardization for numerator component (3) would be inappropriate because all hospitals must minimize boarding regardless of hospital size.

Response: We appreciate commenters' recommendation to assign more weight to numerator component (3). As previously stated, the overall score for the Emergency Care Access & Timeliness eCQM represents the proportion of ED encounters associated with patients of all ages, for all-payers, that experience at least one of the four numerator events during a 12-month period of performance: (1) the patient waited longer than 1 hour after arrival to the ED to be placed in a treatment room or dedicated treatment area that allows for audiovisual privacy during history-taking and physical examination; (2) the patient left the ED without being evaluated; (3) the patient boarded in the ED for longer than 4 hours; and (4) the patient had an ED LOS of longer than 8 hours.\314\ In addition to the overall score, the Emergency Care Access & Timeliness eCQM provides HOPDs with data for each of the individual numerator components; however, the rates for these components are not added or combined to obtain the overall score as they are not mutually exclusive. Therefore, it is not feasible to assign a heavier weight to numerator component (3) without changing the underlying meaning of the measure, or its capacity to provide information that is interpretable or actionable for HOPDs. We recognize, however, that ED boarding is an important issue and we will evaluate the burden and feasibility of the commenters' recommendation as more information on this measure becomes available.

\314\ Yale New Haven Health Services Corporation. (April 2024). Public Comment Summary. Available at https://mmshub.cms.gov/sites/default/files/ECCQFinalSpreadsheetofPublicComments04152024.xlsx. Accessed: October 28, 2025.

We also acknowledge commenters' concerns about applying volume standardization to numerator component (3). As specified, volume standardization for the Emergency Care Access & Timeliness eCQM is applied after the overall score of the four numerator components is calculated. Since the four numerator components are not mutually exclusive, applying volume standardization to each individual numerator outcome could lead to calculation challenges and undesirable statistical distortions when calculating the overall score. As discussed above, the evidence-based clinical guidelines, input from the TEP, literature reviews, and environmental scans did not provide a basis to support using a different threshold for numerator component (3) based on hospital volume or other factors, since prolonged boarding is associated with patient safety risks, regardless of hospital volume. The application of volume standardization occurs after

calculation of the overall score, which allows comparison of hospitals of similar sizes without diminishing the importance of any numerator component.

Comment: A few commenters recommended additional stratification, such as hospital designation or status, hospital-based ED vs. free- standing ED designations, payer type, race, ethnicity, primary language, or hospital teaching status. A commenter recommended replacing the denominator definition of “cases with a mental health diagnosis” with “patients awaiting a psychiatric bed” for the mental health stratification, as the need to locate a psychiatric bed is a well-documented and significant driver of prolonged ED stays.

Response: We note that many of the factors recommended are provider-level characteristics, and as such are not feasible to use as a patient characteristic for stratification. Additionally, the measure collects payer type, race, ethnicity, and sex as supplemental data elements. However, we thank the commenters for their suggestions on additional stratifications for public reporting of the measure and will consider utilizing this information in support of additional future stratifications in the future.

We appreciate the commenter's recommendation regarding the denominator definition for mental health stratification, and note that while psychiatric bed delays were considered, the measure consistently uses a diagnostic based approach when identifying patients for the mental health cohorts. For the denominator definition for the mental health strata, we note that the principal diagnosis (first listed diagnosis at ED discharge), and not the patient disposition, would be used to define strata inclusion. We note that this approach is consistent with the Median Time for Discharged ED Patients measure that we have previously reported in our quality reporting programs.\315\

\315\ Median Time from ED Arrival to ED Departure for Discharged ED Patients. Available at https://ecqi.healthit.gov/sites/default/files/ecqm/measures/CMS32v8.html.

Comment: A few commenters recommended stratification by ED volume, with a commenter suggesting stratifying ED volume as small, medium, or large, to enable meaningful comparisons across hospitals with varying patient volume and resource levels.

Response: For the Emergency Care Access & Timeliness eCQM, volume standardization is applied to the overall score. Our intention is to improve ED efficiency regardless of hospital size. During measure development, volume bands of 20,000 visits were chosen based on existing literature and actual use within the ED measurement and quality community, such as the ED Benchmarking Alliance.\316\ The measure uses volume standardization to address the case mix differences between EDs,\317\ and volume standardization offers the simplest approach, as approved by the industry, without the complexities and unintended consequence of statistical modeling. This is aligned with ACEP's measure approach in the Merit-Based Incentive Payment System (MIPS) to measuring patient flow in the ED setting.318 319 Through volume standardization we allow comparisons across hospitals of all sizes, while accounting for potential variations associated with patient volume, such that large volume EDs will be compared to large volume EDs, while medium and smaller volume EDs will likewise be compared to EDs of similar size.\320\ We appreciate commenters' recommendation regarding stratification based on ED volume and note that ED volume is a facility-level characteristic, rather than a patient-case characteristic, although we will take this into consideration as we monitor implementation of this measure and consider any potential future refinements.

\316\ American College of Emergency Physicians. Augustine, J. (2022). Data Registries in Emergency Care. Clinical Emergency Data Registry (CEDR). Available at https://www.acep.org/cedr/newsroom/spring-2022/data_registries_in_emergency_care/. Accessed: October 28, 2025.

\317\ Welch, S.J., Augustine, J.J., Dong, L., Savitz, L.A., Snow, G., James, B.C. (2012). Volume-Related Differences in Emergency Department Performance. The Joint Commission Journal on Quality and Patient Safety 38 (9): 395-402. Available at https://doi.org/10.1016/s1553-7250(12)38050-1.

\318\ Partnership for Quality Measurement. Emergency Care Access and Timeliness. Available at https://p4qm.org/measures/4625e. Accessed: October 28, 2025.

\319\ Venkatesh, A., Ravi, S., Rothenberg, C., et al. (2021). Fair Play: Application of Normalized Scoring to Emergency Department Throughput Quality Measures in a National Registry. Annals of emergency medicine, 77(5), 501-510. Available at https://doi.org/10.1016/j.annemergmed.2020.10.021. Accessed: November 12, 2025.

\320\ eCQI Resource Center. Emergency Care Access & Timeliness (HOQR). Available at https://ecqi.healthit.gov/ecqm/hosp-outpt/2027/cms1244v1. Accessed: November 13, 2025.

Comment: Several commenters expressed concern that factors outside of a hospital's control, such as shortages of beds and providers throughout the healthcare system, can negatively affect ED efficiency. These commenters encouraged CMS to incorporate robust risk adjustment to account for patient case mix and volumes and the availability of post-acute care services within a hospital's service area. A few commenters expressed concern that the Emergency Care Access & Timeliness eCQM does not distinguish between delays that are within a hospital's control and those driven by systemic capacity issues. A few commenters also recommended reporting even more detailed performance data for numerator events, such as performance metrics for the 90th percentile for the timed numerator components.

Response: Although we acknowledge that ED efficiency could be affected by multiple factors, some of which are outside the control of hospitals and health systems, measurement is essential for tracking and addressing these complex systemic issues and their downstream effects. We believe that many hospitals face such concerns and that timely care is a critical aspect of quality of care, directly impacting patient outcomes, particularly for an ED encounter. Collecting and publicly reporting these data will allow comparisons between hospitals that serve similar communities and support the development of targeted quality improvement strategies.

For the risk-adjustment, we note that the measure is not risk- adjusted because the numerator events are considered access failures regardless of patient acuity or clinical comorbidity. This approach focuses on a clear threshold that reflects operational and patient- experience standards for accessible and timely care. We recognize that bed and provider shortages or limited post-acute options can affect ED times but reiterate that the measure is meant to highlight and provide insight to general patterns in access and timeliness. Facilities may supplement this measure internally with percentile-based analyses as part of their ongoing performance improvement efforts. We maintain that the stratification of results by age and mental health diagnosis, as well as standardization of measure performance scores by ED volume, is sufficient to account for differences between hospitals without further need for risk adjustment or additional performance data detail.

Comment: A few commenters expressed concern with the potential for unintended consequences related to the current structure of the measure. The commenters expressed concern that the measure's focus on time thresholds could put undue pressure on ED staff to rush, and that emphasizing speed over quality could compromise patient care to avoid financial penalties. A commenter expressed support for the exclusions of observation stays from numerator components (3) and (4) but

sought clarity regarding cases where observation stays lead to inpatient admission. Another commenter noted that the measure could potentially lead to the inappropriate use of “observation” status to circumvent the measure's intent.

Response: We note that the Hospital OQR Program is a pay-for- reporting program, and hospitals are only penalized for not submitting data rather than for their performance on the measure. We also note that because the measure does not track patient status after leaving the emergency department, a patient that is admitted as an inpatient from observation status does not impact this measure. For the concern that some hospitals may inappropriately use observation status to circumvent the measure's intent, we note that clinicians are responsible for adhering to all standards for patient care, including using appropriate clinical decision making to determine which patients should be placed in observation status. We will consider monitoring observation status volumes to determine whether hospitals are increasing use of this status concurrent with measure adoption.

Comment: A few commenters expressed concern about the lack of evidence-based guidelines on how to improve performance on the measure. A few commenters advised CMS to work with interested parties in the hospital community to investigate effective solutions to address the underlying causes of ED boarding instead of implementing a generalized accountability measure.

Response: We refer readers to Table S1 in the supplemental attachment (section 7.1) for the measure on the Partnership for Quality Measurement website.\321\ We note that this table details interventions that can improve each of the four numerator components. We also believe that data from this measure could be used as an evidence base to refine interventions and develop additional interventions to improve ED efficiency, for which we will continue to engage with patients, providers, and other interested parties in the hospital community.

\321\ To access the supplemental attachment, select attachments under the downloads option on the https://p4qm.org/measures/4625e website and select section 7.1 in the zip file.

Comment: A few commenters stated that measure performance for hospitals caring for larger proportions of Medicare Advantage patients may be affected by delays while waiting for insurance approval for patient admissions or transfers.

Response: We acknowledge that the prior authorization process used by commercial health plans could lead to delays in care or denials in coverage. We note that the Emergency Care Access & Timeliness eCQM includes all payers, which mitigates the potential for national variations in MA coverage to influence measure performance. Additionally, in measure testing the developer examined differences in measure score by patients' payer type composition (that is, proportion of patients with Medicaid, proportion of patients with Private/Other, and proportion of patients with Medicare) and found the strength of the relationship was weak to moderate and not statistically significant across all three of these compositional characteristics.

Comment: A commenter sought CMS guidance on its plans to ensure consistency across the Medicare Shared Savings Program (MSSP) in applying the revised definitions, providing updated technical specifications and training resources, and monitoring the impact of these changes on MSSP performance scores.

Response: We note that this measure is proposed for the Hospital OQR Program and does not affect current or future requirements for the MSSP, which does not currently include any ED boarding measures.

Comment: A few commenters requested excluding this measure from Overall Hospital Star Ratings and performance-based quality reporting programs.

Response: We have only proposed the Emergency Care Access & Timeliness eCQM for adoption in the Hospital OQR Program at this time. If we determine that it is appropriate for inclusion in the Overall Hospital Star Ratings or performance-based quality reporting programs in the future, we would propose it through notice and comment rulemaking.

Comment: Many commenters requested at least 1 or 2 more years of voluntary reporting to give hospitals, especially small and rural hospitals, adequate time to address processes and systems. Specifically, commenters stated that they would need additional time to map the necessary data elements within their EHR system, evaluate the validity of the resulting data, and adjust clinical workflows. A few commenters described their experiences implementing the STEMI (OP-40) eCQM and stated that an early start to mandatory reporting created an unnecessary burden.

Response: We understand commenters' concerns regarding adequate time to update systems and processes to prepare to report the Emergency Care Access & Timeliness eCQM. However, we sought to balance this concern with the urgency of addressing the ED boarding crisis and decided to propose one year of voluntary reporting. HOPDs will have approximately 25 months from the publication of this final rule with comment period until the start of the mandatory reporting period in January 2028, and approximately 3 and a half years from the publication of this final rule until the submission deadline for the CY 2028 data in May 2029. We note this eCQM was developed with the goal of minimizing implementation burden by using data elements that are already captured in EHRs in structured fields. In addition, replacing the current Median Time for Discharged ED Patients and LWBS measures (which require manual abstraction) with the Emergency Care Access & Timeliness eCQM will alleviate burden for hospitals.

Comment: A few commenters requested an indefinite period of voluntary reporting to allow the agency to determine if the measure provides useful data for the public and for hospital quality improvement. A commenter recommended that after voluntary reporting, there should be a period of mandatory reporting that is not publicly reported.

Response: We note that this measure was developed with input from the public regarding its importance. Specifically, these four outcomes were selected based on published literature demonstrating that each numerator component is associated with patient harm,\322\ as well as input from clinical experts including ED, statistical, and methodological experts and a TEP that was convened by the measure developer.\323\ A PFE Work Group provided feedback on experiences with emergency care, noting long wait times to be seen by a provider, long wait times to be transferred, and gaps in the discharge processes. This demonstrates that the measure would provide useful data for the public and for hospital quality improvement. We strive for transparency in our quality reporting and value-based payment programs, which includes making data available to the public at the first opportunity. We would not publicly report data during

the voluntary reporting period to allow time to confirm that publicly reported data are accurate and complete but will begin to publicly report these data beginning with the first mandatory reporting period consistent with our commitment to transparency.

\322\ Partnership for Quality Measurement. Emergency Care Access and Timeliness. Available at https://p4qm.org/measures/4625e. Accessed: October 15, 2025. Accessed: November 13, 2025.

\323\ Partnership for Quality Measurement. Emergency Care Access and Timeliness. Available at https://p4qm.org/measures/4625e. Accessed: October 15, 2025. Accessed: November 13, 2025.

After consideration of the public comments we received, we are finalizing our proposal to adopt the Emergency Care Access & Timeliness eCQM into the Hospital OQR Program, beginning with voluntary reporting in the CY 2027 reporting period followed by mandatory reporting beginning with the CY 2028 reporting period impacting CY 2030 payment determination. As stated previously, because we are finalizing adoption of the Emergency Care Access & Timeliness eCQM, we will publicly report the overall measure score and rates for the four numerator components, as well as the criteria-specific results regarding the age and mental health strata once the measure becomes mandatory. 2. Removals of the Median Time From 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

In the CY 2026 OPPS/ASC proposed rule (90 FR 33761), we proposed that the Emergency Care Access & Timeliness eCQM would serve as a replacement for two existing chart-abstracted measures in the Hospital OQR Program.

The Median Time for Discharged ED Patients measure (75 FR 72086) and the Left Without Being Seen measure (75 FR 72088 through 72089) were adopted in the CY 2011 OPPS/ASC final rule with comment period to promote transparency, improve patient care and access to EDs, and reduce avoidable delays in the emergency care setting. 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). Both measures are chart-abstracted, requiring human review and manual intervention to extract data elements from clinical documentation.

In the CY 2024 OPPS/ASC final rule with comment period (88 FR 81961), we did not finalize our proposal to remove the Left Without Being Seen measure due in part to public comments emphasizing the importance of the measure in addressing ED overcrowding and boarding. We stated our intention to identify a more granular measure that could replace the Left Without Being Seen measure, which can now be achieved through the adoption of the Emergency Care Access & Timeliness eCQM. We note that Hospital OQR Program measure specifications can be found at https://qualitynet.cms.gov/outpatient.

As stated in section XV.B.1. of this final rule with comment period, the Emergency Care Access & Timeliness eCQM 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. The numerator components of the Emergency Care Access & Timeliness eCQM overlap with data elements of the Median Time for Discharged ED Patients and the Left Without Being Seen measures. The numerator of the Emergency Care Access & Timeliness eCQM is comprised of any ED visit in the denominator where the patient experiences any one of the following: (1) waited longer than 1 hour to be placed in a treatment room or a dedicated treatment area that allows for audiovisual privacy history-taking and physical examination; (2) left the ED without being evaluated by a physician/advanced practice nurse/physician's assistant; (3) boarded (defined as time from a Decision to Admit (order) to ED departure for admitted patients) for longer than 4 hours; or (4) had an ED LOS (time from ED arrival to ED physical departure as defined by the ED departure timestamp) of longer than 8 hours. 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. The Emergency Care Access & Timeliness eCQM also incorporates additional metrics to enhance its comprehensiveness and analytic value, including 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.\324\

\324\ Partnership for Quality Measurement. Emergency Care Capacity and Quality. Available at https://p4qm.org/measures/4625e. Accessed: April 30, 2025.

The Emergency Care Access & Timeliness eCQM therefore provides an alternative approach to quality measurement used to address ED boarding and barriers to emergency care by capturing multiple components of quality and capacity. In addition, the Emergency Care Access & Timeliness eCQM allows for retrieval of patient-level data directly from the EHR. As a result, the Emergency Care Access & Timeliness eCQM, along with our previously adopted eCQMs, advances the Hospital OQR Program toward the use of EHR data for quality measurement, leading to more accurate quality data as well as reduced burden for providers. The adoption of the Emergency Care Access & Timeliness eCQM would allow us to employ a more precise assessment of the timeliness and appropriateness of ED visits and to provide additional information important to patients and hospitals on ED boarding and ED LOS.

Our measure removal policy, codified at 42 CFR 419.46(i)(3), identifies eight factors CMS considers in the removal of quality measures. Removal Factor 4, described at Sec. 419.46(i)(3)(i)(D), is the availability of a more broadly applicable (across settings, populations, or conditions) measure for the topic. Compared to the Median Time for Discharged ED Patients measure and the Left Without Being Seen measure, the Emergency Care Access & Timeliness eCQM is a more broadly applicable measure for the topic. We therefore proposed that, if the Emergency Care Access & Timeliness eCQM is adopted in the Hospital OQR Program, we would remove the Median Time for Discharged ED Patients measure and the Left Without Being Seen measure under removal Factor 4. We proposed that these measure removals would begin with the CY 2028 reporting period/CY 2030 payment determination, when reporting for the Emergency Care Access & Timeliness eCQM becomes mandatory.

We invited public comments on these proposals.

Comment: Many commenters supported the removal of the Median Time for Discharged ED Patients and LWBS measures. Several commenters supported the removal of these measures upon the adoption of the Emergency Care Access & Timeliness eCQM, noting that the eCQM offers a more standardized and improved approach to assessing ED throughput. A commenter supported the removal of the Median Time for Discharged ED Patients and LWBS measures citing that adoption of the Emergency Care Access & Timeliness eCQM would better align with existing technology investments and quality improvement strategy.

Response: We thank the commenters for their support.

Comment: Several commenters supported the replacement of the Median Time for Discharged ED Patients and LWBS measures with the Emergency Care Access & Timeliness eCQM because electronic data sources reduce administrative burden and enhance real time data availability. A few commenters also supported the removal of the Median Time for Discharged ED Patients and LWBS measures to avoid duplicative reporting requirements.

Response: We thank commenters for their support and agree that the removal of the Median Time for Discharged ED Patients and LWBS measures will reduce administrative burden and prevent duplicative reporting.

Comment: A few comments supported the removal of Median Time for Discharged ED Patients and LWBS measures because the measures are no longer endorsed by the CBE. A few commenters supported the removal of the measures because they lack sufficient evidence demonstrating a link to improved patient outcomes. A commenter stated that the measures should be removed even if the Emergency Care Access & Timeliness eCQM is not adopted into the Hospital OQR Program due to concerns regarding the measures' lack of CBE endorsement and poor evidence-base.

Response: We thank the commenters for their support. We note that the Median Time for Discharged ED Patients and LWBS measures went through the measure development lifecycle outlined at the CMS Measures Management System website, which includes measure testing and reliability analysis. Further, section 1833(t)(17) of the Act does not require each measure adopted for the Hospital OQR Program to be CBE- endorsed. Section 1833(t)(17)(C)(i) of the Act provides that the Hospital OQR Program shall, to the extent feasible and practicable, include measures set forth by one or more national consensus building entities. Section 1833(t)(17)(C)(i) of the Act also requires measures developed for the Hospital OQR Program to reflect consensus among affected parties, which may be reflected in ways other than CBE endorsement. We note that the adoption of the Emergency Care Access & Timeliness eCQM is being finalized to replace the existing ED quality measures in the Hospital OQR Program in section XIV.B.1. of this final rule with comment period. This eCQM was submitted to the CBE for endorsement in the Fall 2024 cycle (CBE #4625e) and the CBE endorsed the measure with conditions on February 12, 2025. For more information on CBE endorsement, please refer to section XIV.B.1.e. of this final rule with comment period.

For evidence of impact on patient outcomes, we agree with commenters that it is critical to ensure that quality measures are supported by sufficient evidence. While the Median Time for Discharged ED Patients and LWBS measures have provided useful information on ED throughput, the Emergency Care Access & Timeliness eCQM offers a more robust connection to patient access and safety, as well as to outcome improvement. Therefore, we are finalizing our proposal to adopt the Emergency Care Access & Timeliness eCQM.

Comment: A commenter supported the removal of the Median Time for Discharged ED Patients measure and recommended removing the measure before the CY 2028 reporting period/CY 2030 payment determination.

Response: We acknowledge the commenter's recommendation for earlier removal of the measure but note that the proposed adoption of the Emergency Care Access & Timeliness eCQM begins with voluntary reporting for the CY 2027 reporting period, followed by mandatory reporting beginning with the CY 2028 reporting period/CY 2030 payment determination. Given the importance of ED throughput and its direct impact on patient care, it is essential to maintain mandatory measures within the Hospital OQR Program to ensure continued and reliable assessment of ED performance. This current timeline ensures that there will not be a gap in quality measurement for ED throughput, as there will be a year of overlap between the existing ED throughput measures and the voluntary reporting period for the new eCQM.

Comment: A commenter did not support the removal of the LWBS measure stating that the measure is an indication of ED workload and crowding.

Response: The Emergency Care Access & Timeliness eCQM overlaps with the LWBS measure collecting data on ED workload and crowding for the Hospital OQR Program. We refer readers to section XIV.B.1.b. of this final rule with comment period for additional information on the Emergency Care Access & Timeliness eCQM measure specifications.

After consideration of the comments received, we are finalizing our proposals to remove the Median Time for Discharged ED Patients and LWBS measures from the Hospital OQR Program beginning with the CY 2028 reporting period/CY 2030 payment determination. 3. 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 Beginning With the CY 2027 Reporting Period/CY 2029 Payment Determination To Continue Voluntary Reporting in the CY 2027 Reporting Period and Subsequent Years

In the CY 2024 OPPS/ASC final rule with comment period, we finalized the adoption of the Excessive Radiation eCQM in the Hospital OQR Program measure set, with voluntary reporting beginning in the CY 2025 reporting period followed by mandatory reporting beginning with the CY 2027 reporting period/CY 2029 payment determination, one year later than originally proposed (88 FR 81992). We explained our delay in implementing mandatory reporting of the Excessive Radiation eCQM was in response to commenters' concerns regarding the burden associated with implementing the eCQM.

In the CY 2026 OPPS/ASC proposed rule, we proposed to modify the reporting requirements for the Excessive Radiation eCQM in the Hospital OQR Program by maintaining voluntary reporting instead of transitioning to mandatory reporting of the measure, beginning with the CY 2027 reporting period (90 FR 33762). Our proposal to maintain indefinite voluntary reporting of this measure arose from continued feedback expressing concerns about the complex interfaces necessary to develop, maintain, and report the Excessive Radiation eCQM, including the financial burden and operational feasibility needed to translate CT radiology data into standardized eCQM-consumable data used by the measure. In January 2025, we issued a notice to clarify that hospitals and clinicians who choose to report this eCQM can use any vendor's translation software to calculate this measure,\325\ consistent with the measure's specifications, and stated our intent to monitor measure results to ensure that all reported data for the Excessive Radiation eCQM are both reliable and valid.\326\

\325\ eCQI Resource Center. Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography in Adults eCQM--Measure Clarification. Available at https://ecqi.healthit.gov/excessive-radiation-dose-or-inadequate-image-quality-diagnostic-computed-tomography-adults-ecqm-measure-clarification. Accessed June 5, 2025.

\326\ In that notice, we also clarified that while CMS is not requiring vendors to demonstrate their software's capabilities to CMS, hospitals and clinicians that choose to do so may request information from a vendor about a specific software's ability to generate and transform the radiology data into the necessary format.

We stated that the modification from mandatory to voluntary reporting of the Excessive Radiation eCQM, beginning with the CY 2027 reporting period, would allow HOPDs additional time to integrate, adequately test, and gain experience with implementing the eCQM. This modification would also provide CMS with additional time to monitor implementation progress, including data collection burden and response rates. We stated that we will continue to consider feedback regarding this measure and may propose additional changes in future rulemaking.

We invited public comments on this proposal.

Comment: Many commenters supported the proposed change to maintain voluntary reporting for the Excessive Radiation eCQM. These commenters expressed concern that calculating and reporting the measure creates significant administrative and financial burden and diverts limited resources from patient care without providing commensurate value or improving patient safety. Commenters noted the measure's complexity and reporting requirements create a regulatory burden for which hospitals must divert resources in order to come into compliance. Many commenters noted that the expenses associated with implementing the measure, such as labor and interface costs, impose resource constraints on hospitals that make it difficult to collect and leverage data gained from the measure. Additionally, commenters noted that these expenses are not negated by the software available for free from the measure steward, as the measure requires working with a third-party vendor. Many of these commenters stated that maintaining voluntary reporting appropriately acknowledges the ongoing concerns around provider burden while still allowing hospitals to report data as they are able and avoiding punitive consequences for non-compliance.

Commenters also cited the technical and operational challenges of implementing the Excessive Radiation eCQM as a rationale for supporting voluntary reporting. Several commenters noted the limited health IT infrastructure available to report the measure, particularly for smaller and rural hospitals, which presents significant barriers to implementation. Many commenters noted the measure requires complex integrations across multiple hospital information systems, including Picture Archiving and Communication Systems (PACS), Radiology Information Systems (RIS), CT consoles, and EHRs, and that much of the necessary data reside in imaging software rather than outpatient EMR systems. Several of these commenters stated that extended voluntary reporting is warranted to allow hospitals time to develop the new processes and data extraction methods needed to capture and report this information effectively. Many commenters appreciated the fact that maintaining voluntary reporting allows hospitals time to improve imaging practices. A commenter urged CMS to work closely with hospitals that voluntarily report the measure to determine if the measure is feasible for broader implementation across CMS quality reporting programs. A commenter recommended that CMS align the reporting requirements for the measure across the Hospital OQR and Inpatient Quality Reporting (IQR) Programs to ensure consistency.

Response: We thank the commenters for their support. While we continue to believe in the validity and importance of this measure, and the clinical significance of measuring radiation safety, we acknowledge the current challenges that HOPDs face with respect to the measure's implementation that could necessitate a longer implementation timeframe. We thank the commenter for their recommendation to align reporting requirements across the Hospital OQR and Hospital Inpatient Quality Reporting (IQR) Programs. We will continue to monitor progress during the voluntary reporting period for the Hospital OQR Program, as well as the Hospital IQR Program, where this measure is included on the list of eCQMs from which hospitals may self-select measures to report. We will also continue to engage with hospitals, professional organizations, and health IT interested parties to assess feasibility, interoperability, and opportunities to refine the measure and related implementation pathways. Any further changes to the reporting requirements for this measure would be made in notice and comment rulemaking so that interested parties can prepare. We encourage hospitals to use the voluntary reporting period to improve imaging practices and develop the new processes and data extraction methods needed to capture and report data for this measure effectively, in preparation for future implementation.

Comment: Many commenters expressed concern that the measure relies on a proprietary software platform developed by a single for-profit vendor that also serves as the measure steward. Many commenters stated that this structure creates a potential conflict of interest and could limit transparency, competition, and public trust. Several commenters questioned the vendor's limited experience and technical capacity to oversee the measure, noting issues such as slow responsiveness, nonstandard contracting terms, and inadequate solutions to safeguard patient data. Several commenters raised concerns regarding lack of transparency in the underlying specifications and algorithms, and reliance on non-standardized metrics. Several commenters noted concerns regarding potential privacy and cybersecurity risks associated with transmitting PHI to third-party systems. A commenter highlighted that many current CT systems do not export data in a format that the software can reliably interpret, further complicating implementation.

Due to these concerns, many commenters urged CMS to ensure that any future mandatory implementation of this measure be supported by independent validation, peer-reviewed evidence, and the availability of multiple, vendor-neutral pathways for reporting and compliance. A commenter recommended that CMS explore alternative reporting mechanisms beyond the current single software platform and prioritize development of additional imaging quality measures, including those that recognize the use of emerging technologies such as artificial intelligence, to address existing gaps in diagnostic imaging quality and patient safety. A commenter also recommended that CMS work with the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health Information Technology (ASTP) to address the underlying challenges of this measure to ensure that imaging data can be shared more effectively and broadly.

Response: We acknowledge that the Alara Imaging software for CMS Measure Compliance is proprietary. Regarding commenters' concerns about a conflict of interest, we note that the measure steward makes this software available without charge. In addition, the measure steward has successfully deployed its software across a diverse range of several hundred clinical settings with varied EHR, Picture Archiving and Communication System (PACS), Radiology Information System (RIS), dose monitoring, image quality, and CMS measure submission systems. Furthermore, hospitals are not required to use the Alara Imaging software for

CMS Measure Compliance. They may choose to use any software(s) that performs the necessary functions to generate the same standardized data elements necessary to calculate the measure consistent with the measure's specifications.

Pilot testing conducted by the measure steward was reviewed by an independent TEP, which found that the pilot met the CBE standards for reliability and validity testing. For more information on the Excessive Radiation eCQM pilot, we refer readers to the measure submission materials on the Partnership for Quality Measurement website at https://p4qm.org/measures/3663e and the eCQI Resource Center at https://ecqi.healthit.gov/ecqm/eh/pre-rulemaking/2024/cms1074v1.

Comment: Many commenters expressed concern that the two core metrics of the Excessive Radiation eCQM, “Calculated CT Global Noise” and “Calculated CT Size-Adjusted Dose” lack technical validity, clinical relevance, and implementation feasibility. Many commenters stated that the measure specifications have not been vetted or endorsed by the medical and scientific community, including interested parties such as the American Association of Physicists in Medicine (AAPM), the American College of Radiology (ACR), or the International Electrotechnical Commission (IEC). These commenters noted that the calculation methods for both metrics are not transparent or published, limiting peer review, reproducibility, and validation. Many commenters stated that forcing fixed cutoffs, such as the defined thresholds in the Excessive Radiation eCQM's numerator components, can compromise diagnostic accuracy by pushing CT exams toward too little or too much radiation, resulting in missed findings and unnecessary radiation exposure, respectively. These commenters also stated that the “Calculated CT Global Noise” does not reliably reflect diagnostic image quality and that the “Calculated CT Size-Adjusted Dose” is an imprecise measure of patient safety because it fails to account for factors such as clinical indication, protocol, patient size, scanner technology, and reconstruction methods.

Many commenters stated that maintaining voluntary reporting would give professional organizations and the CT imaging community time to identify metrics that better monitor diagnostic quality and patient outcomes. For example, many commenters recommended adopting the Size Specific Dose Estimate, (SSDE) as a validated alternative that is already implemented in commercial dose-monitoring systems and according to commenters, should be used instead of the “Calculated CT Size- Adjusted Dose”. Many commenters also recommended that CMS assess independent studies and peer-reviewed evidence of the eCQM's two core metrics before making the measure mandatory.

Response: We remain committed to the Excessive Radiation eCQM as a patient safety issue and affirm, as we did in the CY 2024 OPPS/ASC final rule (88 FR 81987), that the measure's data elements are scientifically and practically valid. The measure's framework was published in peer reviewed medical literature, and the measure's thresholds for noise and radiation dose were developed with close input from a diverse TEP, including radiologists and medical physicists.\327\ The image noise thresholds were designed to maintain the diagnostic value of CT scans and empirically derived by radiologists evaluating image quality across a wide variety of studies and practice settings in experiments whose results were reviewed and approved during the measure review process.\328\ Further, the measure is based on evidence and consensus-based clinical guidelines for optimizing CT radiation doses, from organizations such as the ACR,\329\ Society of Interventional Radiology,\330\ Society of Cardiovascular CT,\331\ cardiovascular imaging societies,\332\ Image Wisely 2020,\333\ and the FDA.\334\ In addition, measure testing across 16 inpatient and outpatient hospitals confirmed high availability, accuracy, validity, and reproducibility for all of its required data elements and the variables calculated by the translation software. Multiple bodies under the National Quality Forum (NQF) umbrella, including a Scientific Methods panel, gave the measure high scores for accuracy, validity, and reproducibility which led to a unanimous approval from the NQF.\335\

\327\ Smith-Bindman R, Yu S, Wang Y, et al. (2022). An Image Quality-informed Framework for CT Characterization. Radiology, 302(2), 380-389. Available at https://doi.org/10.1148/radiol.2021210591. Accessed: November 13, 2025.

\328\ Smith-Bindman R, Yu S, Wang Y, et al. (2022). An Image Quality-informed Framework for CT Characterization. Radiology, 302(2), 380-389. Available at https://doi.org/10.1148/radiol.2021210591. Accessed: November 13, 2025.

\329\ American College of Radiology (2015). Development and Revision Handbook. Available at https://www.acr.org/-/media/ACR/Files/Practice-Parameters/DevelopmentHandbook.pdf. Accessed: November 13, 2025.

\330\ Stecker MS, Balter S, Towbin RB, et al. (2009). Guidelines for Patient Radiation Dose Management. Journal of Vascular and Interventional Radiology. 20(7): S263-S273. Available at https://doi.org/10.1016/j.jvir.2009.04.037. Accessed: November 13, 2025.

\331\ Halliburton SS, Abbara S, Chen MY, et al. (2011). Society of Cardiovascular Computed Tomography. SCCT guidelines on radiation dose and dose-optimization strategies in cardiovascular CT. J Cardiovasc Comput Tomogr. 5(4): 198-224. Available at https://doi.org/10.1016/j.jcct.2011.06.001. Accessed: November 13, 2025.

\332\ Hirshfeld JW, Ferrari VA, Bengel FM, et al. (2018). 2018 ACC/HRS/NASCI/SCAI/SCCT Expert Consensus Document on Optimal Use of Ionizing Radiation in Cardiovascular Imaging: Best Practices for Safety and Effectiveness. Catheter Cardiovasc Interv. 92: E35-E97. Available at https://doi.org/10.1002/ccd.27659. Accessed: November 13, 2025.

\333\ Image Wisely 2020. Available at https://www.imagewisely.org/. Accessed: November 13, 2025.

\334\ FDA (2019). Computed Tomography (CT). Available at https://www.fda.gov/radiation-emitting-products/medical-x-ray-imaging/computed-tomography-ct#6. Accessed: November 13, 2025.

\335\ We note that at the time of the measure's endorsement, NQF served as the CBE responsible for measure endorsement activities. The CBE role has since transitioned to Battelle, which now administers the PQM and oversees both the pre-rulemaking and measure endorsement processes.

The Excessive Radiation eCQM aims to ensure CT radiation dose and image quality fall within safe and appropriate thresholds. The measure does not set minimal radiation dose requirements for any CT scan that could inadvertently result in higher doses than are currently used. The radiation dose thresholds are size-adjusted and based on underlying clinical indication, allowing for individualized patient care and clinician discretion for imaging protocol. We note that these dose thresholds are intended as general reference ranges to promote consistent optimization of radiation dose and image quality, not as prescriptive limits that override clinical judgment. We would like to further emphasize that hospitals should use the measure as a CT scan guideline while also adjusting noise and radiation doses when needed to ensure quality care.

The purpose of size adjustment in the Excessive Radiation eCQM is to account for the variation in patient size so that reporting entities are not penalized if they see a different mix of patients. To ensure case mix across reporting entities does not drive outlier values, SSDE is not used for adjustment for several reasons. First, SSDE reflects the average dose per slice rather than the total dose a patient receives during a complete scan, and because multiphase scanning is common, SSDE values may appear reasonable even when total exposure is high. The DLP reflects the total dose to the patient and thus more accurately reflects the radiation used and thus the risk for the study. In addition, SSDE is not consistently reported across CT

manufacturers and would require hospitals to upgrade existing CT machines. Lastly using SSDE for size adjustment would not account for the differences in patient case mix across hospitals. Because radiologists frequently use higher doses of radiation per unit of tissue in larger patients, practices who assess larger patients would be unfairly penalized.

Comment: Many commenters did not support the proposed change to maintain voluntary reporting for the Excessive Radiation eCQM, noting that while CT scans provide essential, life-saving diagnostic benefits, they are frequently performed using radiation doses that are higher than necessary for accurate diagnosis. These commenters, which included both patients and healthcare providers, expressed concern that factors increasing personal cancer risk, such as excessive ionizing radiation, are not being adequately addressed. Many commenters also expressed concerns regarding the lack of standardization and oversight in CT imaging, which according to the commenters results in radiation doses that are highly variable, often unoptimized, and frequently higher than needed for diagnostic purposes, thereby undermining national efforts to minimize unnecessary exposure. Many commenters stated that voluntary reporting is insufficient to protect patients from unnecessary radiation exposure and does not adequately hold hospitals accountable for using standardized, evidence-based radiation doses.

Response: We thank the commenters for their input and note that we remain committed to the Excessive Radiation eCQM as a patient safety issue for cancer prevention. We continue to believe, as we did when this measure was adopted in the Hospital OQR Program measure set, there is evidence that excessive radiation leads to harm,\336\ and evidence that radiation doses could be lowered in many patients' situations without deteriorating image diagnostic utility.337 338 339 340 341 A recent study in the New England Journal of Medicine suggested an association between exposure to radiation from medical imaging and a small but significantly increased risk of hematologic cancer.\342\ We also agree with commenters about the importance of promoting patient safety by ensuring that patients are exposed to the lowest possible level of radiation while preserving image quality. Reducing unnecessary radiation exposure that leads to increased cancer incidence is also an example of primary prevention, or preventing illness before it occurs, a key priority of this administration. We believe that maintaining voluntary reporting supports patient safety goals by allowing the continued monitoring of hospital performance and progress on dose optimization, while providing hospitals with the opportunity to strengthen their technical capacity, refine dose optimization practices, and enhance data quality and consistency before the measure becomes mandatory. Retaining the measure in the program as voluntary ensures that it remains active and that hospitals may opt to report data during this period. This phased approach helps ensure that hospitals are better prepared to achieve sustainable and meaningful dose reductions, thereby advancing patient safety objectives over time.

\336\ Smith-Bindman, R., Chu, P. W., Azman Firdaus, H., Stewart, C., Malekhedayat, M., Alber, S., Bolch, W. E., Mahendra, M., Berrington de Gonz[aacute]lez, A., & Miglioretti, D. L. (2025b). Projected Lifetime Cancer Risks From Current Computed Tomography Imaging. JAMA Internal Medicine, 185(6). Available at https://doi.org/10.1001/jamainternmed.2025.0505. Accessed: November 13, 2025.

\337\ Greffier J, Hamard A, Pereira F, et al. (2020). Image quality and dose reduction opportunity of deep learning image reconstruction algorithm for CT: a phantom study. Eur Radiol, 30(7), 3951-3959. Available at https://doi.org/10.1007/s00330-020-06724-w. Accessed: November 13, 2025.

\338\ Gottumukkala RV, Kalra MK, Tabari A, Otrakji A, Gee MS (2019). Advanced CT Techniques for Decreasing Radiation Dose, Reducing Sedation Requirements, and Optimizing Image Quality in Children. Radiographics, 39(3), 709-726. Available at https://doi.org/10.1148/rg.2019180082. Accessed: November 13, 2025.

\339\ Den Harder AM, Willemink MJ, van Doormaal PJ, et al. (2018). Radiation dose reduction for CT assessment of urolithiasis using iterative reconstruction: A prospective intra-individual study. Eur Radiol, 28(1), 143-150. Available at https://doi.org/10.1007/s00330-017-4929-2. Accessed: November 13, 2025.

\340\ Rob S, Bryant T, Wilson I, Somani BK (2017). Ultra-low- dose, low-dose, and standard-dose CT of the kidney, ureters, and bladder: is there a difference? Results from a systematic review of the literature. Clin Radiol, 72(1), 11-15. Available at https://doi.org/10.1016/j.crad.2016.10.005. Accessed: November 13, 2025.

\341\ Konda SR, Goch AM, Leucht P, et al. (2016). The use of ultra-low-dose CT scans for the evaluation of limb fractures: is the reduced effective dose using CT in orthopaedic injury (REDUCTION) protocol effective? Bone Joint J, 98-B(12), 1668-1673. Available at https://doi.org/10.1302/0301-620X.98B12.BJJ-2016-0336.R1. Accessed: November 13, 2025.

\342\ Smith-Bindman, R., Alber, S. A., Kwan, M. L., Pequeno, P., Bolch, W. E., Bowles, E. J. A., Greenlee, R. T., Stout, N. K., Weinmann, S., Moy, L. M., Stewart, C., Francisco, M., Kofler, C., Duncan, J. R., Ducore, J., Mahendra, M., Pole, J. D., & Miglioretti, D. L. (2025). Medical Imaging and Pediatric and Adolescent Hematologic Cancer Risk. New England Journal of Medicine. Available at https://doi.org/10.1056/nejmoa2502098. Accessed: November 13, 2025.

Comment: A commenter expressed concern that maintaining voluntary reporting would be unfair to hospitals already investing in compliance and would signal a lack of confidence in the measure.

Response: We acknowledge that some hospitals may have already invested in compliance and reiterate that we remain committed to the Excessive Radiation eCQM as a patient safety issue for cancer prevention. Although we proposed extending voluntary reporting of the measure in response to feedback regarding implementation challenges, we also stated our intent to propose any additional changes to this measure in future rulemaking. As such, we intend to return to rulemaking to propose a date to begin mandatory reporting in the future, and we encourage hospitals to use the voluntary reporting period to improve imaging practices and develop the new processes and data extraction methods needed to capture and report data for this measure in preparation for future implementation.

Comment: Several commenters did not support maintaining voluntary reporting for the Excessive Radiation eCQM as they believe the measure is ready for broader adoption across CMS quality reporting programs. A few commenters highlighted their successful implementation of the measure and noted the measure's technical feasibility. A few commenters emphasized that the measure is scientifically sound and supported by peer-reviewed evidence. These commenters maintained that the measure specifications are validated and appropriate for identifying outliers in CT practice, and that the methodology accounts for variations in imaging protocols and technologies, demonstrating its robustness and readiness for broader implementation.

Response: We thank commenters for their feedback regarding the feasibility of the measure and confidence in its evidence-based specifications. We agree that the measure's data elements are scientifically and practically valid, and that the measure could be ready for broader adoption across CMS quality reporting programs. While we believe the measure is technically feasible for some hospitals, the variation in resource levels among hospitals with different characteristics, such as small and rural facilities, combined with feedback we have received regarding the implementation challenges faced by some HOPDs, indicates that more time is needed before reporting for the measure becomes mandatory. As previously stated, any future transition from voluntary to mandatory reporting

would be proposed through notice and comment rulemaking, and we encourage hospitals to use the voluntary reporting period to prepare adequately for future implementation.

While we continue to believe in the validity and importance of this measure in reducing excessive CT radiation dosage as a personal risk factor in developing cancer, we have also received ongoing feedback from interested parties reflecting current significant burden on HOPDs due to implementation challenges, including software integration into facility EHR or EMR systems and the additional processes required to aggregate data components. By keeping reporting voluntary, hospitals will have additional time to integrate and test the measure in their EHR systems effectively. Simultaneously, we can monitor how well hospitals are able to implement the measure over time before reconsidering mandatory reporting requirements in the future. As previously stated, any future transition from voluntary to mandatory reporting would be proposed through notice and comment rulemaking.

After consideration of the comments received, we are finalizing our proposal 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 beginning with the CY 2027 reporting period/CY 2029 payment determination to continue voluntary reporting beginning with the CY 2027 reporting period. We encourage hospitals to use the voluntary reporting period to prepare for future implementation by addressing the remaining technical, operational, and data submission challenges needed to support consistent adoption of the measure. We intend to propose a date to begin mandatory reporting at the next feasible opportunity, which we expect to be the CY 2027 OPPS/ASC proposed rule. 4. Summary of Previously Finalized and Newly Finalized Hospital OQR Program Measure Set for CY 2026 to CY 2031 Payment Determinations

Table 138 summarizes the previously finalized and newly finalized Hospital OQR Program measure set for the CY 2026 to CY 2031 payment determinations, which removes the HCHE, Screening for SDOH, Screen Positive Rate for SDOH, and COVID-19 Vaccination Coverage Among HCP measures as discussed in section XIV.C. of this final rule with comment period; modifies reporting requirements for the Excessive Radiation eCQM from mandatory to voluntary reporting beginning with the CY 2027 reporting period, as discussed in section XV.B.3. of this final rule with comment period; removes the Left Without Being Seen and the Median Time for Discharged ED Patients measures as discussed in section XV.B.2. of this final rule with comment period; and adds the Emergency Care Access & Timeliness eCQM as discussed in section XV.B.1. of this final rule with comment period. BILLING CODE 4120-01-P

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We refer readers to the QualityNet website at https://qualitynet.cms.gov/outpatient for additional information on the reporting periods and submission deadlines for each measure previously finalized in the Hospital OQR Program. 5. Hospital OQR Program Measures and Topics for Future Consideration

We refer readers to section XIV.B. of this final rule with comment period for

our cross-program Request for Information on measure concepts regarding well-being and nutrition for the Hospital OQR Program.

We refer readers to Sec. 419.46(j) and the CY 2025 OPPS/ASC final rule with comment period (89 FR 94418 through 94420) for a discussion of our previously finalized eCQM requirements. 2. Data Submission and Reporting Requirements for the Emergency Care Access & Timeliness eCQM

In section XV.B.1. of this final rule with comment period, we finalized the 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. In the CY 2026 OPPS/ASC proposed rule (90 FR 33766), for the CY 2027 reporting period, we proposed that hospitals that voluntarily submit Emergency Care Access & Timeliness eCQM data could submit data for any quarter(s) (that is, up to all four quarters of data).

We also proposed that beginning with the CY 2028 reporting period/ CY 2030 payment determination, hospitals would be required to report all four calendar quarters (1 calendar year) of data for the Emergency Care Access & Timeliness eCQM. We also proposed to require Emergency Care Access & Timeliness eCQM data submission by May 15 in the year prior to the affected payment determination year, in alignment with our policies on eCQM submission deadlines, as finalized in the CY 2022 OPPS/ASC final rule with comment period (86 FR 63867 through 63870). For example, for the CY 2028 reporting period/CY 2030 payment determination, hospitals would be required to submit eCQM data by May 15, 2029. All deadlines occurring on a Saturday, Sunday, or legal holiday, or on any other day declared at least in part to be a non- workday for Federal employees by statute or Executive Order, would be extended to the first business day thereafter. All current CMS policies regarding eCQM data submission requirements--including file format, zero denominator declarations, case thresholds, submission deadlines, and EHR certification requirements outlined at Sec. 419.46(j) and finalized in the CY 2022 or CY 2025 OPPS/ASC final rules (86 FR 63867 through 63870 and 89 FR 94418 through 94420, respectively) would apply to the Emergency Care Access & Timeliness eCQM for both the voluntary and mandatory data submission periods.

We invited public comments on this proposal.

We did not receive public comments on these proposals, and therefore, we are finalizing the data submission and reporting requirements for the Emergency Care Access & Timeliness eCQM as proposed.

Section 1833(t)(17) of the Act, which applies to subsection (d) hospitals (as defined under section 1886(d)(1)(B) of the Act), states that hospitals that fail to report data required to be submitted on measures selected by the Secretary, in the form and manner, and at a time, specified by the Secretary will incur a 2.0-percentage point reduction to their OPD fee schedule increase factor; that is, the annual payment update factor. Section 1833(t)(17)(A)(ii) of the Act specifies that any reduction applies only to the payment year involved and will not be taken into account in computing the applicable OPD fee schedule increase factor for a subsequent year.

The application of a reduced OPD fee schedule increase factor results in reduced national unadjusted payment rates that apply to certain outpatient items and services provided by hospitals that are required to report outpatient quality data in order to receive the full payment update factor and that fail to meet the Hospital OQR Program requirements. Hospitals that meet the reporting requirements receive the full OPPS payment update without the reduction. For a more detailed discussion of how this payment reduction was initially implemented, we refer readers to the CY 2009 OPPS/ASC final rule with comment period (73 FR 68769 through 68772).

The national unadjusted payment rates for many services paid under the OPPS equal the product of the OPPS conversion factor and the scaled relative payment weight for the APC to which the service is assigned. The OPPS conversion factor, which is updated annually by the OPD fee schedule increase factor, is used to calculate the OPPS payment rate for services with the following status indicators (listed in Addendum B to this final rule with comment period, which is available via the internet on the CMS website): “J1”, “J2”, “P”, “Q1”, “Q2”, “Q3”, “R”, “S”, “T”, “V”, or “U”. Payment for all services assigned to these status indicators will be subject to the reduction of the national unadjusted payment rates for hospitals that fail to meet Hospital OQR Program requirements, with the exception of services assigned to New Technology APCs with assigned status indicator “S” or “T”. We refer readers to the CY 2009 OPPS/ASC final rule with comment period (73 FR 68770 through 68771) for a discussion of this policy. In the CY 2017 OPPS/ASC final rule with comment period (81 FR 79796), we clarified that the reporting ratio does not apply to codes with status indicator “Q4” because services and procedures coded with status indicator “Q4” are either packaged or paid through the Clinical Laboratory Fee Schedule and are never paid separately through the OPPS.

The OPD fee schedule increase factor is an input into the OPPS conversion factor, which is used to calculate OPPS payment rates. To reduce the OPD fee schedule increase factor for hospitals that fail to meet reporting requirements, we calculate two conversion factors--a full market basket conversion factor (that is, the full conversion factor), and a reduced market basket conversion factor (that is, the reduced conversion factor). We then calculate a reduction ratio by dividing the reduced conversion factor by the full conversion factor. We refer to this reduction ratio as the “reporting ratio” to indicate that it applies to payment for hospitals that fail to meet their reporting requirements. Applying this reporting ratio to the OPPS payment amounts results in reduced national unadjusted payment rates that are mathematically equivalent to the reduced national unadjusted payment rates that would result if we multiplied the scaled OPPS relative payment weights by the reduced conversion factor. For example, to determine the reduced national unadjusted payment rates that applied to hospitals that failed to meet their quality reporting requirements for the CY 2010 OPPS/ASC final rule with comment period, we multiplied the final full national unadjusted payment rate found in Addendum B of the CY 2010 OPPS/ASC final rule with comment period by the CY 2010 OPPS final rule with comment period reporting ratio of 0.980 (74 FR 60642).

We note that the only difference in the calculation for the full conversion factor and the calculation for the reduced conversion factor is that the full

conversion factor uses the full OPD update, and the reduced conversion factor uses the reduced OPD update. The baseline OPPS conversion factor calculation is the same since all other adjustments would be applied to both conversion factor calculations. Therefore, our standard approach of calculating the reporting ratio as described earlier in this section is equivalent to dividing the reduced OPD update factor by that of the full OPD update factor. In other words:

Full Conversion Factor = Baseline OPPS conversion factor * (1 + OPD update factor) Reduced Conversion Factor = Baseline OPPS conversion factor * (1 + OPD update factor - 0.02) Reporting Ratio = Reduced Conversion Factor/Full Conversion Factor Which is equivalent to:

Reporting Ratio = (1 + OPD Update factor - 0.02)/(1 + OPD update factor)

In the CY 2009 OPPS/ASC final rule with comment period (73 FR 68771 through 68772), we established a policy that the Medicare beneficiary's minimum unadjusted copayment and national unadjusted copayment for a service to which a reduced national unadjusted payment rate applies would each equal the product of the reporting ratio and the national unadjusted copayment or the minimum unadjusted copayment, as applicable, for the service. Under this policy, we apply the reporting ratio to both the minimum unadjusted copayment and national unadjusted copayment for services provided by hospitals that receive the payment reduction for failure to meet the Hospital OQR Program reporting requirements. This application of the reporting ratio to the national unadjusted and minimum unadjusted copayments is calculated according to Sec. 419.41 of our regulations, prior to any adjustment for a hospital's failure to meet the quality reporting standards according to Sec. 419.43(h). Beneficiaries and secondary payers thereby share in the reduction of payments to these hospitals.

In the CY 2009 OPPS/ASC final rule with comment period (73 FR 68772), we established the policy that all other applicable adjustments to the OPPS national unadjusted payment rates apply when the OPD fee schedule increase factor is reduced for hospitals that fail to meet the requirements of the Hospital OQR Program. For example, the following standard adjustments apply to the reduced national unadjusted payment rates: the wage index adjustment, the multiple procedure adjustment, the interrupted procedure adjustment, the rural sole community hospital adjustment, and the adjustment for devices furnished with full or partial credit or without cost. Similarly, OPPS outlier payments made for high cost and complex procedures will continue to be made when outlier criteria are met. For hospitals that fail to meet the quality data reporting requirements, the hospitals' costs are compared to the reduced payments for purposes of outlier eligibility and payment calculation. We established this policy in the OPPS beginning in the CY 2010 OPPS/ASC final rule with comment period (74 FR 60642). For a complete discussion of the OPPS outlier calculation and eligibility criteria, we refer readers to section II.G. of the CY 2023 OPPS/ASC proposed rule (87 FR 44533 through 44534). 2. Reporting Ratio Application and Associated Adjustment Policy for CY 2026

We proposed to continue our established policy of applying the reduction of the OPD fee schedule increase factor through the use of a reporting ratio for those hospitals that fail to meet the Hospital OQR Program requirements for the full CY 2026 annual payment update factor. For the CY 2026 OPPS/ASC proposed rule, the proposed reporting ratio was 0.9805, which, when multiplied by the proposed full conversion factor of $91.747, equaled a proposed conversion factor for hospitals that fail to meet the requirements of the Hospital OQR Program (that is, the reduced conversion factor) of $89.958. We proposed to continue to apply the reporting ratio to all services calculated using the OPPS conversion factor. We proposed to continue to apply the reporting ratio, when applicable, to all HCPCS codes to which we have proposed status indicator assignments of “J1,” “J2,” “P,” “Q1,” “Q2,” “Q3,” “R,” “S,” “T,” “V,” and “U” (other than New Technology APCs to which we have proposed status indicator assignments of “S” and “T”). We proposed to continue to exclude services paid under New Technology APCs. We proposed to continue to apply the reporting ratio to the national unadjusted payment rates and the minimum unadjusted and national unadjusted copayment rates of all applicable services for those hospitals that fail to meet the Hospital OQR Program reporting requirements. We also proposed to continue to apply all other applicable standard adjustments to the OPPS national unadjusted payment rates for hospitals that fail to meet the requirements of the Hospital OQR Program. Similarly, we proposed to continue to calculate OPPS outlier eligibility and outlier payment based on the reduced payment rates for those hospitals that fail to meet the reporting requirements. In addition to our proposal to implement the policy through the use of a reporting ratio, we proposed to continue to calculate the reporting ratio to four decimals.

We did not receive any public comments on our proposal and are finalizing as proposed. For this final rule with comment period, the final reporting ratio is 0.9805, which, when multiplied by the final full conversion factor of $91.415, equals a final conversion factor for hospitals that fail to meet the requirements of the Hospital OQR Program (that is, the reduced conversion factor) of $89.632. We are finalizing our proposal to continue to calculate OPPS outlier eligibility and outlier payment based on the reduced payment rates for those hospitals that fail to meet the reporting requirements. We are also finalizing our proposals to implement the policy through the use of a reporting ratio, and to continue to calculate the reporting ratio to four decimals to more precisely calculate the reduced adjusted payment and copayment rates for hospitals that fail to meet the Hospital OQR Program requirements for CY 2026 payment.

In the CY 2026 OPPS/ASC proposed rule (90 FR 33768 through 337722), we proposed to adopt the Emergency Care Access & Timeliness electronic clinical quality measure (eCQM) beginning with the CY 2027 reporting period/CY 2029 program determination as an alternative to reporting the Median Time from Emergency Department (ED) Arrival to ED Departure for Discharged ED Patients measure. We also refer readers to section XIV.C. of this final rule with comment period where we finalize the following measure removals: (1) Hospital Commitment to Health Equity (HCHE) measure, beginning with the CY 2025 reporting period/CY 2027 program determination; (2) Screening for Social Drivers of Health (SDOH) measure, beginning with the CY 2025 reporting period; and (3) Screen Positive Rate for SDOH measure, beginning with the CY 2025 reporting period. 1. Adoption of the Emergency Care Access & Timeliness eCQM Beginning With Optional Reporting for the CY 2027 Reporting Period/CY 2029 Program Determination a. Background

Occupancy and boarding rates in United States (U.S.) emergency departments (EDs) continue to worsen and exceed pre-pandemic levels.\344\ ED boarding, defined as holding a patient in the ED when there are no available inpatient beds, often occurs due to shortages of inpatient beds and staff. ED boarding time contributes to ED crowding which heightens safety risks for patients and can lead to stressful working conditions for healthcare personnel.\345\ 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.\346\

\344\ 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.

\345\ 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.

\346\ 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.\347\ \348\ Long ED wait times are also one of the most cited reasons for patients leaving an ED without being evaluated by a clinician.\349\ One recent study indicated that ED crowding can harm sepsis patients by delaying administration of lifesaving intravenous (IV) fluids and antibiotics.\350\ ED boarding time can lead to an increased length of stay (LOS) which is also a strong predictor of poor timeliness of care. One study found that for every patient boarded, the median ED LOS for all admitted patients increased by at least 12 minutes.\351\ While less studied than inpatient boarding, transfer boarding (defined as keeping the patient in the ED after the decision to transfer has been made), can have similar impacts as inpatient boarding, with greater impacts on patients receiving care in rural settings.352 353 The timeliness of care provided at REHs may be further impacted by transfer boarding due to lack of inpatient beds and resources required to coordinate transfers.\354\

\347\ 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.

\348\ 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.

\349\ 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. Journal of the American Medical Association, 5(9), e2233708. Available at https://doi.org/10.1001/jamanetworkopen.2022.33708. Accessed: April 30, 2025.

\350\ 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.

\351\ 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.

\352\ Mohr, N.M., Wu, C., Ward, M.J., McNaughton, C.D., Faine, B., Pomeranz, K., Richardson, K., & Kaboli, P.J. (2022). Transfer Boarding Delays Care More in Low-volume Rural Emergency Departments: A Cohort Study.The Journal of Rural, 38(1), 282-292. Available at https://doi.org/10.1111/jrh.12559. Accessed: April 30, 2025.

\353\ Usher, M., Sahni, N., Herrigel, D., Simon, G., Melton, G.B., Joseph, A., & Olson, A. (2018). Diagnostic Discordance, Health Information Exchange, and Inter-Hospital Transfer Outcomes: A Population Study. Journal of General Internal Medicine, 33(9), 1447- 53. Available at https://doi.org/10.1007/s11606-018-4491-x. Accessed: April 30, 2025.

\354\ McNaughton, C.D., Bonnet, K., Schlundt, D., Mohr, N.M., Chung, S., Kaboli, P.J., & Ward, M.J. (2020). Rural Interfacility Emergency Department Transfers: Framework and Qualitative Analysis. The Western Journal of Emergency Medicine, 21(4), 858-865. Available at https://doi.org/10.5811/westjem.2020.3.46059. 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 manually abstracting the chart-abstracted ED measure adopted in the REHQR Program measure set, the Median Time from ED Arrival to ED Departure for Discharged ED Patients (Median Time for Discharged ED Patients) measure, CMS assessed additional ways to support efforts that reduce patient harm and improve outcomes for patients requiring emergency care while also providing flexibility for REHs. We previously sought comment on eCQM reporting under the REHQR Program in the CY 2024 OPPS/ASC proposed rule (88 FR 49840 through 49841). Adoption of the Emergency Care Access & Timeliness eCQM as an optional measure into the REHQR Program measure set, as discussed in section XVI.C.2.c. of this final rule with comment period, is in response to public comment recommending that CMS add eCQMs as optional measures initially (88 FR 82070). We refer readers to section XVI.C.2. of this final rule with comment period for a discussion of eCQM reporting and submission policies and requirements for the REHQR Program. b. Measure Overview

An intermediate outcome measure, the Emergency Care Access & Timeliness eCQM \355\ as specified for the REH setting calculates the proportion of four outcome metrics that quantify access to and the timeliness of care in an ED setting against specified thresholds, including: (1) patient wait

time; (2) whether the patient left the ED without being evaluated; (3) patient transfer boarding time in the ED; and (4) patient ED LOS. The numerator components for the Emergency Care Access & Timeliness eCQM are described in detail in section XVI.B.1.c. of this final rule with comment period. We note that the population and measure specifications for the Median Time for Discharged ED Patients measure overlaps with the Emergency Care Access & Timeliness eCQM for the numerator outcome metric (4), but that the scope of the proposed Emergency Care Access & Timeliness eCQM is broader than the Median Time for Discharged ED Patients measure.\356\ The Median Time for Discharged ED Patients measure assesses one component, the time patients spent in the ED before being sent home, also known as ED throughput. The Emergency Care Access & Timeliness eCQM measures four different ED components in a single measure and provides REHs with separate data for each individual component. Additionally, the eCQM measures transfer boarding time in the ED and time from arrival to placement in a treatment room, which is not measured by the Median Time for Discharged ED Patients measure, or any other measure currently in the REHQR Program measure set.\357\ As discussed in the CY 2026 OPPS/ASC proposed rule (90 FR 33771 and 33772), to provide flexibility for REHs, we proposed that REHs could elect to report either the Emergency Care Access & Timeliness eCQM or the Median Time for Discharged ED Patients measure beginning with the CY 2027 reporting period/CY 2029 program determination. While CMS proposed that the Emergency Care Access & Timeliness eCQM would not be required to be reported by REHs, we proposed that REHs must nonetheless elect to report either the Emergency Care Access & Timeliness eCQM or the Median Time for Discharged ED Patient measure to meet program requirements, beginning with the CY 2027 reporting period/CY 2029 program determination. We stated our belief that this timeline would provide REHs sufficient time to test and integrate the Emergency Care Access & Timeliness eCQM into existing clinical workflows.

\355\ The Emergency Care Access & 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.

\356\ The Median Time for Discharged ED Patients was adopted in the REHQR Program in the CY 2024 OPPS/ASC final rule with comment period (88 FR 49832).

\357\ Partnership for Quality Measurement. (n.d.). Emergency Care Capacity and Quality. Available at https://p4qm.org/measures/4625e. Accessed: April 30, 2025.

For more information about the testing, feasibility, scientific acceptability, meaningfulness, and validity of the Emergency Care Access & Timeliness eCQM, we refer readers to the “Feasibility” and “Scientific Acceptability” sections of the Emergency Care Access & Timeliness eCQM listing on the Partnership for Quality Measurement website at https://p4qm.org/measures/4625e. c. Measure Calculation

The measure denominator includes all ED encounters by patients of all ages, for all-payers, during a 12-month period of performance. Patients can have multiple encounters during a period of performance, and each encounter is eligible to contribute to the calculation of the measure.\358\

\358\ For proposed measure specifications, we refer readers to the CMS QualityNet REHQR Program website at https://qualitynet.cms.gov/reh/rehqr.

The measure numerator includes any ED encounter in the denominator where the patient experiences any one of the following: (1) the patient waited longer than 1 hour after arrival to the ED to be placed in a treatment room or dedicated treatment area that allows for audiovisual privacy during history-taking and physical examination; (2) the patient left the ED without being evaluated; (3) the patient, if transferred, boarded in the ED for longer than 4 hours; \359\ or (4) the patient had an ED LOS of longer than 8 hours. An encounter is included in the numerator if any one of the four numerator events occurred with events not being mutually exclusive and each contributing only once to the numerator. ED encounters with ED observation stays \360\ are excluded from components (3) and (4).

\359\ This measure component is calculated at the encounter level by subtracting “Decision to Transfer” order time from “ED Departure Time” for visits with the ED disposition of “Transferred” (to an acute care hospital) and then flagging as a numerator event if >240 minutes.

\360\ ED observations stays are defined as an observation encounter where the patient remains physically in an area under control of the ED and under the care of an ED clinician inclusive of observation in a hospital bed. Partnership for Quality Measurement. Emergency Care Capacity and Quality. Available at https://p4qm.org/measures/4625e. Accessed: April 30, 2025.

These four outcomes were selected based on published literature demonstrating that each numerator component is associated with patient harm,\361\ as well as clinical (including ED), statistical, and methodological expert input. Additionally, a Technical Expert Panel (TEP) was convened by the measure developer.\362\ The Patient and Family Engagement (PFE) Work Group provided feedback on emergency care experiences such as long wait times to be seen by a provider, long wait times to be transferred, and gaps in discharge processes.\363\

\361\ Partnership for Quality Measurement. (n.d.). Emergency Care Capacity and Quality. Available at https://p4qm.org/measures/4625e. Accessed: April 30, 2025.

\362\ Partnership for Quality Measurement. (n.d.). Emergency Care Capacity and Quality. Available at https://p4qm.org/measures/4625e. Accessed: April 30, 2025.

\363\ Partnership for Quality Measurement. (n.d.). Emergency Care Capacity and Quality. Available at https://p4qm.org/measures/4625e. Accessed: April 30, 2025.

The numerator thresholds were developed according to evidence and consensus-based clinical guidelines for ED time thresholds from a TEP and environmental scans. For example, the four-hour threshold for numerator component (3), transfer boarding time, was developed per recommendations from The Joint Commission (TJC) and the American College of Emergency Physicians (ACEP).\364\ If this proposal to adopt the Emergency Care Access & Timeliness eCQM for the REHQR Program is finalized, CMS would closely monitor the effect of this measure in REHs and may revise thresholds as appropriate.

\364\ Yale New Haven Health Services Corporation. (2024). Technical Expert Panel (TEP) Evaluation of Measure Emergency Care Capacity and Quality Electronic Clinical Quality Measure (eCQM). Available at https://mmshub.cms.gov/sites/default/files/ECCQ-TEP-Summary-Report-081624.pdf. Accessed: April 30, 2025.

Measure testing for the Emergency Care Access & Timeliness eCQM was conducted by the measure developer across 32 hospital-based EDs, representing a diverse mix of geographic regions, rurality, hospital size, teaching status, trauma level, and electronic health record (EHR) vendors, demonstrating that the measure is reliable, valid, and feasible for all required data elements.\365\ Measure testing results had a wide range in overall scores, and across all strata, indicating variation in performance and implying room for quality improvement.\366\ Although data element feasibility testing was performed at only one REH, the measure was also tested at a few rural hospital-based EDs with similar characteristics of pre-conversion REHs (for example, average bed range of under 25).\367\ Based on this, we believe

these measure testing results are applicable to REHs.

\365\ Partnership for Quality Measurement. (n.d.). Emergency Care Capacity and Quality. Available at https://p4qm.org/measures/4625e. Accessed: April 30, 2025.

\366\ Partnership for Quality Measurement. (n.d.). Emergency Care Capacity and Quality. Available at https://p4qm.org/measures/4625e. Accessed: April 30, 2025.

\367\ Partnership for Quality Measurement. (n.d.). Section 7.1 Supplemental Attachment. Available at https://p4qm.org/sites/default/files/2024-10/4625e-section-7.1-supplemental-attachment.pdf. Accessed: April 30, 2025.

The measure score is calculated at the individual ED level as the proportion of ED encounters where any one of the four outcomes occurred, divided by the number of encounters in a performance period. For CMS Certification Numbers (CCNs) with more than one ED, individual ED scores are then combined as a weighted average for that CCN.\368\ The results of the Emergency Care Access & Timeliness eCQM are stratified into four groups, two by age (18 and older, and under 18) and two by mental health diagnoses (with, and without).\369\ We note that the approach to stratification by age and mental health diagnosis is sufficient to account for differences between REHs without further need for risk adjustment.

\368\ Because REHs are typically a low volume setting, volume standardization is not applied to calculate the Emergency Care Access & Timeliness eCQM, unlike the version of the Emergency Care Access & Timeliness eCQM finalized for adoption into the Hospital OQR Program in section XV.B.1. of this final rule with comment period.

\369\ The principal diagnosis (first listed diagnosis at ED discharge) will be used to define strata inclusion. For this measure's purpose, mental health diagnoses do not include substance use disorder diagnoses. Mental health refers to mental health diagnoses, life stressors and crises, and stress-related physical symptoms.

For additional details regarding the measure specifications, we refer readers to the CMS QualityNet REHQR Program website at https://qualitynet.cms.gov/reh/rehqr. d. Pre-Rulemaking Measure Review (PRMR)

As required under section 1890A of the Act, the Secretary must establish and follow a pre-rulemaking process for selection of quality and efficiency measures, including for the REHQR Program. The pre- rulemaking process, which we refer to as the Pre-Rulemaking Measure Review (PRMR), includes a review of measures published on the publicly available list of Measures Under Consideration (MUC List) by one of several committees convened by the consensus-based entity (CBE), with which we contract in accordance with section 1890 of the Act, for the purpose of providing interested parties input to the Secretary on the selection of quality and efficiency measures under consideration for use in certain Medicare quality programs, including the REHQR Program. We refer readers to the CY 2025 OPPS/ASC final rule with comment period (89 FR 94372) for details on the PRMR process, including the voting procedures used to reach consensus on measure recommendations. The PRMR Hospital Recommendation Group met on January 15 and 16, 2025, to review measures included by the Secretary on the publicly available “2024 Measures Under Consideration List” (MUC List), including the Emergency Care Access & Timeliness eCQM (MUC2024-095), and provided additional recommendations on the potential use of this measure.\370\

\370\ Partnership for Quality Measurement. (2025). 2024-2025 Pre-Rulemaking Measure Review (PRMR) Recommendation Group Final Meeting Summary: Hospital Committee. Available at https://p4qm.org/sites/default/files/2025-02/PRMR-Hospital-Recommendation-Group-Meeting-Summary.pdf. Accessed: April 30, 2025.

The voting results of the PRMR Hospital Recommendation Group for the proposed Emergency Care Access & Timeliness eCQM within the REHQR Program were: 9 members recommended adopting the measure into the REHQR Program; 6 members recommended adoption with conditions; 11 members voted not to recommend the measure for adoption. No voting category reached 75 percent or greater, including the combination of the recommend and the recommend with conditions categories and thus, the Hospital Recommendation Group did not reach consensus.\371\

\371\ Partnership for Quality Measurement. (2025). 2024-2025 Pre-Rulemaking Measure Review (PRMR) Recommendation Group Final Meeting Summary: Hospital Committee. Available at https://p4qm.org/sites/default/files/2025-02/PRMR-Hospital-Recommendation-Group-Meeting-Summary.pdf. Accessed: April 30, 2025.

The PRMR Hospital Recommendation Group noted in their deliberations that the measure will provide important insights into ED wait times which impact experience of care. The Group expressed concern that this measure may cause an increase in cost of care due to patients being transferred from the ED to observation.\372\ While we acknowledge that patients transferred from the ED to observation may result in increased short-term costs due to additional monitoring and extended stays, the measure is designed to address significant issues surrounding the access to timely care which have been proven to reduce long-term costs.\373\ Hospital Recommendation Group members also expressed concern about the lack of CBE endorsement. We note that we submitted the Emergency Care Access & Timeliness eCQM for CBE endorsement for review in the Fall 2024 cycle and the CBE endorsed the measure with conditions for use in the REHQR Program on February 12, 2025.\374\ \375\ We refer readers to section XVI.B.1.e. of this final rule with comment period for additional details on CBE endorsement.

\372\ Partnership for Quality Measurement. (2025). 2024-2025 Pre-Rulemaking Measure Review (PRMR) Recommendation Group Final Meeting Summary: Hospital Committee. Available at https://p4qm.org/sites/default/files/2025-02/PRMR-Hospital-Recommendation-Group-Meeting-Summary.pdf. Accessed: April 30, 2025.

\373\ Dyas, S.R., Greenfield, E., Messimer, S., Thotakura, S., Gholston, S., Doughty, T., Hays, M., Ivey, R., Spalding, J., & Phillips, R. (2015). Process-Improvement Cost Model for the Emergency Department. Journal of Healthcare Management, 60(6), 442- 57. Available at https://doi.org/10.1097/00115514-201511000-00011. Accessed: April 30, 2025.

\374\ Partnership for Quality Measurement. (2024). 2024 Pre- Rulemaking Measure Review Preliminary Assessment. Available at https://p4qm.org/sites/default/files/2024-12/PRMR-PA-MUC2024-075.pdf. Accessed: April 30, 2025.

\375\ Partnership for Quality Measurement. (2025). Fall 2024 Cycle Endorsement and Maintenance (E&M) Technical Report. Available at https://p4qm.org/sites/default/files/Initial%20Recognition%20and%20Management/material/EM-Fall-2024-Initial-Recognition-Final-Project-Report.pdf. Accessed: April 30, 2025.

The Hospital Recommendation Group discussed a few conditions specific to the REHQR Program, including changing the name of the measure to better reflect the measure's focus.\376\ We agree with this feedback and have changed the name of the measure from the Emergency Care Capacity and Quality eCQM to Emergency Care Access & Timeliness. Additionally, Group members recommended stratifying the measure by factors such as care type as well as by region and trauma level designation. We emphasize that the approach to stratification by age and mental health diagnosis is sufficient to account for differences between REHs without further need for additional stratification.\377\

\376\ Partnership for Quality Measurement. (2025). 2024-2025 Pre-Rulemaking Measure Review (PRMR) Recommendation Group Final Meeting Summary: Hospital Committee. Available at https://p4qm.org/sites/default/files/2025-02/PRMR-Hospital-Recommendation-Group-Meeting-Summary.pdf. Accessed: April 30, 2025.

\377\ Partnership for Quality Measurement. (2025). 2024-2025 Pre-Rulemaking Measure Review (PRMR) Recommendation Group Final Meeting Summary: Hospital Committee. Available at https://p4qm.org/sites/default/files/2025-02/PRMR-Hospital-Recommendation-Group-Meeting-Summary.pdf. Accessed: April 30, 2025.

The Hospital Recommendation Group recommended revising the measure specifications to create separate measure components with the encouragement to explore additional measures for patient transfer boarding time and ED LOS as well as conducting further testing to expand the measure's applicability to REHs. We acknowledge the Hospital Recommendation Group's concerns and note that multiple TEPs and interested parties supported the inclusion of more than one numerator component as a strategy for internally balancing the measure and that time thresholds are

based on more than a decade of consensus work.\378\ \379\ \380\ If the proposal to adopt the Emergency Care Access & Timeliness eCQM for the REHQR Program is finalized, CMS would closely monitor the effect of this measure in REHs and revise thresholds as appropriate (90 FR 33771). We note that out of the 32 hospital-based EDs that were tested for reliability, validity, and feasibility, approximately 20 percent were rural EDs, although not in the REHQR Program. Finally, Group members recommended implementing the Emergency Care Access & Timeliness eCQM with a phased approach with 2 years of voluntary reporting. We noted that we proposed adoption of the Emergency Care Access & Timeliness eCQM as an optional measure in lieu of the Median Time for Discharged ED Patients measure to provide additional flexibility for REHs given the anticipated implementation burden of this measure.

\378\ Partnership for Quality Measurement (n.d.). Emergency Care Capacity and Quality. Available at https://p4qm.org/measures/4625e. Accessed: April 30, 2025.

\379\ Yale New Haven Health Services Corporation. (April 2024). Technical Expert Panel (TEP) Evaluation of Measure Equity of Emergency Care Capacity and Quality Electronic Clinical Quality Measure (eCQM). Available at https://mmshub.cms.gov/sites/default/files/ECCQ-TEP-2-Summary-Report.pdf. Accessed: April 30, 2025.

\380\ Yale New Haven Health Services Corporation. (September 2024). Technical Expert Panel (TEP) Evaluation of Measure Emergency Care Capacity and Quality Electronic Clinical Quality Measure (eCQM). Available at https://mmshub.cms.gov/sites/default/files/ECCQ-TEP-Summary-Report-081624.pdf. Accessed: April 30, 2025.