- Q4 2019 HCAHPS data will be used for Hospital VBP for hospitals who submitted it.
- Q1 2020 and Q2 2020 HCAHPS data will not be used for Hospital VBP, even if it is submitted.
- No direction has been given regarding star ratings or publicly reported data.
Earlier this year, CMS announced that Q4 2019, Q1 2020, and Q2 2020 HCAHPS data submission was optional due to the COVID 19 pandemic. On September 2, 2020, CMS published a Federal Register that finally gave us some clarification about the use of that data.
In this rule, CMS explains that they made Q4 2019 HCAHPS submission optional to reduce the reporting burden on hospitals that were responding to the pandemic ahead of the April 1, 2020 submission deadline. They do not believe that the data itself would be affected by the pandemic, and consequently would use any data that was submitted for Q4 2019 for Hospital VBP for TPS scores for the performance period for FY2021 program year and FY2023 baseline data, as originally planned.
For Q1 2020 and Q2 2020, in addition to reducing the burden on hospitals, CMS also was concerned that data collected from those discharges could be greatly impacted by COVID-19. As submission of these quarters was optional, CMS is concerned that only high performing hospitals, or hospitals with more resources/fewer COVID cases, would elect to submit their HCAHPS data, making the submitted data during these quarters unrepresentative of the nation’s hospitals as a whole.
As such, CMS has decided to not use any HCAHPS data that was submitted for Q1 2020 or Q2 2020 to calculate the total performance scores for FY2022 through FY2025 program years, or baseline scores for the FY 2024 through FY 2030 program years.
However, this has not clarified what CMS will do regarding star ratings or the publicly reported HCAHPS data on Hospital Compare. The Q1 2020 data is scheduled to be included for the first time in the publicly reported data published in January 2021, so we anticipate additional information will be released regarding their decision as we approach that date.
While PRC does not know what CMS will decide, we feel that their reasoning to exclude Q1 and Q2 2020 from VBP would be applicable to the publicly reported data as well—including the optional quarters would likely lead to that publicly reported data being skewed toward hospitals with better performances during that time.
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