Comments for the Record
August 12, 2019
Comments on Reducing Administrative Burden To Put Patients Over Paperwork
Thank you for the opportunity to comment on the “Patients Over Paperwork” initiative. Determining ways to further streamline administrative burdens is an admirable goal for any governmental agency. As of this submittal, the Centers for Medicare & Medicaid Services (CMS) inventory of “information collection requirements” (ICRs) accounts for roughly 199 million hours of paperwork annually – the equivalent of 97,628 full-time employees – at a stated cost of $8.2 billion. Examining this pool of paperwork requirements further, there are a series of ICRs that CMS should reassess in order to avoid duplicative and unnecessary requirements.
Most Time-Intensive Paperwork Requirements
Like many agencies whose decisions impact a significant portion of the population, CMS has a host of ICRs that impose significant burdens in the aggregate but are relatively small on a per-respondent basis. It can be difficult to find even marginal per-respondent time savings on items such as forms that only take minutes to complete. As such, focusing on ICRs with a higher per-respondent burden may prove more fruitful in finding potential savings. The following table contains 30 ICR entries (active as of this submittal) in CMS’s portfolio with a per-respondent burden exceeding 100 hours.
|ICR Number||Title||Respondents||Hours||Hours per Respondent|
|0938-1251||Healthcare Fraud Prevention Partnership (HFPP): Data Sharing and Information Exchange (CMS-10501)||55||176,800||3,214.5|
|0938-0974||Payment Error Rate Measurement in Medicaid and the State Children Health Insurance Program (CMS-10166)||34||56,100||1,650.0|
|0938-1353||Marketplace Operations (CMS-10637)||2,930||2,339,000||798.3|
|0938-0050||Hospitals and Health Care Complex Cost Report||6,088||4,097,224||673.0|
|0938-1249||Marketplace Quality Standards (CMS-10520)||1,770||1,085,095||613.0|
|0938-0686||(CMS-R-185) Granting and Withdrawal of Deeming Authority to Private Nonprofit Accreditation Organizations and of State Exemption Under State Laboratory Programs and Supporting Regs)||9||5,464||607.1|
|0938-1012||Payment Error Rate Measurement – State Medicaid and CHIP Eligibility (CMS-10184)||1,583||946,164||597.7|
|0938-1144||Application to Be a Qualified Entity to Receive Medicare Data for Performance Measurement (CMS-10394)||10||5,000||500.0|
|0938-0907||Hospital Wage Index Occupational Mix Survey and Supporting Regulations in 42 CFR, Section 412.64||3,400||1,632,000||480.0|
|0938-0790||Medicare and Medicaid; Programs For All-Inclusive Care For The Elderly (PACE) Contained in 42 CFR Part 460 (CMS-R-244)||165||71,455||433.1|
|0938-0338||(CMS-R-43) Medicare and Medicaid Programs: Conditions of Participation for Portable X-ray Suppliers||1,527||532,959||349.0|
|0938-1188||Medicaid and CHIP Program (MACPro) (CMS-10434)||280||96,844||345.9|
|0938-1028||HEDIS Data Collection for Medicare Advantage (CMS-10219)||515||164,800||320.0|
|0938-0578||Medicaid Drug Rebate Program – Manufacturers and Supporting Regulation at 42 CFR 447.534 (CMS-367)||12,810||3,618,703||282.5|
|0938-0444||(CMS-R-65) Final Peer Review Organizations Sanction and Supporting Regulations||18||4,716||262.0|
|0938-1327||The PACE Organization (PO) Monitoring and Audit Process in 42 CFR Part 460 (CMS-10630)||72||17,280||240.0|
|0938-1264||Program of all-Inclusive Care for the Elderly PACE Quality Data Entry in the CMS Health Plan Monitoring System (HPMS) (CMS-10525)||1,440||330,600||229.6|
|0938-1000||Medicare Parts C and D Program Audit Protocols and Data Requests (CMS-10191)||241||52,261||216.9|
|0938-0463||Skilled Nursing Facility and Skilled Nursing Facility Cost Report and Supporting Regulations in 42 CFR 413.20, 413.24, and 413.106||14,486||2,926,172||202.0|
|0938-0758||Hospice Facility Cost Report||3,545||666,460||188.0|
|0938-1153||Hospice Quality Reporting Program (CMS-10390)||4,259||686,631||161.2|
|0938-0977||Retiree Drug Subsidy Payment Request Instructions (CMS-10170)||2,482||374,782||151.0|
|0938-1286||Quality Improvement Strategy Implementation Plan and Progress Report (CMS-10540)||250||36,000||144.0|
|0938-1022||Hospital Reporting Initiative–Hospital Quality Measures (CMS-10210)||17,600||2,520,100||143.2|
|0938-1114||Medical Loss Ratio (IFR) Information Collection Requirements and Supporting Regulations (CMS-10361)||22||3,080||140.0|
|0938-1312||Establishment of an Exchange by a State and Qualified Health Plans (CMS-10593)||409||56,457||138.0|
|0938-0701||Medicare Health Outcomes Survey (HOS) (CMS-10203)||1,485||183,115||123.3|
|0938-1317||Reapplication Submission Requirement for Qualified Entities under ACA Section 10332 (CMS-10596)||10||1,200||120.0|
|0938-1134||Methods for Assuring Access to Covered Medicaid Services Under 42 CFR 447.203 and 447.204 (CMS-10391)||202||23,898||118.3|
|0938-0688||(CMS-R-13) Conditions of Coverage for Organ Procurement Organizations (OPOs) and Supporting Regulations||128||13,234||103.4|
Altogether, these 30 ICRs represent roughly 22.7 million hours of paperwork. Even a mere 10 percent reduction in this pool would yield nearly 2.3 million hours in savings. While there may be more granular savings possible in ascertaining how certain requirements interact with specific parts of the patient and provider experience, there are items that seem clearly ripe for review on a more general administrative level. The following are two such examples worth highlighting in particular.
Duplicate Hospital Wage Cost Accounting
The “Hospitals and Health Care Complex Cost Report” (ICR # 0938-0050) provides a vast amount of health care cost data that is likely critical in CMS’s ability to manage relevant programs. One of the main cost centers of any hospital is, of course, its employees’ pay. “Part II” of the overall worksheet covers the collection of such wage data. The worksheet is fairly comprehensive in this regard, which in turn calls into question the purpose of another ICR on the above list.
The “Hospital Wage Index Occupational Mix Survey” (ICR # 0938-0907) provides data periodically in order to help calculate a wage index. It is unclear why this collection is necessary in light of the information provided under ICR # 0938-0050. The survey worksheet appears to include similar fields as the overall cost report. In fact, the survey’s instructions explicitly refer back to the methodology utilized in the relevant portion of the cost report.
This seems to make the survey largely superfluous as CMS should already have the necessary data from a given hospital’s overall cost report. Requiring hospitals to then spend time recording that same data again is unduly extraneous. If there are aspects of it that supplement gaps in the cost report, then it should be pared back to simply those items. Otherwise, the overall requirement – and its roughly 1.6 million hours of paperwork – would make an excellent candidate for general reconsideration.
Payment Error Rate Measurement Overall
Minimizing the amount of erroneous payments to Medicaid and the Children’s Health Insurance Program (CHIP) is an important goal. It is, however, unclear why there are two separate information collections devoted towards that end. The ICRs are 0938-0974 and 0938-1012; the abstracts are below.
Improper Payments Information Act (IPIA) of 2002 requires CMS to produce national error rates for Medicaid and SCHIP. To comply with the IPIA, CMS needs the information to be collected from States and providers in order to sample and review adjudicated claims in a randomly selected number of States. Based on the reviews, State-specific error rates will be calculated which will be calculated which will serve as the basis for calculating national error rates for Medicaid and SCHIP.
The Improper Payments Information Act (IPIA) of 2002 requires CMS to produce national error rates for Medicaid and SCHIP. To comply with the IPIA, CMS needs the information to be collected in order to provide some Federal overview of state eligibility determinations to ensure correctness and consistency among states and to use the State-specific error rates as the basis for calculating national eligibility error rates for Medicaid and SCHIP.
Both ICRs originate from the same legislation, the IPIA, and largely contain the same language. Digging deeper, the primary component of 0938-0974 is a single report summarizing a state’s corrective actions. On the other hand, 0938-1012 includes a series of more granular reports regarding erroneous payments. Yet, upon examining the 0938-0974 report more closely, it seems that all the data included in it could be found in the data provided under 0938-1012; it simply puts the onus on the respondent to summarize said data. While that report’s overall burden of 56,100 hours is relatively modest in the overall picture, it does represent one of the highest per-respondent burdens (1,650 hours annually) while providing no real original data.
The above examples are only two issues pulled from a pool of 30 paperwork requirements with notably high per-respondent burdens. They are included here because they represent relatively clear instances of unnecessarily duplicative paperwork requirements. Nevertheless, it would likely be useful for CMS, in ongoing consultation with stakeholders and perhaps informed by other comments in this docket, to further examine the other entries on the list included. While some are relatively modest in the aggregate, their high per-respondent burdens provide the widest margins for even partial reconsideration, if not rescission.