[Federal Register Volume 67, Number 105 (Friday, May 31, 2002)]
[Notices]
[Pages 38128-38132]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 02-13613]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[CMS-1209-N]
Medicare Program; Notice of Modification of Beneficiary
Assessment Requirements for Skilled Nursing Facilities
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Notice.
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SUMMARY: As part of the Secretary's Regulatory Reform Initiative, this
notice offers to skilled nursing facilities (SNFs) the option of using
a modified, shorter version of the minimum data set (MDS) to satisfy
the Medicare SNF payment and quality requirements. The Medicare SNF
prospective payment system rates are based on the assignment of
beneficiaries to case-mix classification groups. Beneficiaries are
assigned to groups based on the information collected by the SNF staff
and recorded on the MDS. The quality measures are also derived from the
information recorded on the MDS and all of those items are included in
this modified, shorter version. This shorter version of the MDS will
reduce the burden on SNFs by approximately one-half, which may result
in saving a significant amount of time that could be made available to
staff for the provision of beneficiary care. We are offering to SNF
providers the option of using the shorter version of the MDS to meet
the requirements to receive payment for Part A SNF stays.
DATES: This notice is effective July 1, 2002.
FOR FURTHER INFORMATION CONTACT: Dana Burley (410) 786-4547.
SUPPLEMENTARY INFORMATION:
I. Background
The Secretary of the Department of Health and Human Services (the
Secretary) has made regulatory reform a priority. To further this goal,
the Secretary established an Advisory Committee on Regulatory Reform to
provide advice on potential administrative and regulatory changes that
could reduce burdens and costs while maintaining or enhancing
effectiveness and access to health care. In order to fulfill its
mandate, among other activities, the committee has held public
hearings, heard testimony from providers and beneficiary groups, and
visited a skilled nursing facility (SNF) to examine the regulatory
burdens imposed on SNFs.
During the course of its deliberations, the Advisory Committee
examined the minimum data set (MDS) and identified almost two dozen MDS
areas for review. While affirming the critical contribution of the MDS
to quality, the committee has identified some MDS issues that relate to
the size of the instrument and the need to focus data collection on
payment, outcome, and survey purposes. The modifications announced in
this notice address one of the issues identified in the course of the
activities undertaken by the Advisory Committee.
In this notice, we are announcing the option of using a shorter MDS
developed for use by providers to assess Medicare beneficiaries for
purposes of
[[Page 38129]]
the SNF prospective payment system (PPS) assessment requirements during
their Part A covered SNF stays. This is one step in our ongoing effort
to streamline our regulatory requirements for providers who participate
in the Medicare program and for our beneficiaries.
The current Medicare assessment requirements are based on section
4432(a) of the Balanced Budget Act of 1997 (BBA), that amended section
1888(e) of the Social Security Act (the Act), which mandated
implementation of a Medicare skilled nursing facility (SNF) prospective
payment system. Section 1888(e)(4) of the Act provides the basis for
establishing the per diem Federal payment rates applied under the PPS
and sets forth the formula for the rates, including the data on which
they are based. In addition, this section of the Act requires annual
adjustments to the PPS rates based on geographic variation and SNF
case-mix and prescribes the methodology for updating the rates in
future years.
The PPS case-mix adjustments are derived from the clinical
information collected by providers about Medicare Part A covered
beneficiaries during their SNF stays, using the minimum data set (MDS).
As a result of a mandate contained in the nursing home reform
legislation in the Omnibus Budget Reconciliation Act of 1987 (OBRA
'87), a uniform MDS was required as a part of the comprehensive
resident assessment for all certified long-term care facilities. The
provisions of OBRA '87 require that certified long-term care facilities
collect information concerning all residents to support care planning
activities. Comprehensive assessments, using the MDS, are required at
admission (no later than 14 days following admission), annually, and
upon a significant change in a resident's condition. In addition,
quarterly reviews of each resident are required. A shorter version of
the MDS has been developed for these quarterly assessments.
With implementation of the SNF PPS, providers were required to
perform MDS assessments of all beneficiaries in Medicare Part A covered
stays on days 5, 14, 30, 60, and 90 of their Medicare covered stays.
The assessments required for the SNF PPS are in addition to those
required by the OBRA '87, although there is often overlap in the timing
of the required assessments so that one assessment may be used to
satisfy both the OBRA '87 and SNF PPS requirements.
At the time of implementation of the SNF PPS, we were aware that
some refinements to the payment system might be required as we learned
more during the national operational period. However, because of what
we learned from the demonstration, and in order to have full national
level data on Medicare beneficiaries (including their resource use
requirements), we did not believe that a shorter version of the MDS was
appropriate at that time.
The SNF PPS has now been in place for more than 2 full years and we
believe that it is now feasible to offer providers the option of using
a shorter version of the MDS. There is no regulatory impediment to our
making available, as an option, a shorter version of the MDS for
purposes of Medicare payment and quality monitoring. We find that the
information that we have collected from the full MDS since
implementation of the Medicare SNF PPS, which is stored in the National
MDS Repository, in addition to the continued collection of information
from both the full MDS and the optional shorter version, are adequate
to support payment, program integrity, quality monitoring, and provider
and beneficiary educational activities.
The OBRA '87 requirements remain unchanged. Only those MDS
assessments that are performed solely for the purpose of satisfying the
Medicare SNF PPS assessment requirements are affected by this decision
to offer a shorter version of the MDS. For those Medicare SNF PPS
assessments, SNFs may, at their option, use a shorter version of the
MDS, the Medicare PPS Assessment Form, Version 2002 (MPAF). This
shorter version of the MDS will be available for provider use beginning
July 1, 2002 and is currently available on the SNF PPS web site at
www.hcfa.gov/medicare/SNFPPS.htm. The MPAF contains all of the MDS
items needed to calculate the beneficiary's RUG-III classification and
Quality Indicators.
The nursing home reform provisions of the OBRA '87 established the
MDS as key to the process for ensuring the quality of care for nursing
home residents. All current assessments address quality of care,
although the OBRA '87-required 14-day and 90-day assessments are
intended primarily for quality evaluation and care planning support.
The shorter version of the MDS offered in this notice in no way
undermines the important quality assurance and care planning support
functions of the process. We remain committed to the ongoing collection
of information, as specified in the OBRA '87, as a cornerstone of the
provision of high quality care for all long term care facility
residents.
In addition to the quality provisions of OBRA '87, the Secretary
has initiated a Nursing Home Quality Initiative, designed to assess the
quality of care provided by SNFs. As an integral part of this
initiative, we are making information about local nursing homes
available to members of the communities in which they operate. The
first step in this process, to pilot test quality measures and publish
those scores, is underway in 6 States (Florida, Maryland, Ohio, Rhode
Island, Washington, and Colorado). Quality measurement and assuring
that high quality care is provided to all residents in certified
nursing facilities remains a priority and will be the focus of ongoing
research activity. Therefore, the MPAF was designed so that it includes
all of the data elements required to derive all of the current quality
measures.
Due to our strong interest in quality assurance and our ongoing
research efforts related to outcome measures for quality, as well as
MDS accuracy, new payment and classification systems and assessment
instruments across post-acute care settings, it is certain that, over
time, the scope and content of items included on all MDS assessment
instruments will change. For example, we are planning to modify the
full MDS in order to simplify some items and update others, according
to clinical practices. This modification will be the MDS 3.0, which we
expect to complete in 2004. Similarly, we are engaged in a significant
effort to develop tools to help providers educate staff and assure the
accuracy of their MDS assessments. This work is being performed through
a Program Safeguard contract and includes monitoring of other aspects
of nursing facility practices, in addition to the MDS accuracy studies.
We will also work on developing systems by which we can monitor MDS
assessments on a national level.
II. Development of the MPAF
Development of this new, shorter version of the MDS was based on
the RUG-III Quarterly, Optional Version, 1997 Update. This version of
the MDS contains almost all of the items needed to calculate the
Medicare RUG-III case-mix classification groups and is already part of
the State standard MDS systems. However, the RUG-III Quarterly does not
include Sections AA8b and T of the MDS that are essential for the PPS,
the risk adjustment items necessary for calculating the Quality
Indicators, certain items required for the Quality Medical Review
function of the Peer Review Organizations (PROs), or items we believed
may be useful for refinements to the payment system.
The addition of items to the RUG-III Quarterly from the MDS to
satisfy the
[[Page 38130]]
requirements of ongoing Medicare payment policy research, PRO tasks,
and quality monitoring resulted in an assessment form that is somewhat
longer than the RUG-III Quarterly, but still significantly shorter than
the full MDS.
III. Optional Use of the MPAF
The MPAF will be available for use July 1, 2002. Providers may
choose to use this shorter version of the MDS to satisfy the Medicare
SNF PPS requirements for assessments at days 5, 14, 30, 60, and 90 of
Medicare Part A covered stays. The requirement for an Other Medicare
Required Assessment (OMRA) 8 to 10 days after cessation of all
rehabilitation therapy may also be satisfied by using the MPAF.
With the implementation of the SNF PPS, compliance with the OBRA
'87 requirement for an Initial Admission Assessment by the 14th day and
the Medicare SNF PPS requirements for an assessment at days 5 and 14
has been met routinely by performing one assessment to meet both
requirements. This has been a fairly seamless combination of
requirements, since the SNF PPS requirements, before the implementation
of this optional MPAF, called for a full MDS assessment and the Initial
Admission Assessment also required the full MDS, as well as additional
care planning activities. It will still be possible to use one
assessment to comply with both the OBRA '87 clinical rules and the
Medicare SNF PPS assessment requirements. The provider will be required
to meet the more rigorous standard (comprehensive assessment to comply
with the requirement for an initial admission assessment) and may use
that assessment to comply with the lesser Medicare requirement.
IV. Implementation
The items on the MPAF are the same as they appear on the full MDS.
We have not altered wording, instructions for completion, or numbering
in development of the MPAF. For example, MDS item I1m (hip fracture) on
the full MDS is also item I1m (hip fracture) on the MPAF, even though
on the MPAF this item is followed by I1r (aphasia), rather than I1n
(missing limb), which has been removed from this shorter version of the
assessment form. Since our intent in providing this revised, shortened
version of the MDS is to alleviate burden on providers, we have
maintained the ordering and numbering system of the MDS items. We
believe that this will minimize confusion for clinical staff who are
used to the item numbering as it exists on the full version of the MDS
and support ease of use of the revised version.
With the implementation of the MPAF, the burden on SNF providers
will also be lessened. Once the MPAF is implemented, we will no longer
require a Medicare SNF PPS assessment to be performed using the full
MDS. Rather, only the new MPAF will be required. The MPAF will be
essentially a RUG-III 1997 Update Quarterly assessment form with items
added to allow evaluation of SNF quality of care.
Beginning July 1, 2002, facilities will have the option to (1)
submit Medicare SNF PPS records using only the MPAF items, or (2)
continue to submit Medicare SNF PPS records using the full MDS. The
standard MDS system used by the States will accept either type of
record as valid. The standard system will validate and store only the
set of MPAF items. Additional items will be ignored by the system. Some
providers may wish to continue to send a full MDS assessment to avoid
revising MDS data entry software. If that is the case, no submission
errors or warnings will result.
When a Medicare SNF PPS assessment would be coupled with a required
clinical assessment (for example, a 14-day Medicare SNF PPS assessment
combined with an initial admission assessment) we will require the MDS
record to include all of the MPAF items plus any additional items
required by the clinical assessment, in order to satisfy both sets of
assessment requirements.
If any Medicare SNF PPS assessment is combined with a comprehensive
assessment (initial assessment, annual assessment, significant change
in status assessment, or significant correction of prior full MDS
assessment), we will require the record submitted to include all
comprehensive assessment items.
When a Medicare SNF PPS assessment is coupled with a quarterly
assessment or a significant correction of a prior quarterly assessment,
we will require the record submitted to include all MPAF items and any
additional items required on the State's quarterly assessment. In
States using our standard minimum quarterly or standard RUG-III
quarterly assessment, the MPAF items will include all items on the
quarterly assessments, and only the MPAF will be required. In States
that require additional quarterly items, not included on the MPAF,
those additional items will be required to be included on a combined
Medicare SNF PPS and quarterly assessment record. For example, in the 7
States that require a full MDS assessment as the quarterly assessment,
a record combining a Medicare SNF PPS assessment and a quarterly
assessment will have to include all of the full MDS items.
V. Collection of Information Requirements
In compliance with the requirement of section 3506(c)(2)(A) of the
Paperwork Reduction Act of 1995 (PRA), the Centers for Medicare and
Medicaid Services (CMS) (formerly known as the Health Care Financing
Administration (HCFA)), Department of Health and Human Services, is
publishing the following summary of proposed collection for public
comment. Interested persons are invited to send comments regarding this
burden estimate or any other aspect of this collection of information,
including any of the following subjects: (1) The necessity and utility
of the proposed information collection for the proper functions of the
agency's functions; (2) the accuracy of our estimate of the information
collection burden; (3) ways to enhance the quality, utility, and
clarity of the information to be collected; and (4) the use of
automated collection techniques or other forms of information
technology to minimize the information collection burden.
We are, however, requesting an emergency review of the information
collection referenced below. In compliance with the requirement of
section 3506(c)(2)(A) of the PRA, we have submitted to the Office of
Management and Budget (OMB) the following requirements for emergency
review. We are requesting an emergency review because the collection of
this information is needed before the expiration of the normal time
limits under OMB's regulations at 5 CFR Part 1320. We cannot reasonable
comply with the normal clearance procedures because the MPAF will be
effective on July 1, 2002.
We are requesting OMB review and approval of this collection within
15 days of the date of this publication, with a 180-day approval
period. Written comments and recommendations will be accepted from the
public if received by the individuals designated below within 14 days
of this publication. During this 180-day period, we will publish a
separate Federal Register notice announcing the initiation of an
extensive 60-day agency review and public comment period on these
requirements.
Summary: SNFs are required to submit the resident assessment data
described at 42 CFR 483.20, in the manner necessary to administer the
payment rate methodology described in Sec. 413.337. Pursuant to
sections 4204(b)
[[Page 38131]]
and 4214(d) of OBRA '87, the current requirements related to the
submission and retention of resident assessment data are not subject to
the PRA. However, the requirement to maintain performance of patient
assessment data for days 5, 30, and 60 following admission, necessary
to administer the payment rate methodology described in Sec. 413.337,
is subject to the PRA, and is approved by OMB under approval number
0938-0739, with a current expiration date of April 30, 2003.
Since we are now making the collection and submission of certain
MDS items optional, as referenced in this notice, we are soliciting
comments on the optional data elements and burden reduction associated
with the revised reporting requirements.
We have submitted a copy of this notice to OMB for its review of
the information collection requirements.
To obtain copies of the supporting statement and any related forms
for the proposed paperwork collections referenced above, access our web
site address at http://www.hcfa.gov/regs/prdact95.htm, or E-mail your
request, including your address, telephone number, OMB number, and CMS
document identifier, to [email protected], or call the Reports
Clearance Office at (410) 786-1326.
Interested persons are invited to send comments regarding the
burden or any other aspect of these collections of information
requirements. However, as noted above, comments on these information
and recordkeeping requirements must be mailed and/or faxed to the
designees referenced below, within 14 days of the publication of this
notice:
Centers for Medicare & Medicaid Services, Office of Information
Services, Standards and Security Group, Division of CMS Enterprise
Standards, 7500 Security Boulevard, Room N2-14-26, Baltimore, MD 21244-
1850, Fax: (410) 786-0262 Attn: John Burke, CMS-1209-N, and,
Office of Information and Regulatory Affairs, Office of Management and
Budget, New Executive Office Building, Room 10235, Washington, DC
20503, Fax: (202) 395-6974 or (202) 395-5167, Attn: Allison Herron
Eydt, CMS Desk Officer, CMS-1209-N.
VI. Regulatory Impact Analysis
We have examined the impact of this notice as required by Executive
Order 12866, the Unfunded Mandates Reform Act (UMRA, Pub. L. 104-4),
the Regulatory Flexibility Act (RFA, Pub. L. 96-354), and the
Federalism Executive Order 131232.
Executive Order 12866 directs agencies to assess costs and benefits
of available regulatory alternatives and, when regulation is necessary,
to select regulatory approaches that maximize net benefits (including
potential economic, environmental, public health and safety effects,
distributive impacts, and equity). A regulatory impact analysis (RIA)
must be prepared for major rules with economically significant effects
($100 million or more annually). This notice is not significant as
defined in Title 5, United States Code, section 804(2).
The UMRA also requires (in section 202) that agencies prepare an
assessment of anticipated costs and benefits before developing any rule
that may result in an expenditure in any year by State, local, or
tribal governments, in the aggregate, or by the private sector, of $110
million or more. This notice will have no consequential effect on
State, local, or tribal governments. We believe the private sector cost
of this notice falls below these thresholds as well.
Executive Order 13132 (effective November 2, 1999) establishes
certain requirements that an agency must meet when it promulgates
regulations that impose substantial direct compliance costs on State
and local governments, preempt State law, or otherwise have Federalism
implications. As stated above, this notice will have no consequential
effect on State and local governments.
The RFA requires agencies to analyze options for regulatory relief
on small entities. For purposes of the RFA, small entities include
small businesses, nonprofit organizations, and governmental agencies.
Most SNFs and most other providers and suppliers are small entities,
either by virtue of their nonprofit status or by having revenues of $10
million or less annually. For purposes of the RFA, all States and
tribal governments are not considered to be small entities, nor are
intermediaries or carriers. Individuals are also not included in the
definition of a small entity. The provisions of this notice, to make
available a shorter version of the MDS to meet Medicare payment
requirements, creates no additional regulatory burden on small
entities.
In addition, section 1102(b) of the Act requires us to prepare an
RIA if a rule may have a significant impact on the operations of a
substantial number of small rural hospitals. This analysis must conform
to the provisions of section 604 of the RFA. For purposes of section
1102(b) of the Act, we define a small rural hospital as a hospital that
is located outside of a Metropolitan Statistical Area and has fewer
than 100 beds. This notice only applies to those few small rural
hospitals that have distinct-part skilled nursing units. For those few
providers, the option provided by this notice decreases the regulatory
burden and requires no action by the provider.
We do not believe that there will be any negative effect on either
the quality of care delivered, or on our ability to monitor the quality
of that care, as a result of decreasing the amount of clinical
information that will be collected for Medicare beneficiaries during
their SNF stays. The MPAF includes all of the assessment items required
for the resident assessment instrument by the OBRA '87, as well as all
of the items to support current quality monitoring. Further, the
Secretary's Advisory Committee on Regulatory Reform strongly favored a
reduction of the amount of data collection required from nursing
facilities, an indication of the expected reception by the public of
this new version of the MDS.
Facilities may be concerned about making changes to their computer
systems in order to be able to enter and transmit the MPAF
electronically. We note that there is no requirement for facilities to
integrate this version of the MDS into their systems. The facility has
complete discretion regarding when, and if, it chooses to begin use of
this assessment form. The RAVEN grouper and MDS transmission software
that is available at no cost from our web site at www.hcfa.gov/medicare/mds20/mdssoftw.htm will support the use of the MPAF. Also, the
State systems will accept the MPAF beginning July 1, 2002.
We estimate that the MPAF will require approximately half as much
time to complete as the full MDS. Completion of the MPAF will require
approximately 45 minutes, compared to approximately 90 minutes required
to complete the MDS currently in use. Depending on the SNF's level of
Medicare participation, use of the MPAF may result in saving a
significant amount of time that could be made available to staff for
the provision of beneficiary care.
VII. Waiver of Proposed Rulemaking
We ordinarily publish a notice of proposed rulemaking in the
Federal Register to provide a period for public comment before the
provisions of a notice such as this take effect. We can waive this
procedure, however, if we find good cause that a notice and comment
procedure is impracticable, unnecessary, or contrary to the public
interest and incorporate a statement of
[[Page 38132]]
the finding and its reasons in the notice issued.
We find that it is unnecessary and contrary to the public interest
to undertake notice and comment rulemaking because this notice merely
provides SNFs with the option to use a shorter version of the MDS to
satisfy the Medicare assessment requirements, thus, lessening the
burden on the SNF providers. There is no change to the current
practices of SNF providers in completing the MDS resident assessment
instrument. Therefore, for good cause, we waive prior notice and
comment procedures.
(Catalog of Federal Domestic Assistance Program No. 93.773,
Medicare--Hospital Insurance; and Program No. 93.774, Medicare--
Supplementary Medical Insurance Program)
Dated: March 12, 2002.
Thomas A. Scully,
Administrator, Centers for Medicare & Medicaid Services.
Dated: April 24, 2002.
Tommy G. Thompson,
Secretary.
[FR Doc. 02-13613 Filed 5-24-02; 4:53 pm]
BILLING CODE 4120-01-P