June 5, 2023

The Honorable Chiquita Brooks-LaSure

Administrator
Centers for Medicare & Medicaid Services
Hubert H. Humphrey Building
200 Independence Avenue, S.W., Room 445-G
Washington, DC 20201

RE: CMS-1783-P, Medicare Proposed Rule to Update the Inpatient Psychiatric Facility Prospective
Payment System for Fiscal Year (FY) 2024

Dear Administrator Brooks-LaSure:

On behalf of its member hospitals, the Mississippi Hospital Association (MHA) appreciates this
opportunity to provide comments to the Centers for Medicare & Medicaid Services (CMS) regarding the
proposed rule to update the Medicare fee-for-service (FFS) prospective payment system (PPS) for
Inpatient Psychiatric Facilities (IPFs) for fiscal year (FY) 2024. The proposed net payment increase of 1.9
percentage points, relative to FY 2023 payment levels, is woefully inadequate and does not reflect recent
and current cost pressures faced by IPFs.

Even prior to the pandemic acute care hospitals shared concerns with us that they often treat
emergency department patients who have a critical need for inpatient behavioral health services. In
many cases, the acute care hospitals board these patients – sometimes for weeks – without payment
while they wait for an IPF bed to become available for the patient based on the patient’s age
(adolescent, geriatric, etc.) and gender.

This scenario limits the capacity for hospitals to care for patients who need acute care services and
increases their costs as they provide room and board, meals, laundry, housekeeping, and other services
to “boarders” who are waiting for IPF care. In some cases, these “boarders” require constant supervision
by hospital staff to ensure they don’t injure themselves or others. This scenario is unacceptable.

The COVID-19 pandemic has further heightened the need for behavioral health services across
Mississippi and the U.S. for individuals of all ages as highlighted daily by tragic events. We continue to
urge the CMS to work with the Biden-Harris Administration, hospitals, and other stakeholders to increase
the availability of behavioral health services. Our specific comments regarding the FY 2024 proposed rule
are below.

Payment Update

MHA is concerned about the CMS’ proposed 3.1% annual market basket update given the surging
inflation that IPFs continue to experience. In addition, Medicare continues to pay less than the cost of
providing care with the latest Medicare FFS margin data, indicating that, in total, Medicare payments
cover only about 95% of the cost of care provided by hospitals. Absent substantial financial support in
the final rule, IPFs will struggle to continue providing these vital services in their communities
particularly as IPFs and other post-acute providers continue to face intense labor shortages and
challenges. These staffing challenges impact the ability of inpatient hospitals to discharge patients in a
timely manner, leading to increased expenses without commensurate revenue, higher lengths of stay,
and limited bed capacity in the hospital setting. MHA has long advocated that the right care be provided
at the right time in the most appropriate care setting and urges the CMS to increase the market basket
update to recognize the unprecedented inflation currently faced by IPFs and other providers.

We also remain concerned about the proposed application of the 0.2% productivity cut for FY 2024.
MHA urges CMS to closely monitor the impact of such productivity adjustments and explore ways to use
the agency’s authority to offset or waive these adjustments.

Wage Index Policies

We continue to support the policy adopted for FY 2023 that implements a permanent 5% cap on any
decrease in a provider’s wage index, relative to the prior year. However, MHA urges CMS to implement
this policy in a non-budget-neutral manner which would both stabilize provider reimbursement and
avoid further unexpected reductions for other providers.

Proposed Modification to the Excluded Unit Regulation

Currently, to be paid under the IPF PPS, and excluded from the hospital inpatient PPS, an IPF unit of a
hospital must be paid under the IPF PPS effective at the beginning of a cost reporting period and may not
attain this payment status in the middle of a cost report period. This requirement is burdensome for
hospitals as it is often difficult to predict the timing for the completion of a construction project for a
new IPF. This results in the hospital being unable to guarantee the completion at the beginning of a cost
reporting period and can lead to significant revenue loss if the hospital must wait until the start of the
next cost reporting period to be paid under the IPF PPS.

The CMS proposes to allow greater flexibility for hospitals to open an IPF-excluded unit. Specifically, CMS
proposes allowing a hospital to open a new IPF unit anytime during the cost reporting year if certain
requirements are met. MHA believes this is a positive change that will increase access to IPF services and
urges CMS to finalize this proposal.
Cost Outlier Threshold

Outlier payments were established to provide additional payments for extremely costly cases. An outlier
payment is made when the cost for an IPF case exceeds a fixed dollar loss threshold amount plus the
federal per diem payment amount for the case. Costs are determined by multiplying the IPF’s overall
cost-to-charge ratio by the allowable charges for the case. When a case qualifies, the CMS pays 80% of
the difference between the estimated cost and the adjusted threshold amount for days 1 through 9 of
the stay, and then 60% of the difference for the tenth day and beyond.

The CMS has established a target of 2% of total IPF PPS payments to be set aside for high-cost outliers.
The CMS proposes to update the threshold to $34,750 for FY 2024, which is a 41% increase over the
current $24,630 threshold. This significant increase will have a dramatic impact on IPFs as they continue
to face intense financial challenges. MHA requests that CMS explain in greater detail the factors driving
the increase and that CMS examine its methodology and consider making changes to mitigate increases
to the outlier threshold.

Proposed Updates to the IPF Quality Reporting Program (QRP)

The Affordable Care Act requires that IPFs that do not successfully participate in the IPFQRP are subject
to a 2-percentage point reduction to the market basket update for the applicable year. In the FY 2024
proposed rule, CMS proposes to adopt four new measures, modify an existing measure, and remove two
measures.

Modification of the COVID-19 Vaccination Coverage among Healthcare Personnel (HCP COVID-19
Vaccine) Measure

Beginning with the FY 2025 IPF QRP, CMS proposes to modify the existing Healthcare Personnel (HCP)
COVID-19 Vaccination measure used in the IPF QRP. The current measure assesses the number of HCP
who have received a complete vaccination course against COVID-19. In this rule, CMS proposes to
replace the definition of “complete vaccination course” with a definition of “up to date” with the
CDC-recommended COVID-19 vaccines. CMS proposes this modification to incorporate new CDC
guidance related to booster doses and their associated timeframes.

MHA supports vaccination as a means of keeping both staff and patients safe but we have concerns
regarding this measure. The CDC maintains guidance that receiving a dose of the COVID-19 vaccine may
or should be delayed if a person has or has recently had a COVID-19 infection. This could impact the
timing of an employee’s vaccine dosage, resulting in an inaccurate reporting of employees “up to date”
on vaccination.

Vaccination administration rates can ebb and flow significantly based on factors outside the control of
hospitals and other providers, including holidays, weather, vaccine/pharmaceutical supply chain
management, staff availability, and more. The frequency and speed with which these rates change will
not accurately depict the vaccination rate of a facility’s patients or staff.
The CDC confirms the following: “Adolescents and adults in rural areas had a much lower primary series
completion rate and up-to-date vaccination coverage. Bivalent booster coverage was lower among
non-Hispanic Black or African American (Black) and Hispanic or Latino (Hispanic) adolescents and adults
compared with non-Hispanic White (White) adolescents and adults. Among adults who were open to
receiving booster vaccination, 58.9% reported not having received a provider recommendation for
booster vaccination, 16.9% had safety concerns, and 4.4% reported difficulty getting a booster vaccine.”

Hospitals fully support promoting vaccines among all populations, including at community-centered
locations and through trusted community partners, in addition to hospital-operated facilities. However,
these continuing disparities in vaccine uptake reflect not on the local hospital’s efforts to vaccinate their
patients, but often in differences deeply rooted in culture, religion, ethnicity, socioeconomic status, and
more. These disparities should not be a measure associated with a hospital or an indicator of patient
safety. Rather, they should be used to guide all vaccine advocates’ efforts to increase vaccination rates in
their communities.

As mentioned above, disparities remain in different geographic areas, among races, and more. These
same disparities tend to exist within the healthcare workforce. Therefore, while hospitals and post-acute
care facilities will continue to educate and encourage all employees to be vaccinated against COVID-19 to
protect themselves and their patients, challenges remain to overcome historical challenges and should
not be measured against a hospital’s ability to provide a safe environment.

MHA opposes the proposed modification to the HCP measure and urges the CMS to abandon the
agency’s proposal to modify this measure.

Addition of new measures

The CMS is proposing to adopt four new measures for the IPF QRP:

Facility Commitment to Health Equity (attestation in calendar year (CY) 2024 reporting period for CY
2025/FFY 2026 payment determination). The CMS proposes to adopt this structural measure that
assesses whether an IPF demonstrates certain equity-focused organizational competencies. IPFs would
be asked to attest to several statements within five domains including:

● Equity is a strategic priority

● Data collection
● Data analysis
● Quality improvement
● Leadership engagement

Several domains comprise multiple attestation statements. To receive credit for the domain, an IPF
would have to attest affirmatively to each statement within that domain. Performance would be scored
out of five points. The measure has not been tested for IPFs and is not endorsed by a consensus-based
entity (CBE), and the CMS has not submitted it for endorsement. While this measure aligns with areas
the MHA believes are important, we recommend requiring attestation for three of the five items.
Screening for Social Drivers of Heath (SDOH) (voluntary reporting CY 2024 followed by required
reporting CY 2025/FFY 2027 payment determination). CMS proposes to adopt this structural measure
that evaluates whether IPFs are screening patients for certain health-related social needs (HRSNs). The
CMS explains that IPFs could use a self-selected screening tool to collect data on HRSNs including food
insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety. IPFs
would report the number of inpatients admitted to the IPF who are 18 years or older at the time of
admission who were screened for all five HRSNs. Similar to above, this measure has not had adequate
testing and is not endorsed by a CBE, and has not been submitted by the CMS for endorsement. MHA
opposes mandatory reporting of this measure until it receives endorsement for the IPF setting and urges
the CMS to continue voluntary reporting until such time.

Screen Positive Rate for SDOH (voluntary reporting CY 2024 followed by required reporting CY
2025/FFY 2027 payment determination). CMS proposed to adopt this measure that assesses the
percentage of patients admitted to an IPF who were screened for the HRSNs listed above who screen
positive for one or more. IPFs would report five separate rates—one for each need. The measure is
intended to provide information to IPFs on the level of unmet HRSNs among patients served and not for
comparison between IPFs. The measure is not endorsed by a CBE nor has the CMS submitted it for
endorsement. MHA opposes the adoption of this measure until it is endorsed for use in the IPF setting.

Psychiatric Inpatient Experience (PIX) Survey (voluntary reporting CY 2025 followed by required
reporting CY 2026/FFY 2028 payment determination). The CMS proposes to adopt a specific patient
experience of care instrument, the PIX survey, and a measure based on patient responses on a 5-point
Likert scale to survey items. The survey comprises 23 items across four domains, including:

● Relationship with treatment team

● Nursing presence
● Treatment effectiveness
● Healing environment

This measure would be reported as five separate rates: one for each of these four domains and one
overall rate. Mean rates would be publicly reported on Care Compare. The survey would be distributed
to patients on paper or a tablet computer by administrative staff beginning 24 hours prior to planned
discharge. Patients would be excluded from the measure if they are younger than 13 years old at
discharge or unable to complete the survey due to cognitive or intellectual limitations.

CMS acknowledges that IPFs already administer different patient experience of care surveys to their
patients and would need to transition to the PIX survey. As a result, the CMS proposes a voluntary
reporting period during which IPFs would be able to start administering the PIX survey and collecting
survey data in CY 2025 to report on a voluntary basis in 2026 and would be required to administer the
survey and collect data during 2026 to report during 2027 with payment implications in 2028.

IPFs are concerned about the limited testing of the survey and the administrative burden of transitioning
to another survey at a time when IPFs are facing extreme staffing shortages. MHA recommends that the
CMS implement this measure on a voluntary basis only.

Removal of two measures from the IRF QRP

The CMS proposes to remove two measures from the IRF QRP beginning with the FY 2025 IRF QRP
including:

● Patients Discharged on Multiple Antipsychotic Medications with Appropriate Justification

(HBIPS-5)
● Tobacco Use Brief Intervention Provided or Offered and Tobacco Use Brief Intervention
(TOB-2/2a)

CMS believes the HBIPS-5 measure is no longer aligned with current clinical guidelines and practice. The
agency believes the cost of the TOB-2/2a measure outweighs its benefits and is somewhere duplicative
since a related measure, Tobacco Use Treatment Provided or Offered at Discharge and Tobacco Use
Treatment at Discharge (TOB-3/3a) would be retained since the CMS believes this measure would better
drive improvement in patient outcomes. MHA supports the CMS proposal to remove the two measures
and encourages CMS to finalize this proposal.

Summary

MHA appreciates this opportunity to provide comments to the CMS on the FY 2024 IPF proposed rule
and believes that our proposed changes will have a positive impact on IRFs and all patients they serve. If
you have questions regarding this comment letter, please contact me at (601) 368-3201 or
[email protected].

Sincerely,

Timothy H. Moore
President/Chief Executive Officers
Mississippi Hospital Association