Hospitals are already in the mandatory reporting of the hybrid measures CMS 529 and CMS 844, which is July 1, 2023 to June 30, 2024. Many hospitals had significant issues with meeting the data submission requirements for the July 1, 2021 to June 30, 2022 voluntary reporting period. In addition, Hospitals that submitted results for the recent voluntary period (July 1, 2022 to June 30, 2023) will see not the results until the spring of 2024. At that time, the current mandatory reporting period will be almost over. If a hospital discover issues with meeting the data submission requirements for vital signs and labs, it may be too late for them to correct the issue and raise their percentages to meet the thresholds for the mandatory period. We saw numerous issues with the data that we last received back from CMS in May of 2023. CMS is also changing the IPP of the measures to include all Medicare patients. It is entirely reasonable that CMS makes reporting these two measures mandatory for the current reporting period. However, I would ask that CMS postpone the penalty for not meeting the data submission requirements, which amounts to failing the IQR program with the ¼ percent reduction of its Annual Payment Update. Many hospitals may not be aware that they are not meeting the data completeness requirements until it is too late to correct the issues.

I have been informed by CMS that the failure to meet the data submission requirements for the Hybrid eCQM measures will result in failure to meet the IQR program with a 1/4 percent payment adjustment. Please delay the penalty for meeting the data submission requirements, while keeping the submission of CMS 529 and CMS 844 mandatory.