June 9, 2026
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-1849-P
P.O. Box 8013
Baltimore, MD 21244-8013
Dear Administrator Oz,
The Society of Hospital Medicine (SHM), representing the nation’s more than 50,000 hospitalists, appreciates the opportunity to provide comments on the proposed rule: Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals (IPPS) and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year (FY) 2027 Rates; Requirements for Quality Programs; and Other Policy Changes (CMS-1849-P).
Hospitalists are physicians whose professional focus is the general medical care of hospitalized patients. In addition to managing the clinical care of patients, hospitalists work to enhance the performance of their hospitals and health systems. The unique position of hospitalists in the healthcare system affords a distinctive role in facilitating both the individual physician-level and systems- or hospital-level performance agendas. It is from these perspectives that we offer our comments.
Hospital Readmissions Reduction Program
Proposed Adoption of the Hospital 30-Day, All-Cause, Risk-Standardized Readmission Rate Following Sepsis Hospitalization Measure
SHM continues to oppose the use of 30-day readmission windows across CMS quality and value-based payment programs. Reducing avoidable readmissions is an important systemwide goal that can improve patient outcomes and support more efficient use of limited healthcare resources. However, substantial evidence suggests that a 30-day window is overly broad and does not provide hospitals and hospitalists with a reasonable measure of preventable readmissions.
A 2018 study in Annals of Internal Medicine examined the preventability of early (within 7 days) and late (8 to 30 days) readmissions across 10 U.S. academic medical centers.[1] The study found that more than 36% of early readmissions were reasonably considered preventable, compared with 23% of late readmissions. It also examined where interventions are most effective, finding that hospitals are better positioned to prevent early readmissions, while outpatient clinics and the home are better settings for addressing later readmissions. These findings raise important concerns about the use of 30-day readmission measures in hospital-level quality programs.
SHM urges CMS to reconsider its use of 30-day readmission windows in hospital- and clinician-level measures. As the cited research indicates, a 7-day readmission window would better capture hospital and clinician performance and provide a more meaningful target for hospital-based quality improvement efforts.
Crosscutting Quality Program Proposals and Requests for Comment
Proposed Adoption of the Advance Care Planning Electronic Clinical Quality Measure in the Hospital Inpatient Quality Reporting Program
CMS proposes implementing an Advance Care Planning eCQM in the IQR program. SHM agrees that high-quality advance care planning and goals of care discussions are essential to caring for patients at the end of life. This measure, as structured, would assess whether an advance care plan form or discussion is documented in the medical record. While we support expanding access to these important conversations, this measure does not evaluate their quality. As a process measure, this measure may contribute to note bloat in the EMR, as documentation will likely be copied over repeatedly in the patient’s record.
We also have some concerns about this measure being broadly applicable to all adult patients over 18. While there are situations where a conversation about end-of-life care may be appropriate with younger patients, performance on this measure may inadvertently cause emotional distress with younger and otherwise healthy hospitalized patients. We suggest inclusion of stratification based on age or other criteria that targets the most relevant patient population for this measure, which could include (but not limited to) oncology patients, ICU patients, patients with high comorbidity scores, and patients with high readmission risk scores.
Measuring Emergency Care Access and Timeliness in the Hospital Inpatient Quality Reporting and Hospital Value-Based Purchasing Programs—Request for Information
CMS requested feedback on the potential implementation of a composite measure “Measuring Emergency Care Access and Timeliness.” This measure includes patient wait time, left without being evaluated, patient boarding time in the emergency department (ED), and patient ED length of stay. This measure was previously adopted for use in the Hospital Outpatient Quality Reporting program in the CY 2026 OPPS/ASC final rule. CMS is considering implementing the measure in the IQR and HVBP programs.
It is no doubt that ED boarding is a multifaceted and pernicious challenge facing the healthcare system. This problem is exacerbated by the shortage of primary care providers and on-going loss of insurance coverage and resultant lack of coverage for primary care for many patients across the country. This leads many patients to use the ER as a primary point of care. Staffing in hospitals and nursing homes is also a critical factor in availability of inpatient bed space and timely discharges. We urge CMS, this administration, and Congress to consider these issues holistically and across relevant policy levers, as opposed to the narrow silo of using a measure to address ED boarding.
Specific to aspects of the measure, we have concerns about the heterogeneity of the population of patients who leave an ER without being seen. This variability makes it challenging to interpret the results of this measure in the context of quality or efficiency of the hospital. We also ask CMS to consider how the measure accounts for frequent or high utilizers of the emergency department, as these may again not be reflective of the hospital or ED care provided but exogenous patient- or social-related factors.
The discussion cites a wide range of interventions in the inpatient setting that may be tried to help with throughput and alleviate bedspace in the hospital. We appreciate that CMS acknowledges there is not a “one-size-fits-all” solution for this problem.
CMS asks whether it is appropriate for hospitals to be held accountable for this measure in hospital-level programs, beyond the ED’s being held accountable in the HOQR program. On the one hand, yes, hospital leadership is critical to solving ED boarding and allocating resources to address this problem. There are many issues within a hospital that may contribute to ED boarding, including staffing (nursing, case managers, social work, etc.), bed availability, availability of specialists, and diagnostic or service availability. On the other hand, there are many downstream roadblocks or bottlenecks that affect hospital occupancy beyond the direct control of a hospital. These include payer prior authorization delays and availability of nursing homes and other post-discharge care. In addition, nursing home quality can be a limitation in patients’ choices for appropriate discharge locations. We caution that hospitals themselves cannot control all these external factors, and well-intentioned measures like this may encourage consolidation in the healthcare system.
We are concerned this measure will create new pressures in the inpatient setting for accelerated discharges, such as discharge by 11am or noon, despite ample evidence of the ineffectiveness of these interventions. We urge CMS to be cautious about implementation of this ED throughput composite measure as a hospital measure, and to consider ways to more meaningfully measure inpatient throughput.
These challenges are particularly acute in rural settings. For example, rural hospitals often do not have round-the-clock specialty care, case management or social work available. Rural hospitals also may not have a geographically close network of nursing homes or other post-discharge care settings, making hospital throughput and discharges particularly difficult and time intensive. All these factors contribute to delays in care and, ultimately, timely discharge of patients.
Potential Future Use of the Adult Community-Onset Sepsis Standardized Mortality Ratio Measure in the Hospital Inpatient Quality Reporting Program—Request for Information
SHM appreciates CMS’ intentional approach to implementing a new major sepsis measure through this request for information about the potential future use of the sepsis mortality ratio measure. Sepsis is a major driver of inpatient morbidity, mortality and resource use.
A thoughtfully specified sepsis mortality measure could help focus attention on comprehensive, hospital-wide approaches to sepsis care, including timely recognition, diagnostic optimization, evidence-based antimicrobial management and stewardship, infection prevention, and hospital-wide quality improvement for one of the most serious infectious syndromes treated in acute care settings. Consistent with comments SHM, along with IDSA and other partnership societies, have previously submitted in support of this measure and our shared goal of shifting from SEP-1 toward more meaningful outcome-based sepsis metrics, SHM supports CMS’ continued development and future use of the Adult Community-Onset Sepsis Standardized Mortality Ratio measure in the Hospital IQR Program.
SHM encourages CMS to maintain a deliberate and transparent approach as it prepares this measure for adoption, including clear communication with stakeholders about any refinements to the specifications, attribution rules and data requirements. Any sepsis mortality measure should continue to be supported by a clear and clinically credible case definition, robust risk adjustment and testing that demonstrates the measure can distinguish quality of care from differences in patient acuity, comorbidities and presentation patterns across hospitals. As part of this work, SHM urges CMS to provide analyses that explicitly assess the potential impact of coding behavior and to demonstrate that the measure is resilient to shifts in coding intensity or strategy over time. SHM encourages continued stakeholder engagement on this measure to ensure that any future proposal advances accountability and patient outcomes without creating unintended consequences for hospitals caring for the sickest and most medically complex patients.
As CMS considers the implementation of this measure, we also encourage consideration for challenges in rural hospital settings. For example, rural populations tend to be sicker, older and overall have less contact with the healthcare system, which can appear as patients with more severe initial presentations in the hospital. These populations may also face challenges through social determinants of health, including distance to access care, higher tobacco use rates, higher rates of poverty, social isolation and lack of access to transportation, utilities and high-speed internet access.
Requirements for and Changes to the Hospital Inpatient Quality Reporting Program
Proposed Adoption of the Excess Days in Acute Care After Hospitalization for Diabetes Measure
CMS proposes to adopt the Excess Days in Acute Care After Hospitalization for Diabetes measure into the IQR. SHM voiced concern about this measure during the 2025 Measures Under Consideration process and are disappointed with the proposal to implement this measure for the 2029 payment determination. We agree that diabetes, as a common health condition faced by millions of Americans, is a good candidate for measures to address chronic illness. However, we do not support the measure as currently structured for use in the IQR program. We ask CMS to narrow the measure window, clarify measure specifications, and consider alternate programs for the measure.
Like our opposition in readmission measures, we have concerns about the use of a 30-day measure window in Excess Days in Acute Care measures. A 30-day window is too long and incorporates excess days beyond the reasonable control of a hospital or hospitalist team. Like readmissions measures, we would support a measure that narrowly targets avoidable or preventable excess days and believe a shorter 7-day window would be more meaningful as a measure.
Diabetes, as an exceedingly common chronic condition in the U.S., has a wide range of symptom severity and associated conditions. We continue to be concerned that this hospital-level measure is not targeted towards the conditions and complications typically associated with hospitalization for diabetes, including but not limited to coma, diabetic ketoacidosis (DKA), diabetic foot ulcer, and hyperosmolar hyperglycemic state (HHS).
Because this measure is dependent not only on care delivered in the hospital, but also outpatient resources and post-discharge follow-up, this measure may be better suited for an ACO-type environment. Much of the performance on this measure may be driven by availability of post-discharge resources, such as durable medical equipment or pharmacy availability.
Proposed Adoption of the Hospital Harm—Postoperative VTE Electronic Clinical Quality Measure; Proposed Removals in the Hospital IQR Program Measure Set (VTE-1, VTE-2, STK-2)
SHM supports the removal of VTE Prophylaxis (VTE-1), ICU VTE Prophylaxis (VTE-2), and Discharge on Antithrombotic Therapy (STK-02) as they may no longer be driving improvement for patients.
Updates to the Form, Manner, and Timing of Quality Data Submission
Proposal for Mandatory Reporting of the Hospital Harm Electronic Clinical QualityMeasures
SHM supports CMS’ proposal for a two-year runway for future hospital harm measures to become mandatory for reporting. We believe this offers more clarity about CMS’ intention with these measures, while giving hospitals and clinicians time to adopt and understand the new measures. We urge CMS to remain open to feedback on potential problems and issues with measures during this two-year implementation phase. The agency should continue to conduct notice-and-comment for measures that meet the two-year threshold to enable stakeholders to flag concerns or flaws in measures.
RFI on Future Potential Performance-Based Measure of Electronic Prior Authorization
SHM appreciates CMS’ intention of creating efficiencies in prior authorization processes and applauds many of its recent efforts to streamline these onerous rules. While we understand the Promoting Interoperability program is a lever with which CMS can affect behavior, we respectfully urge the agency to consider ways to incentivize MA plans, private payers, and third party EHR vendors to accelerate adoption of ePrior Authorization.
Conclusion
SHM appreciates the opportunity to provide feedback on the Inpatient Prospective Payment System proposed rule. If you have any questions or require further information, please contact Josh Boswell, Chief Legal Officer at jboswell@hospitalmedicine.org.
Sincerely,
Efrén C. Manjarrez, MD, FACP, SFHM
President
Society of Hospital Medicine
[1] Graham KL, Auerbach AD, Schnipper JL, et al. Preventability of Early Versus Late Hospital Readmissions in a National Cohort of General Medicine Patients. Ann Intern Med. 2018;168(11):766-774. doi:10.7326/M17-1724