CMS Proposes Quality Measures for Health Care Worker Vaccinations

 Published: May 13, 2021

By: Anne Marie Hummel



The Centers for Medicare & Medicaid Services (CMS) has recently issued proposed rules impacting a variety of facilities that are paid under Medicare’s prospective payment system (PPS) that could affect respiratory therapists. These include inpatient and long-term care hospitals, inpatient rehabilitation facilities, and skilled nursing facilities. A key provision in these rules is a proposal to adopt a COVID-19 Vaccination Coverage among Healthcare Personnel (HCP) measure that will require hospitals and other facilities to report COVID-19 vaccinations of healthcare workers in their facilities as they are considered among those at greatest risk of developing severe illness from COVID-19.

Recognizing that front line workers employed in acute care hospitals were among the first prioritized to be vaccinated, CMS believes it is important to incentivize and track vaccination in these facilities through quality measurement. Thus, the proposed measure “is designed to assess whether hospitals are taking steps to limit the spread of COVID-19 among their workforce, reduce the risk of transmission within their facilities, help sustain the ability of hospitals to continue serving their communities through the public health emergency, and assess the nation’s long-term recovery and readiness efforts”. Overall, it is intended to strengthen the ongoing response to the public health emergency and future health threats.

With respect to the inpatient prospective payment rules, at the start there will be a shortened reporting period from October 1, 2021 through December 31, 2021 affecting the calendar year reporting period and the fiscal year 2023 payment determination. Quarterly reporting will begin with the FY 2024 payment determination and subsequent years. In assessing the measure, the denominator consists of the number of health care workers eligible to work in the health care facility for at least one day during the submission period, excluding persons with contraindications to COVID-19 vaccination that are described by the Centers for Disease Prevention and Control (CDC), with the numerator being the cumulative number of eligible health care workers who received a completed vaccination course against COVID-19 since the date the vaccine was first available or on a repeated interval if revaccination is recommended. The SNF and IRF measures are similar but the reporting requirements will be different as they will be required to use the CDC/National Healthcare Safety Network (NHSN) as the method of data submission beginning with their FY 2023 respective quality reporting programs.

While the AARC recognizes that vaccinations are a personal choice, the Association encourages the vaccination of all healthcare workers, including respiratory therapists.

Email with questions or comments, we’d love to hear from you.

Anne Marie Hummel

Anne Marie Hummel is the AARC’s Associate Executive Director for Advocacy and Government Affairs where she brings her years of regulatory experience in the Federal Government to overseeing federal and state legislative and regulatory policies that impact the respiratory care profession. Check out AARC’s Advocacy menu on our website to learn more. Outside of work, Anne Marie loves interior design, tackling 1000-piece puzzles and spending time with her granddaughter.

Heading to the New Era

Elevate | Engage | Advocate | Educate

Copyright © 2024 American Association for Respiratory Care
9425 N. MacArthur Blvd, Suite 100, Irving, TX 75063-4706
(972) 243-2272  |