Emergency Care Access & Timeliness (ECAT)

This information should be retrievable directly from the electronic medical record; however, significant resources would be required to build, validate, and maintain the abstraction and reporting workflows necessary for reliable measure submission. For Critical Access Hospitals (CAHs) and Rural Emergency Hospitals (REHs), this would likely necessitate additional staffing, increased reliance on health information technology vendors or third-party abstractors, and associated costs that may be disproportionate to hospital size and available resources. The Kansas Hospital Association suggests this measure be assessed for costs and resources that would be added to hospitals to fulfill the measure. 

This measure shows a different spin on the typical timeliness measures for emergency room care. Agree these are still very relevant with overcrowding and poor throughput within the ED.  Providers are forced to find creative and innovative ways to improve the quality and movement patient experience.  

The American Medical Association (AMA) appreciates the potential consideration of a measure that addresses a very important issue and believes that it will facilitate hospital efforts to improve the care received by patients within the emergency department (ED) setting. However, clarification on why this measure should be considered for the Hospital Inpatient Quality Reporting Program when it is already included in the Hospital Outpatient Quality Reporting Program would be helpful. In addition, we request that additional changes be made to the measure in the near future. 

We agree with standardizing ED volumes for outcomes 1, 2, and 4; however, we do not believe that outcome 3 should be standardized since hospitals, regardless of the volume, should have an equal opportunity and responsibility to ensure that patients are not kept in the ED longer than necessary.

We also continue to encourage CMS to revise this measure to a composite where outcome 3 would be weighted more heavily than the other three outcomes (40% to 20%). This change would enable hospitals and others to evaluate performance across each of the outcomes, while also signaling that boarding times should always be no longer than 4 hours at a minimum. 

The AHA agrees that tracking information related to wait times and length of stay in the ED is important for hospital and health system planning purposes.  We also agree that ED boarding is a significant issue that effects patients’ experience of care and that can make it more challenging to deliver the best outcomes for patients. At the same time, ED wait times, throughput and boarding are also broader systemic issues whose drivers are often well beyond the control of hospitals and health systems. By considering this measure for adoption into the IQR, PIP and HVBP programs, we are concerned that CMS would be asking hospitals to shoulder the accountability for addressing this issue alone but with often limited ability to make improvement on measure performance. Furthermore, we are concerned by several other technical and conceptual shortcomings of this measure and believe further work is necessary for the measure to be ready for use in any national measurement program. For these reasons, the AHA does not recommend the adoption of this measure. 

Conceptually, the measure’s specifications do not sufficiently capture the complexity of ED operations and those of the hospital care continuum. The measure relies upon time windows without a clear base in evidence to determine appropriate access, assumes that ED throughput is solely a factor of ED and hospital operations, and inadequately accounts for differences in patient case mix and volumes. The field currently lacks evidence-based guidelines on how to improve performance on the measure. However, we believe that a more proactive approach to addressing these issues would involve CMS working with the AHA, its members, policymakers and other stakeholders to investigate and implement effective solutions rather than using a generalized accountability measure.

The measure concept focuses on ED operations; the idea of “throughput” relies on the conclusion that other parts of the hospital can accommodate any ED volume at any time and thus inadequate ED operations are the lone driver of delays. The reasons for variations in wait times in the ED are many, and several if not most of these drivers are outside of the control of the ED and the hospital as a whole. Admission times rely partly on availability of staffed inpatient beds; patient turnover decisions elsewhere in the hospital, such as in the ICU, are made based on patient clinical needs. While initial triage in the ED is based on medical priority, delays in admission can occur after the initial evaluation as providers wait for insurance authorization. 

As has been well documented by providers as well as by Department of Health and Human Services Office of Inspector General and congressional investigations, the prior authorization process used by Medicare Advantage and large commercial health plans places significant administrative burden on hospitals and other providers. Perhaps more importantly, it is directly harmful to Medicare beneficiaries— at best delaying their care and at worst outright denying medically necessary treatment. Despite important steps taken by CMS in recent years to strengthen the oversight of Medicare Advantage plans’ use of prior authorizations, providers have seen little meaningful change in MA plan behavior and no increased access for beneficiaries. Additionally, post-acute care providers still face challenges with MA plans listing them within their networks. These issues would be exacerbated in pay-for-performance programs where providers who serve a high proportion of MA patients would face disadvantages.

For these reasons, we are concerned that those hospitals that care for larger proportions of Medicare Advantage patients could perform worse on this measure because of decisions by Medicare Advantage plan to delay needed care and narrow their networks, and not because of the quality of care hospitals deliver. This situation could be especially problematic given that the remains variation in Medicare Advantage participation nationally. While it is true that in 2024 Medicare Advantage covered approximately 50% of Medicare beneficiaries, 21 states and the District of Columbia had Medicare Advantage rates under 50%, and 14 states had enrollment rates under 40%. For public reporting programs like the OQR to work in a fair manner, hospitals must be assured that measure performance is truly their own, and not disproportionately influenced by factors beyond their control.

The proposed measure also does not account for other factors that are not solely within hospitals’ control but could greatly impact ED throughput and boarding, and therefore, measure performance. Certain diagnoses may require specialist consultations, which can be difficult to garner in health professional shortage areas. A severe shortage of primary care in many communities means that conditions that could have been caught before they became emergent become serious and lead to larger volumes of emergency department visits. In addition, for medical issues that require prompt but not emergent attention, long wait times for primary care mean that patients have few choices other than an emergency department to receive care. In addition, our nation continues to face critical shortages of behavioral health care professionals, inpatient psychiatric beds and other supportive care for those who need behavioral health services. These structural shortages all influence the ability of hospital EDs to move patients to the next level of care and, therefore, how long a patient may spend in the ED. By assessing ED operations in a vacuum, the measure would not provide insight into predominant drivers of long ED waits that are influenced by hospitals. Instead, could simply be measuring the variation 

We are also concerned that the measure assesses performance based on timing that is not well supported by evidence as having an impact on patient outcomes. The measure calculates the proportion of all ED encounters during a 12-month period where the patient experiences a wait or stay in the ED longer than a specified length of time (e.g., one hour after arrival to be placed in a treatment room for evaluation). However, it is unclear whether there exists evidence that these particular time windows—one hour, four hours, etc.—have any marginal influence on patient outcomes. Studies cited in the measure’s documentation demonstrate that longer wait times are sometimes associated with poorer outcomes, but the various studies use definitions of ED length of stay ranging from two to 24 hours. We are unsure that it would be accurate to determine that a hospital that averaged 61 minutes to place a patient in a room for evaluation is “worse” than a hospital that averaged 60 minutes to do the same thing.

Another concern relates to the potential unintended consequences that use of this measure may impose, such as premature discharge from the ED, inappropriate reductions in inpatient admissions, increases in staff burnout, worsening disparities of care, and increased costs due to increases in observation volume. 

We appreciate that the measure has been updated since its earlier assessment in the Pre-Rulemaking Measure Review process to stratify rates by age and mental health diagnosis. However, we are concerned that the latter stratification approach does not include patients with primary diagnoses of substance use disorder (SUD). Clinical and federal guidelines generally include SUD alongside mental illness in the category of behavioral health due to their frequently overlapping patient presentation. In other words, separating ED throughput rates acknowledges the unique considerations for treating patients with diagnoses of mental illness; patients with SUD diagnoses require those same considerations. 

Finally, the field has yet to coalesce around best practices to improve performance on this measure. Several of the examples of changes in care for improvement provided in the measure’s supporting documentation are related to transformations of the care environment outside of the ED, such as use of “hospital home” care models. Others are suggestions that would require significant investments, clinical research, and policy change, such as “changes to diagnostic testing/imaging processes” or “Triage interventions, including predictive models, use of clinicians, and others.” Quality measures serve the dual purposes of informing patient decision-making and informing quality improvement efforts; due to the lack of targeted interventions demonstrated to influence measure performance, this measure is unlikely to fulfill those purposes. 

CMS is considering expanding use of MUC2025-072: Emergency Care Access & Timeliness (ECAT) measure to include the Hospital IQR Program, Medicare Promoting Interoperability Program and Hospital Value-Based Purchasing (VBP) Program. Currently, this measure will be used in the Hospital Outpatient Quality Reporting Program on a voluntary basis for calendar year 2027. Given the limited experience hospitals have had with this measure, Vizient discourages CMS from broadening application of the measure at this time. 

In addition, key experts have raised concerns with the measure, which also aligns with Vizient’s concerns. For example, the Measure Emergency Care Capacity and Quality Electronic Clinical Quality Measure (eCQM) TEP raised persistent implementation concerns around accurately capturing time to place a patient in a private treatment space, which Vizient agrees creates practical challenges and could make the measure less actionable.¹

Related to actionability, Vizient anticipates that the outcomes from the measure will not be sufficiently clinically useful. For example, the measure only captures wait times and does not account for patient acuity, severity or other clinical factors that meaningfully influence emergency department operations and patient outcomes. 

In addition, without careful attention to stratification for acuity or severity, the measure risks drawing misleading comparisons between hospitals that treat fundamentally different patient populations. High‑acuity emergency departments may appear to perform worse simply because they care for sicker, more complex patients who require longer evaluation and stabilization times. These issues can also limit quality improvement opportunities, benchmarking and meaningful identification of variation in emergency care delivery. 

Vizient is also concerned that the ECAT measure could create confusion, as key concepts such as “dedicated treatment area” and “boarding” could be interpreted differently. Clear and consistent definitions are essential to ensure hospitals interpret and report these elements uniformly. Without precise definitions, hospitals may classify treatment areas or boarding status differently, undermining the validity of the measure and limiting its usefulness for quality improvement. Standardization is also necessary to ensure that data collected across diverse emergency departments can be reliably used to assess capacity constraints and identify opportunities to improve patient flow and emergency care delivery. Given these concerns, Vizient recommends that P4QM and CMS work closely with stakeholders to better understand stakeholder experiences for those voluntarily reporting this measure under the Outpatient Quality Reporting Program. Such information will be critical to consider should this measure evolve or be included in other CMS programs. 

1. https://mmshub.cms.gov/sites/default/files/ECCQ-TEP-2-Summary-Report.pdf

We recommend risk adjustment for factors beyond hospital control (regional bed availability, EMS surges) and phased implementation with confidential reporting before public display. Benchmarking by peer cohort is essential to ensure fairness. 

 On behalf of our nearly 40,000 members, the American College of Emergency Physicians (ACEP) appreciates the opportunity to comment on CMS’s Emergency Care Access & Timeliness (ECAT) proposed measure. ACEP strongly supports CMS’ proposals to incorporate the Emergency Care Access and Timeliness eCQM into more CMS reporting programs going forward. The goal of the measure is to help monitor the issue of patients “boarding” in the ED—a scenario where patients often wait for hours, days, or even weeks in the ED while waiting for an inpatient bed after admission to the hospital or transfer to another facility. The inclusion of this measure in the Hospital Outpatient Quality Reporting was a positive step and ACEP supports its inclusion in more hospital reporting programs. We suggest CMS follow the same rollout process used in 2026 Hospital OQR inclusion of ECAT, where the measure is voluntary in the first year to give participants time to implement the necessary processes and systems for a successful incorporation.

While supportive of this measure, Premier recommends voluntary reporting for this measure for a few years to give hospitals time to build out and test this eCQM measure properly. Premier also supports the stratification for psychiatric/mental health disorders as a principal diagnosis.  However, Premier is concerned that improvement on this measure will be minimal without giving hospitals additional resources to address ED throughput. Premier also encourages CMS to test the measure in the Hospital Inpatient Quality Reporting Program prior to implementing it in the Hospital Value Based Purchasing Program.

Support with modification: Supportive of this measures priorities, however recommend clear attribution rules and denomintator standards to ensure stability in MA performance. 
This measure poses challenges in accurate and equitable measurement (number of ED beds, access to transportation, etc.).

We support the adoption of this emergency department (ED) eCQM as a means to reduce reliance on chart-abstracted measures and associated reporting burden. However, there are significant technical and operational considerations that must be addressed, including how the measure will be implemented within the current capabilities and variability of EHR vendor systems.

We request clarification regarding how CMS intends to delineate Emergency Care Assessment and Treatment (ECAT) eCQM data across the Hospital Inpatient Quality Reporting (IQR) and Outpatient Quality Reporting (OQR) Programs in order to avoid double counting and inconsistent attribution.

Specifically, clarification is requested on whether performance will be delineated by patient class for each program (e.g., inpatient versus outpatient/ED). If patient class is used to distinguish reporting across programs, additional guidance is needed regarding how encounters without a clearly defined patient class, such as events where a patient leaves the emergency department without being evaluated, will be attributed across OQR and IQR.

Further, we request clarification on how CMS intends to operationalize the four ECAT components across reporting and payment programs, including whether each component will be scored individually for purposes of the Hospital Value-Based Purchasing (HVBP) Program, or whether a composite scoring approach is anticipated.

If this measure moves forward, which we anticipate, we recommend that the initial years of HVBP implementation be limited to reporting only, allowing sufficient time for technical specifications, attribution logic, and EHR mappings to be finalized, tested, and consistently implemented across hospitals and vendor platforms.

Your measures will promote premature admission of patients who do not require hospital care. There are many conditions, such as dehydration, chest pain, and weakness that can be resolved with ED care. That care though often takes several hours for serial diagnostic testing and/or treatment, such as IV fluids, lab testing and diagnostic testing that may take more than a few hours. By setting these arbitrary measures, you will be forcing doctors to admit patients to the hospital, as inpatient or with observation services, in order to "stop the ED clock" when another hour or two of ED care could avoid that. And once admitted, instead of a few more hours, that patient will be staying for a day or two, with evaluation by the hospitalist and consultants, creating more costs, and more hospital crowding, and resulting in beds being occupied by patients who do not need it, limiting accss to those beds for patients who truly need them. 

Don't do it. Just don't.