Federal Register / Vol. 75, No. 221 / Wednesday, November 17, 2010 / Proposed Rules 70165 

of Veterans Affairs, approved this 

document on October 18, 2010, for 

publication. 

List of Subjects in 38 CFR Part 3 

Administrative practice and 

procedure, Claims, Disability benefits, 

Health care, Veterans, Vietnam. 

Dated: November 9, 2010. 

Robert C. McFetridge, 

Director, Regulations Policy and 

Management, Department of Veterans Affairs. 

■ For the reasons set out in the 

preamble, VA proposes to amend 38 

CFR part 3 as follows: 

PART 3—ADJUDICATION 

Subpart A—Pension, Compensation, 

and Dependency and Indemnity 

Compensation 

1. The authority citation for part 3, 

subpart A continues to read as follows: 

Authority: 38 U.S.C. 501(a), unless 

otherwise noted. 

2. Amend § 3.317 by revising 

paragraph (a)(2)(i)(B)(3) to read as 

follows: 

§ 3.317 Compensation for certain 

disabilities due to undiagnosed illnesses. 

(a) * * * 

(2) * * * 

(i) * * * 

(B) * * * 

(3) Functional gastrointestinal 

disorders, including, but not limited to, 

irritable bowel syndrome and functional 

dyspepsia (excluding structural 

gastrointestinal diseases); or Note to 

paragraph (a)(2)(i)(B)(3): Functional 

gastrointestinal disorders are a group of 

conditions characterized by chronic or 

recurrent symptoms that were present 

for at least 6 months prior to diagnosis 

and have been currently active for 3 

months, that are unexplained by any 

structural, endoscopic, laboratory, or 

other objective signs of disease or injury 

and that may be related to any part of 

the gastrointestinal tract. Common 

symptoms include abdominal pain, 

substernal burning or pain, nausea, 

vomiting, altered bowel habits 

(including diarrhea, constipation), 

indigestion, bloating, postprandial 

fullness, and painful or difficult 

swallowing. Specific functional 

gastrointestinal disorders include, but 

are not limited to, irritable bowel 

syndrome, functional dyspepsia, 

functional vomiting, functional 

constipation, functional bloating, 

functional abdominal pain syndrome, 

and functional dysphagia. 

[FR Doc. 2010–28707 Filed 11–16–10; 8:45 am] 

BILLING CODE 8320–01–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

42 CFR Chapter IV 

[CMS–1345–NC] 

Medicare Program; Request for 

Information Regarding Accountable 

Care Organizations and the Medicare 

Shared Saving Program 

AGENCY: Centers for Medicare & 

Medicaid Services (CMS), HHS. 

ACTION: Request for information. 

SUMMARY: This document is a request for 

comments regarding certain aspects of 

the policies and standards that will 

apply to accountable care organizations 

(ACOs) participating in the Medicare 

program under section 3021 or 3022 of 

the Affordable Care Act. 

DATES: Comment Date: To be assured 

consideration, comments must be 

received at one of the addresses 

provided below, no later than 5 p.m. on 

December 3, 2010. 

ADDRESSES: In commenting, please refer 

to file code CMS–1345–NC. Because of 

staff and resource limitations, we cannot 

accept comments by facsimile (FAX) 

transmission. 

You may submit comments in one of 

four ways (please choose only one of the 

ways listed): 

• Electronically. You may submit 

electronic comments on this regulation 

to http://www.regulations.gov. Follow 

‘‘Submit a comment’’ instructions. 

• By regular mail. You may mail 

written comments to the following 

address ONLY: Centers for Medicare & 

Medicaid Services, Department of 

Health and Human Services, Attention: 

CMS–1345–NC, P.O. Box 8013, 

Baltimore, MD 21244–8013. 

Please allow sufficient time for mailed 

comments to be received before the 

close of the comment period. 

• By express or overnight mail. You 

may send written comments to the 

following address ONLY: Centers for 

Medicare & Medicaid Services, 

Department of Health and Human 

Services, Attention: CMS–1345–NC, 

Mail Stop C4–26–05, 7500 Security 

Boulevard, Baltimore, MD 21244–1850. 

• By hand or courier. Alternatively, 

you may deliver (by hand or courier) 

your written comments ONLY to one of 

the following addresses prior to the 

close of the comment period: 

a. For delivery in Washington, DC— 

Centers for Medicare & Medicaid 

Services, Department of Health and 

Human Services, Room 445–G, Hubert 

H. Humphrey Building, 200 

Independence Avenue, SW., 

Washington, DC 20201. 

(Because access to the interior of the 

Hubert H. Humphrey Building is not 

readily available to persons without 

Federal government identification, 

commenters are encouraged to leave 

their comments in the CMS drop slots 

located in the main lobby of the 

building. A stamp-in clock is available 

for persons wishing to retain a proof of 

filing by stamping in and retaining an 

extra copy of the comments being filed.) 

b. For delivery in Baltimore, MD— 

Centers for Medicare & Medicaid 

Services, Department of Health and 

Human Services, 7500 Security 

Boulevard, Baltimore, MD 21244–1850. 

If you intend to deliver your 

comments to the Baltimore address, call 

telephone number (410) 786–7195 in 

advance to schedule your arrival with 

one of our staff members. 

Comments erroneously mailed to the 

addresses indicated as appropriate for 

hand or courier delivery may be delayed 

and received after the comment period. 

FOR FURTHER INFORMATION CONTACT: 

Thomas Carey, (410) 786–4560 or 

Thomas.Carey@cms.hhs.gov. 

SUPPLEMENTARY INFORMATION: 

Inspection of Public Comments: All 

comments received before the close of 

the comment period are available for 

viewing by the public, including any 

personally identifiable or confidential 

business information that is included in 

a comment. We post all comments 

received before the close of the 

comment period on the following Web 

site as soon as possible after they have 

been received: http:// 

www.regulations.gov. Follow the search 

instructions on that Web site to view 

public comments. 

Comments received timely will also 

be available for public inspection as 

they are received, generally beginning 

approximately 3 weeks after publication 

of a document, at the headquarters of 

the Centers for Medicare & Medicaid 

Services, 7500 Security Boulevard, 

Baltimore, Maryland 21244, Monday 

through Friday of each week from 

8:30 a.m. to 4 p.m. To schedule an 

appointment to view public comments, 

phone 1–800–743–3951. 

I. Background 

The Affordable Care Act seeks to 

improve the quality of health care 

services and to lower health care costs 

by encouraging providers to create 

integrated health care delivery systems. 

These integrated systems will test new 

reimbursement methods intended to 


erowe on DSK5CLS3C1PROD with PROPOSALS-1
70166 Federal Register / Vol. 75, No. 221 / Wednesday, November 17, 2010 / Proposed Rules 

create incentives for health care 

providers to enhance health care quality 

and lower costs. One important delivery 

system reform is the Medicare Shared 

Savings Program under section 3022 of 

the Affordable Care Act, which 

promotes the formation and operation of 

accountable care organizations (ACOs). 

Under this provision, ‘‘groups of 

providers * * * meeting the criteria 

specified by the Secretary may work 

together to manage and coordinate care 

for Medicare * * * beneficiaries 

through an [ACO].’’ An ACO may 

receive payments for shared savings if 

the ACO meets certain quality 

performance standards and cost savings 

requirements established by the 

Secretary. We are developing 

rulemaking for the establishment of the 

Shared Savings Program under section 

3022 of the Affordable Care Act. In 

addition, section 3021 of the Affordable 

Care Act establishes a Center for 

Medicare and Medicaid Innovation 

(CMMI) within CMS, which is 

authorized to test innovative payment 

and service delivery models to reduce 

program expenditures while preserving 

or enhancing the quality of care. We are 

considering testing innovative payment 

and delivery system models that 

complement the Shared Savings 

Program in the CMMI. In both of these 

efforts, we are seeking to advance ACO 

structures that are organized in ways 

that are patient-centered and foster 

participation of physicians and other 

clinicians who are in solo or small 

practices. 

We have already conducted 

substantial outreach and had 

discussions with and received feedback 

from a wide array of physician groups, 

as well as groups representing other 

clinicians, hospitals, employers, 

consumers, and other interested parties, 

about how ACO programs can best be 

structured. In particular, CMS, along 

with the Office of the Inspector General 

(OIG) of the Department of Health and 

Human Services (DHHS) and the 

Federal Trade Commission hosted a 

public workshop on October 5, 2010, to 

discuss the application and enforcement 

of the antitrust laws, physician selfreferral prohibition, Federal antikickback statute, and civil monetary 

penalty law to the variety of possible 

ACO structures under the Shared 

Savings Program and other innovative 

payment models that CMMI is 

authorized to test under section 3021 of 

the Affordable Care Act. Prior to the 

public workshop, the three agencies 

solicited written comments and 

statements from industry stakeholders 

regarding a variety of issues, including 

the planned legal structures and 

business models of ACOs. 

II. Solicitation of Comments 

As we develop our initial rulemaking 

for the Shared Savings Program and 

begin the development of potential 

models in the CMMI, we are seeking 

additional information, particularly 

from the physician community, on the 

following questions: 

• What policies or standards should 

we consider adopting to ensure that 

groups of solo and small practice 

providers have the opportunity to 

actively participate in the Medicare 

Shared Savings Program and the ACO 

models tested by CMMI? 

• Many small practices may have 

limited access to capital or other 

resources to fund efforts from which 

‘‘shared savings’’ could be generated. 

What payment models, financing 

mechanisms or other systems might we 

consider, either for the Shared Savings 

Program or as models under CMMI to 

address this issue? In addition to 

payment models, what other 

mechanisms could be created to provide 

access to capital? 

• The process of attributing 

beneficiaries to an ACO is important to 

ensure that expenditures, as well as any 

savings achieved by the ACO, are 

appropriately calculated and that 

quality performance is accurately 

measured. Having a seamless attribution 

process will also help ACOs focus their 

efforts to deliver better care and 

promote better health. Some argue it is 

necessary to attribute beneficiaries 

before the start of a performance period, 

so the ACO can target care coordination 

strategies to those beneficiaries whose 

cost and quality information will be 

used to assess the ACO’s performance; 

others argue the attribution should 

occur at the end of the performance 

period to ensure the ACO is held 

accountable for care provided to 

beneficiaries who are aligned to it based 

upon services they receive from the 

ACO during the performance period. 

How should we balance these two 

points of view in developing the patient 

attribution models for the Medicare 

Shared Savings Program and ACO 

models tested by CMMI? 

• How should we assess beneficiary 

and caregiver experience of care as part 

of our assessment of ACO performance? 

• The Affordable Care Act requires us 

to develop patient-centeredness criteria 

for assessment of ACOs participating in 

the Medicare Shared Savings Program. 

What aspects of patient-centeredness are 

particularly important for us to consider 

and how should we evaluate them? 

• In order for an ACO to share in 

savings under the Medicare Shared 

Savings Program, it must meet a quality 

performance standard determined by 

the Secretary. What quality measures 

should the Secretary use to determine 

performance in the Shared Savings 

Program? 

• What additional payment models 

should CMS consider in addition to the 

model laid out in Section 1899(d), either 

under the authority provided in 1899(i) 

or the authority under the CMMI? What 

are the relative advantages and 

disadvantages of any such alternative 

payment models? 

(Catalog of Federal Domestic Assistance 

Program No. 93.773, Medicare—Hospital 

Insurance; and Program No. 93.774, 

Medicare—Supplementary Medical 

Insurance Program) 

Dated: November 10, 2010. 

Donald M. Berwick, 

Administrator, Centers for Medicare & 

Medicaid Services. 

[FR Doc. 2010–28996 Filed 11–12–10; 4:15 pm] 

BILLING CODE 4120–01–P 

FEDERAL COMMUNICATIONS 

COMMISSION 

47 CFR Parts 1 and 17 

[WT Docket No. 08–61; WT Docket No. 03– 

187; DA 10–2178] 

Federal Communications Commission 

Announces Public Meetings and 

Invites Comment on the Environmental 

Effects of Its Antenna Structure 

Registration Program 

AGENCY: Federal Communications 

Commission. 

ACTION: Proposed rule. 

SUMMARY: In this document, the Federal 

Communications Commission 

announces public meetings regarding 

the pending Programmatic 

Environmental Assessment (PEA) of its 

Antenna Structure Registration (ASR) 

program and invites comment on the 

environmental effects of its antenna 

structure registration program. 

DATES: Interested parties may file 

comments on or before January 14, 

2011. 

ADDRESSES: You may submit comments, 

identified by DA 10–2178, WT Docket 

No. 08–61 and WT Docket No. 03–187, 

by any of the following methods: 

› Federal eRulemaking Portal: 

http://www.regulations.gov. Follow the 

instructions for submitting comments. 

› Federal Communications 

Commission’s Web site: http:// 

www.fcc.gov/cgb/ecfs/ or through a link 


erowe on DSK5CLS3C1PROD with PROPOSALS-1