Federal Register / Vol. 65, No. 118 / Monday, June 19, 2000 / Notices 37985

ANNUAL BURDEN ESTIMATES

Instrument Number of Respondents

Number of responses per

respondent

Average burden hours per

response

Total burden

hours

Application ....................................................................................................... 500 1 20 10,000

Estimated Total Annual Burden Hours ..................................................... ........................ ........................ ........................ 10,000

In compliance with the requirements

of Section 3506(c)(2)(A) of the

Paperwork Reduction Act of 1995, the

Administration for Children and

Families is soliciting public comment

on the specific aspects of the

information collection described above.

Copies of the proposed collection of

information can be obtained and

comments may be forwarded by writing

to the Administration for Children and

Families, Office of Information Services,

370 L’Enfant Promenade, SW.,

Washington, DC 20447, Attn: ACF

Reports Clearance Officer. All requests

should be identified by the title of the

information collection.

The Department specifically requests

comments on: (1) Whether the proposed

collection of information is necessary

for the proper performance of the

functions of the agency, including

whether the information shall have

practical utility; (b) the accuracy of the

agency’s estimate of the burden of the

proposed collection of information; (c)

the quality, utility, and clarity of the

information to be collected; and (d)

ways to minimize the burden of the

collection of information on

respondents, including through the use

of automated collection techniques or

other forms of information technology.

Consideration will be given to

comments and suggestions submitted

within 60 days of this publication.

Dated: June 13, 2000.

Bob Sargis,

Reports Clearance Officer.

[FR Doc. 00–15339 Filed 6–16–00; 8:45 am]

BILLING CODE 4184–01–M

DEPARTMENT OF HEALTH AND

HUMAN SERVICES

Administration for Children and

Families

Proposed Information Collection

Activity; Comment Request

Proposed Projects

Title: Uniform Project Description for

Discretionary Grant Application Form

OMB No. 0970–0139

Description: ACF has more than forty

discretionary grant programs. The

proposed information collection form

would be a uniform discretionary

application form usable for all of these

grant programs to collect the

information from grant applicants

needed to evaluate and rank applicants

and protect the integrity of the grantee

selection process. All ACF discretionary

grant programs would be eligible but not

required to use this application form.

The application consists of general

information and instructions; the

Standard Form 424 series that requests

basic information, budget information

and assurances; the Program Narrative

requesting the applicant to describe how

these objectives will be reached; and

certifications. Guidance for the content

of information requested in the Program

Narrative is found in OMB Circulars A–

102 and A–110.

Respondents: Applicants for ACF

Discretionary Grant Programs.

ANNUAL BURDEN ESTIMATES

Instrument Number of respondents

Number of responses per

respondent

Average burden hours per

response

Total burden

hours

UPD ................................................................................................................. 4,133 1 4 16,532

Estimated total annual burden hours ....................................................... 16,532

In compliance with the requirements

of Section 3506(c)(2)(A) of the

Paperwork Reduction Act of 1995, the

Administration for Children and

Families is soliciting public comment

on the specific aspects of the

information collection described above.

Copies of the proposed collection of

information can be obtained and

comments may be forwarded by writing

to the Administration for Children and

Families, Office of Information Services,

370 L’Enfant Promenade, S.W.,

Washington, D.C. 20447, Attn: ACF

Reports Clearance Officer. All requests

should be identified by the title of the

information collection.

The Department specifically requests

comments on: (a) whether the proposed

collection of information is necessary

for the proper performance of the

functions of the agency, including

whether the information shall have

practical utility; (b) the accuracy of the

agency’s estimate of the burden of the

proposed collection of information; (c)

the quality, utility, and clarity of the

information to be collected; and (d)

ways to minimize the burden of the

collection of information on

respondents, including through the use

of automated collection techniques or

other forms of information technology.

Consideration will be given to

comments and suggestions submitted

within 60 days of this publication.

Dated: June 13, 2000.

Bob Sargis,

Reports Clearance Officer.

[FR Doc. 00–15340 Filed 6–16–00; 8:45 am]

BILLING CODE 4184–01–M

DEPARTMENT OF HEALTH AND

HUMAN SERVICES

Health Resources and Services

Administration

Children’s Hospitals Graduate Medical

Education Payment Program:

Proposed Eligibility and Funding

Criteria and List of Eligible Hospitals

AGENCY: Health Resources and Services

Administration, HHS.

37986 Federal Register / Vol. 65, No. 118 / Monday, June 19, 2000 / Notices

ACTION: Notice.

SUMMARY: The Health Resources and

Services Administration (HRSA)

announces the Children’s Hospitals

Graduate Medical Education (CHGME)

Payment Program, authorized under

section 340E of the Public Health

Service (PHS) Act (the Act) (42 U.S.C.

256e), as added by the Healthcare

Research and Quality Act of 1999

(Public Law 106–129), enacted

December 6, 1999. This notice requests

comments on proposed eligibility

criteria, funding factors and

methodology, and performance

measures for participating hospitals for

the CHGME program. It includes a list

of hospitals meeting these proposed

eligibility criteria. In compliance with

the Paperwork Reduction Act of 1995,

the Department will obtain prior Office

of Management and Budget clearance to

any data collections imposed on the

public.

DATES: Interested persons are invited to

comment by July 19, 2000. All

comments received on or before July 19,

2000 will be considered in the

development of the criteria and

methodology for the CHGME program.

Comments will be addressed

individually or by group in the final

notice published in the Federal

Register.

ADDRESSES: All written comments

concerning this notice should be

submitted to F. Lawrence Clare,

Division of Medicine, Bureau of Health

Professions, Health Resources and

Services Administration, Room 9A–21,

Parklawn Building, 5600 Fishers Lane,

Rockville, Maryland 20857; or by e-mail

to: ChildrensHospitalGME@hrsa.gov.

FOR FURTHER INFORMATION CONTACT: F.

Lawrence Clare, Division of Medicine;

telephone (301) 443–7334.

SUPPLEMENTARY INFORMATION:

Purpose

The Children’s Hospitals Graduate

Medical Education Payment Program

provides funds to children’s hospitals to

support the training of pediatric and

other residents in graduate medical

education programs (GME). Since

Federal financial support of graduate

medical education is extensively

supported by the Medicare system, this

program compensates for the disparity

in the level of Federal funding for

teaching hospitals for pediatrics versus

other types of teaching hospitals. For

example, on average a freestanding

children’s hospital receives $374 per

resident in Medicare funds versus an

average of $87,034 per resident for a

non-children’s hospital.

The CHGME program is an interim

measure to assist children’s hospitals to

continue their teaching programs while

Congress examines the medical

education funding system. The

Secretary of HHS (the Secretary) has

delegated the authority for the

administration of the CHGME program

to HRSA which redelegated it to the

Bureau of Health Professions (BHPr).

Available Funds

The Act authorizes $280 million for

fiscal year (FY) 2000 and $285 million

for FY 2001. Under the FY 2000

appropriations law, $40 million has

been appropriated for this program. The

Act directs the Secretary to make

payments for both direct and indirect

expenses to each eligible children’s

hospital.

I. Dividing the CHGME Appropriation

Between Direct and Indirect Medical

Education

The Act requires the Secretary to

make payments to children’s hospitals

for both direct and indirect medical

education expenses (DME and IME).

Although the Act authorizes funds for

FY 2000 and FY 2001 in specific

amounts for each, the Appropriation Act

does not similarly divide the

appropriation between DME and IME.

In FY 2000, section 340E(f) authorizes

the appropriation of $90 million for

DME and $190 million for IME. To

conform with the allocation of funds

indicated in the Act, the Secretary will

divide the amount appropriated

between DME and IME based on the

ratio set forth in the authorizing statute,

approximately one-third of the funds to

DME and two-thirds to IME.

II. Proposed Hospital Eligibility Criteria

The Act requires HHS to make

payments to ‘‘children’s hospitals that

operate graduate medical education

programs.’’ A children’s hospital is

defined as a hospital in which more

than 50 percent of its patients are under

the age of 18, referencing the definition

of children’s hospital contained in

section 1886(d)(1)(B)(iii) of the Social

Security Act (42 U.S.C. 1395ww).

Regulations at 42 CFR 412.23(d) use this

definition in the Prospective Payment

Systems (PPS) for Inpatient Hospital

Services. The Department proposes to

define a children’s hospital eligible for

funding by adopting this definition of

children’s hospital from the PPS

regulations as follows:

A children’s hospital must-

(1) Have a provider agreement with a

unique Medicare provider number as a

hospital, under Section

1886(d)(1)(B)(iii) of the Social Security

Act;

(2) Be engaged in furnishing services

to inpatients who are predominantly

individuals under the age of 18; and

(3) Participate in an accredited

graduate medical education program.

The Congressional intent of the

CHGME program is to provide funds

only to children’s hospitals that do not

have access to Medicare payments

under the PPS system to achieve some

degree of parity in support. Fifty-nine

was the number of teaching hospitals

certified by Medicare as children’s

hospitals at that time.

Accordingly, the proposed eligibility

criteria exclude children’s hospitals

which are part of a hospital system,

rather than freestanding. Even if a

children’s hospital is separately

identified in the AMA Directory but

shares a Medicare provider number as

part of a health system, it still would not

be considered to be an eligible

children’s hospital under these criteria.

Since these hospitals have access to

Medicare direct and indirect GME

funding as part of the PPS, they are able

to receive the higher levels of Medicare

GME paid to PPS hospitals, by being

able to (1) factor a higher Medicare

patient proportion into the direct GME

funding formula, and (2) receive, as part

of a PPS hospital system, indirect GME

funds. Thus, these hospitals are not

within the universe of intended

beneficiaries of the CHGME program.

The physical characteristics or

location of a children’s hospital are

irrelevant to eligibility. Even if a

children’s hospital is separated

physically from its adult hospital

partner, sharing a Medicare provider

number makes the children’s hospital

ineligible because it then qualifies for

Medicare GME funds for its pediatric or

other residents under the PPS as part of

the adult hospital partner.

Payments made to a children’s

hospital will have no effect on payments

received under the Medicare or

Medicaid programs. The intent of the

CHGME program is to create a degree of

parity between children’s hospitals and

adult hospitals. Accordingly, the

CHGME program will operate

independently from the Medicare and

Medicaid programs.

Based on the proposed eligibility

criteria, the Department has identified

the following-listed hospitals

potentially eligible for this program as

of December 6, 1999. Any hospitals

meeting the proposed criteria which are

not included on the list may inform the

Department of their eligibility during

the comment period for this notice. The

Secretary will then publish a revised list

Federal Register / Vol. 65, No. 118 / Monday, June 19, 2000 / Notices 37987

of eligible hospitals for FY 2000 in the

final Federal Register notice.

Medicare

Provider

Number

Facility name City State

01–3300 Children’s Hospital of Alabama .................................................................. Birmingham .......................................................... AL

04–3300 Arkansas Children’s Hospital ..................................................................... Little Rock ............................................................ AR

05–3300 Valley Children’s Hospital ........................................................................... Madera ................................................................. CA

05–3301 Children’s Hospital Medical Center ............................................................ Oakland ............................................................... CA

05–3302 Children’s Hospital of Los Angeles ............................................................ Los Angeles ......................................................... CA

05–3303 Children’s Hospital and Health Center ....................................................... San Diego ............................................................ CA

05–3304 Children’s Hospital of Orange County ........................................................ Orange ................................................................. CA

05–3305 Lucile Salter Packard Children’s Hospital .................................................. Palo Alto .............................................................. CA

06–3301 The Children’s Hospital .............................................................................. Denver ................................................................. CO

07–3300 Connecticut Children’s Medical Center ...................................................... Hartford ................................................................ CT

08–3300 Alfred I Dupont Institute .............................................................................. Wilmington ........................................................... DE

09–3300 Children’s Hospital National Medical Center .............................................. Washington .......................................................... DC

10–3300 All Children’s Hospital ................................................................................ Saint Petersburg .................................................. FL

10–3301 Miami Children’s Hospital ........................................................................... Miami ................................................................... FL

11–3300 Egleston Children’s Hospital at Emory ....................................................... Atlanta .................................................................. GA

12–3300 Kapiolani Women’s & Children’s Medical Center ....................................... Honolulu ............................................................... HI

14–3300 Children’s Memorial Hospital ...................................................................... Chicago ................................................................ IL

14–3301 Larabida Children’s Hospital ...................................................................... Chicago ................................................................ IL

15–3300 St. Vincent’s Children’s Specialty Hospital ................................................. Indianapolis .......................................................... IN

19–3300 Children’s Hospital ...................................................................................... New Orleans ........................................................ LA

21–3301 Kennedy Krieger Institute ........................................................................... Baltimore .............................................................. MD

22–3300 Franciscan Children’s Hospital & Rehabilitation Center ............................ Brighton ............................................................... MA

22–3302 The Children’s Hospital .............................................................................. Boston .................................................................. MA

23–3300 Children’s Hospital of Michigan .................................................................. Detroit .................................................................. MI

24–3300 Gillette Children’s Hospital ......................................................................... Saint Paul ............................................................ MN

24–3301 Children’s Health Care—Saint Paul ........................................................... Saint Paul ............................................................ MN

24–3302 Children’s Health Care—Minneapolis ........................................................ Minneapolis .......................................................... MN

26–3301 St. Louis Children’s Hospital ...................................................................... Saint Louis ........................................................... MO

26–3302 Children’s Mercy Hospital ........................................................................... Kansas City ......................................................... MO

28–3300 Boys Town National Research Hospital ..................................................... Omaha ................................................................. NE

28–3301 Children’s Memorial Hospital ...................................................................... Omaha ................................................................. NE

31–3300 Children’s Specialized Hospital .................................................................. Mountainside ....................................................... NJ

32–3307 Carrie Tingley Hospital ............................................................................... Albuquerque ........................................................ NM

33–3301 Blythdale Children’s Hospital ...................................................................... Valhalla ................................................................ NY

36–3300 Children’s Hospital Medical Center ............................................................ Cincinnati ............................................................. OH

36–3302 Rainbow Babies and Children’s Hospital ................................................... Cleveland ............................................................. OH

36–3303 Children’s Hospital Medical Center ............................................................ Akron ................................................................... OH

36–3304 Cleveland Clinic Children’s Rehabilitation Hospital .................................... Cleveland ............................................................. OH

36–3305 Children’s Hospital ...................................................................................... Columbus ............................................................. OH

36–3306 Children’s Medical Center .......................................................................... Dayton ................................................................. OH

36–3307 Northside and Tod Children’s Hospital ....................................................... Youngstown ......................................................... OH

37–3301 Children’s Medical Center .......................................................................... Tulsa .................................................................... OK

39–3307 St. Christopher’s Hospital for Children ....................................................... Philadelphia ......................................................... PA

39–3302 Children’s Hospital of Pittsburgh ................................................................ Pittsburgh ............................................................. PA

39–3303 Children’s Hospital of Philadelphia ............................................................. Philadelphia ......................................................... PA

40–3301 University Pediatric Hospital ....................................................................... San Juan ............................................................. PR

44–3302 St. Jude Children’s Research Hospital ....................................................... Memphis .............................................................. TN

44–3303 East Tennessee Children’s Hospital .......................................................... Knoxville .............................................................. TN

45–3300 Cook Ft. Worth Children’s Medical Center ................................................. Fort Worth ............................................................ TX

45–3301 Driscoll Children’s Hospital ......................................................................... Corpus Christi ...................................................... TX

45–3302 Children’s Medical Center of Dallas ........................................................... Dallas ................................................................... TX

45–3304 Texas Children’s Hospital ........................................................................... Houston ............................................................... TX

45–3305 Santa Rosa Children’s Hospital ................................................................. San Antonio ......................................................... TX

46–3301 Primary Children’s Medical Center ............................................................. Salt Lake City ...................................................... UT

49–3301 Children’s Hospital—King’s Daughters ....................................................... Norfolk ................................................................. VA

50–3300 Children’s Hospital & Regional Medical Center ......................................... Seattle .................................................................. WA

50–3301 Mary Bridge Children’s Health Center ........................................................ Tacoma ................................................................ WA

52–3300 Children’s Hospital of Wisconsin ................................................................ Milwaukee ............................................................ WI

Changes in Eligibility Status

For each fiscal year, the Secretary will

publish a Federal Register notice

inviting applicants for the CHGME

program and listing the eligible

children’s hospitals. Since HHS

calculates the payments for each fiscal

year by dividing the available funds by

the resident count data submitted by the

eligible hospitals, additional hospitals

cannot be included for funding for that

fiscal year after the allocation has been

made. Newly-qualifying institutions

must notify HHS as soon as possible to

be added to the list of eligible hospitals

for the next fiscal year.

A children’s hospital which loses its

eligibility during the course of a fiscal

year must notify HHS immediately of

the change in status. The Department

will then declare the hospital to be

37988 Federal Register / Vol. 65, No. 118 / Monday, June 19, 2000 / Notices

ineligible and terminate its payments

under the CHGME program. The

hospital will remain liable for the

reimbursement, with interest, of any

money received during a period of

ineligibility.

Funds that are returned to the

Department during a fiscal year by the

termination of hospitals from the

CHGME program will be distributed as

follows: (1) Direct GME funds will be 8

placed in the direct GME withholding

account and distributed to the

remaining children’s hospitals as part of

the reconciliation process; and (2) the

IME funds will be distributed to the

remaining children’s hospitals during

the fiscal year based on the IME

formula. The latter approach is

necessary because IME funding has no

reconciliation process.

III. Determining Resident Counts in the

CHGME Program

Definition. Section 340E(c)(1) of the

Act provides that the amount of the

payment to a children’s hospital for

direct medical expenses is equal to the

product of the amount per resident as

determined under paragraph (2) of that

section and—

the average number of full-time equivalent

(FTE) residents in the hospital’s approved

graduate medical residency training

programs, as determined under section

1886(h)(4) [42 U.S.C. 1395ww(h)(4)] of the

Social Security Act during the fiscal year.

Section 340E(g)(1) of the Act defines

the term ‘‘approved graduate medical

residency training program’’ by

reference to section 1886(h)(5)(A) of the

Social Security Act (42 U.S.C.

1395ww(h)(5)(A)). Regulations at 42

CFR 413.86 implement these provisions.

Accordingly, the term ‘‘approved

graduate medical residency training

program’’ means a residency or other

postgraduate medical training program

in allopathic medicine, osteopathic

medicine, dentistry, and podiatry

approved by the indicated accrediting

body in which participation may be

counted toward certification in a

specialty or subspecialty. Only residents

in allopathic medicine, osteopathic

medicine, dentistry, and podiatry will

be counted to determine the amount of

direct and indirect medical expenses

paid to children’s hospitals.

Residency FTE Reporting Period

The Act requires the Secretary to

make CHGME payments ‘‘for each of

fiscal years 2000 and 2001,’’ (emphasis

added). ‘‘Fiscal Year’’ means the Federal

Fiscal Year from October 1 of each year

through September 30 of the following

year, not to be confused with the

hospital cost-reporting periods used for

Medicare GME purposes. The CHGME

statute distinguishes ‘‘fiscal year’’ from

a hospital’s ‘‘cost reporting period.’’

‘‘Cost reporting period’’ is used in two

provisions to differentiate specific time

periods from the Federal fiscal year.

Accordingly, the Secretary is

interpreting ‘‘fiscal year’’ to mean

‘‘Federal fiscal year.’’ To receive

CHGME funds, a hospital must submit

the number of FTE residents at the

hospital during the Federal fiscal year

for which payments are being made.

Counting FTE Residents

Section 340E(c)(1)(B) requires that the

average number of FTE residents in the

hospital’s approved residency programs

be determined according to section

1886(h)(4)(42 U.S.C. 1395ww(h)(4)) of

the Social Security Act. This section is

implemented by regulations at 42 CFR

413.86(f), (g), (h), and (i). These

provisions indicate: How to determine

the total and weighted numbers of FTE

residents; the required documentation

and certification for purposes of

application for Medicare payments by

hospitals for cost reporting periods; and

the application of the ‘‘caps’’ (described

in sec. 1886(h)(4)(f) of the Social

Security Act (42 U.S.C.

1395ww(h)(4)(f))) and ‘‘rolling averages’’

(described in sec. 1886(h)(4)(g) of the

Social Security Act (42 U.S.C.

1395ww(h)(4)(g))) to FTE resident

counts prior to weighting. Hospitals

must certify the accuracy of their FTE

resident counts and apply the Medicare

cap and rolling average to this count.

Because these requirements are

closely tied to Medicare, the Department

will be using Medicare data to assist in

verifying the submitted counts.

Comment is solicited on whether the

program should require the

standardized reporting of resident

counts currently required in the

Medicare Intern and Resident

Information System (IRIS).

The cap requires an accurate count for

the last hospital cost reporting year

ending on or before December 31, 1996.

The Department will rely on the

resident counts reported on Medicare

cost reports to verify each hospital’s

count. Some hospitals may have

previously undercounted their residents

in their Medicare cost reports due to the

insignificance of their Medicare

payments. Because of the cap, hospitals

that underreported that number should

consider requesting the Department to

reopen their Medicare cost reports,

pursuant to 42 CFR 405.1885, to revise

the numbers submitted for cost reports

that are subject to reopening.

The regulations at 42 CFR 413.86 do

not apply to a hospital which had not

previously submitted Medicare cost

reports but had been operating a

residency training program. Hospitals

must determine their resident counts in

the cost-reporting year ending in 1996.

In cases where this is very difficult to

establish from existing records, it is

necessary to propose an FTE counting

methodology addressing this situation.

For most hospitals, program size and

resident rotations among the

participating institutions are relatively

stable from year to year. Therefore, a

hospital could address missing FTE

counts for earlier years by starting with

the assumption that these counts would

be the same as the FY 1999 count in the

absence of changes in the residency

programs after 1996. The incremental

effect of any changes could be estimated

by adjusting the FY 1999 and FY 2000

counts to determine resident FTE counts

for FY 1996 through FY 1998. Examples

of adjustments for incremental changes

in FTE counts follow:

Example A: The children’s hospital has 24

residents in a pediatric residency program.

The residents spend 90 percent of their time

at the children’s hospital and 10 percent

rotating to other hospitals. The hospital’s

unweighted FTE count for its cost reporting

period beginning in FY1999 is 21.6 (the

unweighted FTE count is the FTE number of

residents prior to weighting the residents

who have exceeded the number of years of

formal training necessary to satisfy the

requirements of the appropriate approving

body related to board certification or 5 years,

whichever is less, by 0.5). The unweighted

FTE count for its cost reporting period

ending in calendar year 1996 is deemed to be

21.6. This becomes the cap, which applies to

Federal fiscal years 2000 and beyond.

Example B: The children’s hospital had 24

residents in its pediatric residency program

(8 in each of 3 residency years) until the

program year beginning July 1, 1999, when

the number of first year residents was

increased to 10. The residents spend all their

time at the children’s hospital. The hospital’s

unweighted FTE count for its cost-reporting

period ending 12/31/99 is 25, because the

additional first year residents added 1.0 to

the FTE resident count (two residents for 6

months each). The count for its cost reporting

period ending in calendar year 1996, and the

hospital’s cap from that point on, is deemed

to be 24.

Example C: The children’s hospital is a

major participating institution for five

residency programs. During its cost-reporting

period ending 6/30/99, 100 residents rotated

from other hospitals for rotations of 1 to 6

months. The hospital’s unweighted FTE

count was 25. The same affiliation

agreements have been in effect since before

1996 and there were no significant changes

in the size of the residency programs or

rotation schedules. The hospital’s

unweighted count for its cost reporting

period ending in calendar year 1996 (which

ended 6/30/96), and therefore its cap for

future years, is deemed to be 25.

Federal Register / Vol. 65, No. 118 / Monday, June 19, 2000 / Notices 37989

Example D: The children’s hospital is a

major participating institution for five

residency programs. During its cost-reporting

period ending 6/30/99, 100 residents rotated

from other hospitals for rotations of 1 to 6

months. The hospital’s unweighted FTE

count was 25. During the program year

beginning in 1997, the hospital started

serving as a training site for the first time for

a family practice program which sends three

residents for 3 months each for a continuity

clinic in each of the first two family practice

program years. The residents count as 1.5

FTE in the hospital’s FTE count for its FY

ending 6/30/99 (0.75 FTE for 1st year

residents and 0.75 for 2nd year residents).

The hospital’s count for its cost reporting

period ending in calendar year 1996 (FY

ending 6/30/96), and therefore its cap, is

deemed to be 23.5.

If no prior counts were reported, it

would then only be necessary to

determine the 1996-based cap from the

FY1999 and FY2000 actual counts if the

number of residents had increased after

1996. The cap would not be operative if

there had been no change or a decrease

since 1996.

Similarly, Medicare applies a ‘‘rolling

average’’ to resident counts (42 CFR

413.86(g)(5)). Unlike the cap, the rolling

average is applied to weighted FTE

resident counts. For the hospital’s first

cost reporting period beginning on or

after October 1, 1997, the weighted FTE

count equals the average of the weighted

count for that period and the preceding

cost reporting period. For cost reporting

periods beginning on or after October 1,

1998, the hospital’s weighted FTE count

equals the average of that reporting year

and the two preceding cost reporting

years.

For the weighted FTE resident count

for Federal fiscal years 2000 and 2001,

the hospital must determine the

weighted FTE resident count for each

Federal fiscal year beginning October 1,

1997 (which is also the effective date of

the caps). The FTE resident counts for

these years are needed to determine the

cap and the rolling average for Federal

fiscal years 1999 and 2000.

IV. Determining Direct Medical

Education Payments

Section 340E(a) requires the Secretary

to make payments for direct and

indirect expenses associated with

operating approved graduate medical

residency training programs for each of

fiscal years 2000 and 2001. Section

340E(b) describes direct expenses as

covering the costs of 13 operating

approved graduate medical residency

training programs. Subsection (e)(1)

requires the Secretary to determine the

amount of direct and indirect payments

for each hospital before the beginning of

each fiscal year for which payments are

made and to make these payments to

each hospital in 26 equal installments

during the fiscal year. If the Secretary

determines that the funds appropriated

for the CHGME program for a fiscal year

are insufficient to provide the total

payments due to hospitals for that fiscal

year, the Secretary will reduce the

amount of payments to each hospital on

a pro-rata basis.

The Act also provides a method for

refining the accuracy of the direct

payments made to each hospital. Under

subsection (e)(2), the Secretary must

withhold up to 25 percent from each

direct medical education interim

installment payable to hospitals to

permit the final adjustment and

reconciliation of the number of FTE

residents for whom direct payments are

being made. At the end of that fiscal

year, each participating hospital must

submit information to enable the

Secretary to determine the percentage (if

any) of the total amount withheld that

is due each hospital for the fiscal year.

The hospital may request a hearing on

the Secretary’s payment determination.

The Secretary pays each hospital any

balance due or recoups any

overpayments made.

Due to the time limitations in

establishing a new program and the one

year availability of the $40 million

appropriated in FY 2000, for the

CHGME program, the Secretary will

obligate the entire CHGME

appropriation in FY 2000, without the

withholding of direct payments.

Determination of the Amount of Direct

Medical Education Payment

Section 340E(c)(1) requires that the

payments to a children’s hospital for

direct medical education expenses for a

fiscal year equal the product of:

• The updated per resident amount as

determined under subsection (c)(2); and

• The average number of FTE

residents in the hospital’s graduate

approved medical residency program as

determined under section 1886(h)(4) of

the Social Security Act during the fiscal

year.

Section 340E(c)(2) determines the

updated per resident amount for direct

medical education using the following

methodology. The Secretary will:

(1) Determine the hospital’s single per

resident amount: Compute for each of

every (not just children’s) teaching

hospital a single per resident amount

computed equal to the weighted average

of the primary care per resident amount

and the non-primary care per resident

amount computed under 1886(h)(2) of

the Social Security Act for cost

reporting periods ending during FY

1997;

(2) Determine the wage and non-wagerelated proportion of the single per

resident amount: Estimate the average

proportion of the single per resident

amount that is attributable to wages and

wage-related costs;

(3) Standardize per resident amounts:

Establish a standardized per resident

amount for each children’s hospital that

is adjusted for wages;

(4) Determine a national average per

resident amount: Compute a national

average per resident amount equal to the

average of the standardized amounts

computed above weighted by the

average number of FTE residents at the

children’s hospitals; and

(5) Apply factors 1–4 to each hospital:

Compute for each children’s hospital

the national average per resident

amount after adjustment for wagerelated costs.

Updating the Per Resident Amount

The legislation provides for updating

the per resident amount for each

hospital by the estimated percentage

increase in the consumer price index for

all urban consumers during the period

beginning October 1997 and ending

with the midpoint of the hospital’s cost

reporting period that begins in FY 2000.

Since the CHGME will operate on a

fiscal rather than a cost reporting year

basis, it is inappropriate to end the

adjustment period with the midpoint of

the cost reporting year. To do so would

create inconsistent and inequitable

results, rendering the provision

ineffective. To give effect to the intent

of updating the per resident amount, the

Secretary will update the per resident

amounts to a common date, the

midpoint of the current fiscal year.

Determining the Single Per Resident

Amounts

The Secretary proposes to use the

Health Care Financing Administration’s

(HCFA’s) Hospital Cost Report

Information System (HCRIS), an

electronic reporting system, to

determine the hospitals single per

resident amounts. HCRIS is organized

by the cost reporting period beginning

dates. The data base for determining the

per resident amounts paid to children’s

hospitals is from all teaching hospitals,

not just children’s teaching hospitals.

HCRIS files are updated quarterly as the

cost reports move through the cost

report settlement process. The

September 30, 1999, HCRIS update file

has 1206 hospitals reporting residents

for cost reporting periods ending in FY

1997.

37990 Federal Register / Vol. 65, No. 118 / Monday, June 19, 2000 / Notices

Wage Adjustment in Standardizing Per

Resident Amounts

Section 340E states that the

Secretary—

shall establish a standardized per resident

amount for each such hospital by—

(i) Dividing the single per resident amount

computed under subparagraph (A) into a

wage-related and non-wage related portion

by applying the proportion determined under

subparagraph (B);

(ii) Dividing the wage-related portion by

the factor applied under section 1886(d)(3)(E)

of the Social Security Act for discharges

occurring during fiscal year 1999 for the

hospital’s area; and

(iii) Adding the non-wage-related portion

to the amount computed under clause (ii).

Subparagraph (B) requires the Secretary to:

[E]stimate the average proportion of the

single per resident amounts computed under

subparagraph (A) that is attributable to wages

and wage-related costs.

Under the Medicare program, direct GME

expenses include intern and resident salaries

and fringe benefits; compensation to teaching

physicians for the teaching and supervision

of residents; and other, allocated hospital

costs. Earlier HCRIS public use files indicate

that the labor-related share of the PPS rate for

inpatient operating costs is at 71.1 percent.

However, this figure may not be appropriate

for the per resident amount since it includes

direct patient care costs, such as drugs and

room and board costs.

The Department is analyzing the Medicare

cost reports to develop a more accurate

estimate of the labor-related share of the per

resident amount. HHS intent is to complete

this analysis in time for the final Federal

Register notice. Until the analysis is

completed, the Secretary proposes that the

PPS labor-related share be used to

standardize wages in determining the

national standard per resident amount.

Determining Payments

Each hospital will be requested to submit

an annual application containing the number

of weighted FTE residents in all its graduate

training programs. Using this data, the

Secretary will calculate the hospital’s direct

GME payment using the following formula:

Y X WI X FTE ii i = + ( ) *. * *. * 711 289

Where—

X = national average per resident amount

Xz = national pro-rata average per resident

amount (based on funds available)

WI = wage index (for the area in which the

hospital is located)

FTE = weighted number of FTE residents

working at the hospital

Y = direct GME payment to a hospital

i = indicates an individual hospital

n = the number of children’s hospitals

participating in the program

Σ = sum of (the following)

Z = the total funds available for direct

payments

The total direct GME payments to all

children’s teaching hospitals equal the sum

of payments to all individual hospitals:

Y X WI total

i

n

= + ( ) =

∑

1

.* . * 711 289 i i FTE

To calculate the pro rata average per

resident amount based on the funds available

(Xz) without knowing the national average

per resident amount (X), the Secretary will

use the following equation:

X Z Z

i

n

= + ( ) =/.* . * ∑ 711 289

1

WI FTE i i

The final Federal Register notice will

contain a computed national per resident

amount.

V. Determining Indirect Medical Education

Payments

Sections 340E(a) and (b)(1)(B) require the

Secretary to make payments for indirect

expenses associated with operating approved

graduate medical residency training

programs for each of fiscal years 2000 and

2001. Section 340E(b)(1) requires that the

payments be made for an approved program

‘‘for a fiscal year,’’ and section 340E(b)(1)(B)

describes indirect payments as covering

‘‘expenses associated with the treatment of

more severely ill patients and the additional

costs relating to teaching residents in such

programs.’’

Subsection (e)(1) requires the Secretary to

determine the amount of both direct and

indirect payments for each hospital before

the beginning of each fiscal year for which

payments are made and to make these

payments to each hospital in 26 equal

installments during the fiscal year.

Subsection (d)(2)(B) provides that the

indirect payments are equal to the amount

appropriated for such expenses for the fiscal

year under subsection (f)(2), but unlike the

DME payment, there is no provision for

withholding a portion of IME payments or

making a final reconciliation after the close

of the fiscal year.

Section 340E(d)(2) requires the Secretary to

determine the appropriate amount of indirect

medical education payments for expenses

associated with the treatment of more

severely ill patients and the additional costs

relating to teaching residents in such

programs to a children’s hospital by

considering:

• Variations in case mix among children’s

hospitals; and

• The hospitals’ number of FTE residents

in approved training programs.

Determination of Case Mix

The statute provides no guidance on the

case mix measure to be used for determining

indirect payments. Hence, the Secretary is

seeking comments on this issue.

Case mix information for hospitals is

typically generated as a by-product of a

billing or administrative reporting system.

Children’s hospitals currently use various

DRG systems and weights. These include the

HCFA Diagnosis-Related Group (DRG); the

All-Payer DRG (AP-DRG); and the All-Payer

Refined DRG (APR-DRG) systems. To require

a hospital to report its case mix index using

a different classification system from its

current system would create an

administrative burden.

Accordingly, the Secretary proposes to:

(1) Identify the case-mix indexes that are

commonly used by children’s hospitals; and

(2) Explore the feasibility of adjustment

factors derived from comparative studies that

allow for approximate equilibration of the

various case mix indexes that may be used.

Determining the Number of FTE Residents

Section (d)(2)(A) states that in determining

the amount of payments to a children’s

hospital for indirect medical education

expenses, the Secretary shall take into

account ‘‘ * * * the number of full-time

equivalent residents’’ in the hospital’s

approved residency programs. Unlike direct

payments, it does not specify that the FTE

residents be counted as determined under

section 1886(h)(4) of the Social Security Act.

FTE residents under Medicare are also

counted differently for direct (sec. 1886(h)(4))

of the Social Security Act) and indirect (42

CFR 412.105(a)(1)) payments. Under the

latter, ‘‘full-time equivalent residents’’ are

counted without the weighting applied to the

count for direct payment determination.

The Secretary will use the number of FTE

residents during the fiscal year as determined

under 42 CFR 412.105(a)(1) to determine

indirect payments to a hospital.

Factoring in Teaching Intensity

The statute does not specify a factor for

determining teaching intensity. Traditionally,

the indirect expenses associated with

teaching activity are based on costs per case.

Teaching hospitals tend to have higher costs

per case relative to other hospitals in the

same area with a comparable case mix. The

higher costs are generally associated with

treating a more critically ill patient

population than non-teaching hospitals and

with the use of more resources, such as

diagnostic tests, when residents are involved

in the care of patients. A close relationship

exists between higher costs and teaching

intensity as measured by the ratio of either

interns/residents-to-beds, or the ratio of

residents to the average daily census of the

hospital.

The Secretary proposes to determine

teaching intensity using one of the following

factors derived from the Medicare formula:

• The ratio of residents to average daily

census; or

• The ratio of residents to beds.

In summary, the Secretary proposes to

calculate IME payments for a hospital using

the number of FTE residents; a case mix

index; a case mix adjustment factor to

correlate hospitals’ case mix information to

the case mix index selected for the CHGME

program; a teaching intensity adjustment;

and volume. Due to the time required to

statistically model and analyze the various

alternatives, the case mix index, case mix

adjustment factor, and the teaching intensity

adjustment are not currently available. The

Secretary will include a detailed

methodology for distribution of the IME

funds in the final Federal Register notice to

be published in July. Although FY 2000 IME

funds must be distributed this fiscal year

based on the IME formula published in the

July notice, we will solicit comments and

change the distribution formula for

subsequent cycles if appropriate.

Federal Register / Vol. 65, No. 118 / Monday, June 19, 2000 / Notices 37991

VI. Evaluation Criteria

The CHGME program is subject to the

Government Performance and Results Act of

1993 (GPRA), Public Law 103–62. GPRA

provides Congress with information on

whether and in what respects a program is

working well or poorly to support its

oversight of Federal agencies and their

budgets. Therefore, GPRA requires each

Federal agency to prepare an annual

performance plan covering each program

activity set forth in the budget of the agency.

The Department must evaluate all programs

for effectiveness, efficiency, and continuous

improvement. To measure effectiveness, it

must obtain performance information from

recipients of HHS funds.

Performance Goals

The performance goals described below are

those included in the President’s FY 2001

GPRA performance plan. These goals are still

formative because HHS is unable to set

targets until it obtains the necessary data.

The Department requests public comment on

the appropriateness and feasibility of these

performance measures. The Department is

particularly interested in receiving comments

on the feasibility of each goal, in terms of the

hospitals’ ability to both provide data and

measure the success of the program.

Goals I and II listed below take into

consideration that some information

requirements may be more easily obtained for

residents in programs sponsored by the

children’s hospital than for residents who

rotate in from programs sponsored by another

teaching hospital. Comments are requested

on the practicality and value of reporting this

information on residents who rotate in from

programs sponsored by other hospitals, as

well as those from residency programs

sponsored by the children’s hospital.

Proposed Goal I: Eliminate Barriers to Care

A. Maintain the number of FTE residents

supported by the children’s hospitals

receiving funds under the program. The

health care workforce environment requires

that sufficient numbers and types of

physicians be appropriately and adequately

trained to care for pediatric populations.

Financial pressures common to the academic

health center community may raise interest

in reducing or eliminating training programs.

These hospitals and their training programs

provide a significant service to the local,

regional, and sometimes national

community. A reduction in training programs

could impair the provision of those services

as well as the production of one-quarter of

the Nation’s pediatricians and a majority of

pediatric specialists. The following data

elements provide an accurate accounting of

and trends in the number of resident FTEs

training in children’s hospitals, and are

fundamental in determining payments under

the program.

Proposed Required Data: While the

number of trainees in a given hospital’s

training program is currently collected by the

Health Care Financing Administration

(HCFA) for freestanding children’s hospitals

that request reimbursement from Medicare,

not all freestanding children’s hospitals that

are eligible for participation in the CHGME

Program have submitted this information to

HCFA. Generally, each hospital has a fairly

good accounting of the number of trainees in

residency programs sponsored directly by the

hospital; but, accounting for the number of

trainees rotating to a freestanding children’s

hospital for a portion of their training is more

complicated. Not all children’s hospitals

have quantified the FTE residents rotating to

their hospital from other training programs.

To receive CHGME payments, hospitals

must accurately report trainees’ numbers.

HHS proposes to require each hospital to

submit on an annual application the

aggregate number of FTE residents, by

program, who are:

• In the recipient children’s hospital and

sponsored by the hospital;

• Rotating into the recipient hospital from

residency programs sponsored by other

institutions; and

• Sponsored by the hospital and rotating to

other hospitals.

These data should already be available

now from children’s hospitals that furnish

Medicare cost report resident data and

submit reports under the IRIS. As noted

above, comment is being solicited on

whether the program should require the

standardized reporting of resident counts that

is currently required by Medicare in cost

reports and IRIS.

B. Increase the percentage of residents’

training that is supported in rural and

underserved areas. Research on access to

health care services has focused on the

contribution of physicians treating the

underserved. Residency training programs

located in rural areas and medically

underserved communities (MUCs) (as

defined in sec. 799B(6) of the PHS Act; 42

U.S.C. 295p(6)) provide much needed care in

their communities while residents learn the

knowledge, skills and attitudes necessary to

adequately and appropriately care for these

rural and underserved populations.

Proposed Required Data: The Department

proposes to require each hospital to submit

on an annual application the FTE count for

resident time spent in training in MUCs and

rural areas. The definition for the designation

of rural areas will be taken from the United

States Department of Agriculture’s UrbanRural County Continuum Code classification

system.

Proposed Goal II: Improve Public Health and

Health Care Systems.

A. Monitor financial status of hospitals’

total and operating margins.

B. Monitor the proportion of

uncompensated care patients.

C. Monitor the proportion of Medicaid

patients. Children’s hospitals have a very

high portion of Medicaid patients, at 40

percent of gross patient revenues. Another 4

percent represent charity and bad debt.

Children’s hospitals also have on average

poorer financial status than other teaching

hospitals. In 1995, 58 percent of children’s

hospitals had negative operating margins.

This may have been aggravated by major

changes in the health care system, including

the expansion of managed care and increased

enrollments in Medicaid managed care, and

increased efforts to constrain health care

costs. These changes in the health care

system put health facilities that train

physicians at a competitive disadvantage. A

negative operating margin could affect the

long-term viability of children’s hospitals

and their ability to continue providing a high

proportion of care to children covered by

Medicaid and uncompensated care. It may

also affect their ability to continue training a

high proportion of the nation’s general and

subspecialty pediatric and other residents,

since, in the competitive marketplace, payers

of health care services have few if any

incentives to pay higher costs to sites that

train health professionals.

Proposed Required Data: The Department

proposes to require each hospital to submit

on an annual application the following:

• Total and operating margins;

• Percentage of patients served who are

enrolled in Medicaid; and

• Percentage of uninsured patients and

uncompensated care.

Economic and Regulatory Impact

Executive Order 12866 directs agencies to

assess all costs and benefits of available

regulatory alternatives and, when rulemaking

is necessary, to select regulatory approaches

that provide the greatest net benefits

(including potential economic,

environmental, public health, safety

distributive and equity effects). In addition,

under the Regulatory Flexibility Act (RFA) of

1980, if a rule has a significant economic

effect on a substantial number of small

entities, the Secretary must specifically

consider the economic effect of the rule on

small entities and analyze regulatory options

that could lessen the impact of the rule.

Executive Order 12866 requires that all

regulations reflect consideration of

alternatives, of costs, of benefits, of

incentives, of equity, and of available

information. Regulations must meet certain

standards, such as avoiding an unnecessary

burden. Regulations which are ‘‘significant’’

because of cost, adverse effects of the

economy, inconsistency with other agency

actions, effects on the budget, or novel legal

or policy issues, require special analysis.

The Department has determined that

resources to implement this rule are required

only of the children’s hospitals in submitting

their applications and of the Department in

reviewing them. Therefore, in accordance

with the RFA of 1980, and the Small

Business Regulatory Enforcement Fairness

Act of 1996, which amended the RFA, the

Secretary certifies that this rule will not have

a significant impact on a substantial number

of small entities. The Secretary has also

determined that this rule does not meet the

criteria for a major rule as defined by

Executive Order 12866 and would have no

major effect on the economy or Federal

expenditures.

We have determined that the rule is not a

‘‘major rule’’ within the meaning of the

statute providing for Congressional Review of

Agency Rulemaking, 5 U.S.C. 801. Similarly,

it will not have effects on State, local, and

tribal governments and on the private sector

such as to require consultation under the

Unfunded Mandates Reform Act of 1995.

Further, Executive Order 13132 establishes

certain requirements that an agency must

37992 Federal Register / Vol. 65, No. 118 / Monday, June 19, 2000 / Notices

meet when it promulgates a rule that imposes

substantial direct compliance costs on State

and local governments, preempts State law,

or otherwise has Federalism implications.

We have reviewed this proposed action

under the threshold criteria of Executive

Order 13132, Federalism, and, therefore,

have determined that this action would not

have substantial direct effects on the rights,

roles, and responsibilities of States.

Paperwork Reduction Act of 1995

In accordance with section 3507(a) of the

Paperwork Reduction Act (PRA) of 1995, the

Department is required to solicit public

comments, and receive final Office of

Management and Budget (OMB) approval, on

collections of information. As indicated, in

order to implement the Children’s Hospital

Graduate Medical Education Payment

Program (CHGME), certain information is

required as set forth in this notice in order

to determine eligibility for payment.

In accordance with the PRA, we are

submitting to OMB at this time the following

requirements for seeking emergency review

of these provisions. HRSA has requested an

emergency review because the data collection

and reporting of this information is needed

before the expiration of the normal time

limits under OMB’s regulations at 5 CFR part

1320, to ensure the timely availability of data

as necessary to ensure payment to eligible

children’s hospitals. A 30-day notice was

published in the Federal Register on May 15,

2000 to provide for public comment and to

request an expedited review of the

information collection associated with the

CHGME. Delaying the data collection would

delay implementation of the statutory

purpose of providing payments by the end of

the fiscal year to children’s hospitals that

support training of residents in graduate

medical education programs.

Collection of Information: The Children’s

hospital Graduate Medical Education

Program.

Description: Data is collected on the

number of full-time equivalent residents in

applicant children’s hospital training

programs to determine the amount of direct

and indirect expense payments to

participating children’s hospitals. Indirect

expense payments will also be derived from

a formula that requires the reporting of case

mix index information from participating 25c

children’s hospitals. Hospitals will be

requested to submit such information in an

annual application.

Description of Respondents: Children’s

Hospitals operating approved graduate

medical residency training programs.

Estimated Annual Reporting: The

estimated average annual reporting for this

data collection is approximately 138 hours

per hospital. The estimated annual burden is

as follows:

Form name

No. of

respondents

Responses

per respondent

Total responses

Hours

per response

Total

hour

burden

Form E (Short) .................................................................................................................................. 42 1 42 99.9 4,194

Form E (Long) .................................................................................................................................. 12 1 12 46.7 560

Form F (Short) .................................................................................................................................. 42 1 42 8 336

Form F (Long) .................................................................................................................................. 12 1 12 8 96

IME Data ........................................................................................................................................... 54 1 54 14 756

Required GPRA Tables .................................................................................................................... 54 1 54 28 1,512

Total ........................................................................................................................................... 54 7,454

National Health Objectives for the Year 2000

The Public Health Service is committed to

achieving the health promotion and disease

prevention objectives of Healthy People

2000, and its successor, Healthy People 2010.

These are Department-led efforts to set

priorities for national attention. The CHGME

program is related to the priority area 1

(Access to Quality Health Services) in

Healthy People 2010, which is available

online at http://www.health.gov/

healthypeople/.

Education and Service Linkage

As part of its long-range planning, HRSA

will be targeting its efforts to strengthening

linkages between Department education

programs and programs which provide

comprehensive primary care services to the

underserved.

Smoke-Free Workplace

The Department strongly encourages all

award recipients to provide a smoke-free

workplace and promote abstinence from all

tobacco products, and Public Law 103–227,

the Pro-Children Act of 1994, prohibits

smoking in certain facilities that receive

Federal funds in which education, library,

day care, health care, and early childhood

development services are provided to

children.

This program is not subject to the Public

Health Systems Reporting Requirements.

Dated: May 17, 2000.

Claude Earl Fox,

Administrator, Health Resources and Services

Administration.

Dated: April 11, 2000.

Donna E. Shalala,

Secretary.

[FR Doc. 00–15332 Filed 6–16–00; 8:45 am]

BILLING CODE 4160–15–P

DEPARTMENT OF HOUSING AND

URBAN DEVELOPMENT

[Docket No. FR–4564–N–04]

Notice of Proposed Information

Collection: Healthy Homes Initiative

AGENCY: Office of Lead Hazard Control

ACTION: Notice.

SUMMARY: The proposed information

collection requirement described below

will be submitted to the Office of

Management and Budget (OMB) for

review, as required by the Paperwork

Reduction Act. The Department is

soliciting public comments on the

subject proposal.

DATES: Comments Due Date: August 18,

2000.

ADDRESSES: Interested persons are

invited to submit comments regarding

this proposal. Comments should refer to

the proposal by name and/or OMB

Control Number and should be sent to:

Ms. Gail Ward, Reports Liaison Officer,

Department of Housing and Urban

Development, 451 7th St., SW, Room

P3206, Washington, DC 20410.

FOR FURTHER INFORMATION CONTACT:

Ellen R. Taylor (202) 755–1785 ext. 116

(this is not a toll free number), for

copies of the proposed forms and other

available documents.

SUPPLEMENTARY INFORMATION: The

Department will submit the proposed

information collection to OMB for

review, as required by the Paperwork

Reduction Act of 1995 (44 U.S.C.

Chapter 35, as amended).

The Notice is soliciting comments

from members of the public and affected

agencies concerning the proposed

collection of information to: (1) Evaluate

whether the proposed collection of

information is necessary for the proper

performance of the functions of the

agency, including whether the

information will have practical utility;

(2) Evaluate the accuracy of the agency’s

estimate of the burden of the proposed

collection of information; (3) Enhance