[Federal Register Volume 83, Number 123 (Tuesday, June 26, 2018)]
[Notices]
[Pages 29796-29798]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2018-13592]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Resources and Services Administration


Proposed Standards for the Children's Hospitals Graduate Medical 
Education Payment Program's Quality Bonus System

AGENCY: Health Resources and Services Administration (HRSA), Department 
of Health and Human Services.

ACTION: Final response.

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SUMMARY: HRSA published a notice in the Federal Register on October 11, 
2017, soliciting feedback on the establishment of the Children's 
Hospitals Graduate Medical Education Payment (CHGME) Program's Quality 
Bonus System (QBS). In particular, HRSA requested feedback on the 
Fiscal Year (FY) 2019 and beyond multi-step implementation of the 
system, including demonstration of engagement in state or regional-
level initiatives, documentation, and payment structure. This notice 
summarizes and responds to the comments received during the 60-day 
comment period.

ADDRESSES: Additional information about the CHGME is available at 
https://bhw.hrsa.gov/grants/medicine/chgme.

FOR FURTHER INFORMATION CONTACT: Malena Crawford, Project Officer, 
Children's Hospitals Graduate Medical Education Payment Program, 
Division of Medicine and Dentistry, HRSA at <a href="/cdn-cgi/l/email-protection#0e434d7c6f7968617c6a4e667c7d6f20696178"><span class="__cf_email__" data-cfemail="5d101e2f3c2a3b322f391d352f2e3c733a322b">[email protected]</span></a> or (301) 
443-7334.

SUPPLEMENTARY INFORMATION: The CHGME statute was amended in 2013. The 
amendments permit up to 25 percent of the total amount appropriated 
annually in excess of $245 million, but not to exceed $7,000,000, to 
provide payments to newly qualified hospitals, as defined in section 
340E(h) of the Public Health Service Act. The statute additionally 
states that the Secretary may establish a quality bonus system for 
CHGME hospitals using any remaining funds after payments are made to 
newly qualified hospitals. In FY 2018, Congress appropriated $315 
million to the CHGME Program. Of this, approximately $4 million in 
payments were made to newly qualified hospitals. If funding levels and 
mechanisms remain constant in FY 2019, it is estimated that 
approximately $3 million may be available annually for the CHGME QBS.
    On October 16, 2017, through a Federal Register Notice (FRN), HRSA 
announced a 60-day public comment period to solicit input on the CHGME 
QBS proposed standards. HRSA proposed a multi-step implementation 
beginning in FY 2019 that initially will recognize high-level 
engagement of CHGME hospitals in state and regional health care 
transformation, as well as engagement of resident trainees in these 
activities. HRSA sought public comment on the timeline, eligibility, 
standards, documentation, and payment structure as described in the 
FRN. HRSA also requested comment on proposed QBS measures, potential 
data sources, and tiering of QBS payments for FY 2020 and beyond. HRSA 
received feedback on the following program components in response to 
the FRN:

<bullet> QBS Goals
<bullet> Qualifying Initiatives for the FY 2019 QBS
<bullet> Measures and Metrics
<bullet> Payment Structure
<bullet> Documentation, Reporting Requirements and Reducing Reporting 
Burden
<bullet> Implementation Timeline for FY 2020 and Beyond

    HRSA carefully reviewed the comments received and used them to 
guide the development of the FY 2019 CHGME QBS and to inform future 
iterations of the CHGME QBS. Final guidance for the FY 2019 CHGME QBS 
will be published in the FY 2019 CHGME Notice of Funding Opportunity 
(NOFO).

Comments on the Proposed Standards of the Quality Bonus System

    HRSA received 17 responses to the request for comments. Thirteen 
commenters are current CHGME hospitals and four are state/national 
associations. Comments are summarized below.

QBS Goals

Summary of Comments
    Nearly all commenters supported establishing the CHGME QBS to 
recognize and reward quality training programs for residents supported 
by the CHGME program and agreed with the approach to recognize 
engagement in initiatives geared towards transforming pediatric health 
care to improve access, quality, and cost effectiveness. However, many 
commenters questioned whether there was enough information about these 
initiatives to establish a baseline, draw comparisons between 
children's hospitals, and make judgements about relative performance. 
Several suggested the proposed approach could be enhanced by starting 
with documentation of transformation activities in which residents are 
involved. Specifically, one commenter recommended ``that HRSA work to 
identify current residents' engagement in quality initiatives and how 
residents can further engage on broader based initiatives before 
transitioning the Quality Bonus Program to other criteria in FY 2020 
and beyond.'' A few commenters also requested that HRSA offer more 
clear and specific goals for the multi-step implementation of the QBS.
Response
    After considering feedback from stakeholders, the revised goal of 
the QBS will be to recognize hospitals for quality improvement & GME 
transformation efforts in high priority focus areas and build standards 
to increase engagement and involvement of residents in broader 
initiatives. HRSA will implement a baseline phase for CHGME QBS in FY 
2019. Information collected during this baseline phase will be used to 
establish QBS standards for implementation in FY 2021. In order to 
qualify for the QBS payment, CHGME awardees must submit documentation 
in the FY 2019 reconciliation application describing the hospital's 
initiatives, resident curriculum, and direct resident involvement in 
the following areas: Integrated care models, telehealth/HIT, population 
health, social determinants of health, and additional initiatives to 
improve access

[[Page 29797]]

and quality of care to rural/underserved communities.

Qualifying Initiatives for the FY 2019 QBS

Summary of Comments
    Many commenters recommended expanding the list of initiatives that 
would qualify for the QBS and mentioned a number of other initiatives 
that children's hospitals are currently involved in, which included 
national and regional non-federal collaboratives. One commenter 
recommended recognizing initiatives that address pediatric health 
disparities (e.g., childhood obesity, immunizations, access to care, 
poverty, food insecurity, population health, child abuse, opioid 
overuse) at the local and regional levels, initiatives that positively 
impact the health of surrounding communities, hospital quality 
improvement projects, and other quality-related programs that meet the 
goals of the Healthy People 2020. Another commenter recommended 
recognizing resident participation in medical homes and clinically 
integrated networks.
    Several commenters recommended that HRSA start by compiling a list 
of the quality improvement and transformation efforts that residents 
currently engage in to identify focus areas for increased engagement 
and involvement. A few commenters expressed concerns that resident 
engagement in these initiatives may be limited due to training 
requirements that require rotating to a variety of clinical sites and 
normal resident turnover in training programs that typically last 
between 3-5 years.
Response
    HRSA considered the commenters' recommendations for qualifying 
initiatives for FY 2019 and has revised the FY 2019 QBS qualification 
requirements taking into consideration the comments received. As 
mentioned above, in order to qualify for the FY 2019 QBS payment, CHGME 
awardees must submit documentation in the FY 2019 reconciliation 
application describing the hospital's initiatives, resident curriculum, 
and direct resident involvement in the following areas: integrated care 
models, telehealth/HIT, population health, social determinants of 
health, and additional initiatives to improve access and quality of 
care to rural/underserved communities. In all areas, CHGME awardees 
will be required to highlight initiatives aimed at improving access and 
quality of care to rural and/or underserved communities. More details 
will be included in the FY 2019 CHGME NOFO.

Measures and Metrics

Summary of Comments
    Several commenters recommended focusing the QBS measures and 
metrics on the CHGME program and its goals, including measures 
regarding the quality of resident training. Commenters offered a number 
of potential measures and metrics that ranged from residency training 
characteristics, graduate outcomes, clinical learning environment 
outcomes, and health care transformation activities. One commenter 
recommended developing measures and metrics to evaluate how well 
training programs prepare graduates to improve the quality of care 
provided to local communities and integrate quality improvement into 
their clinical practice. They also recommended that quality measures 
could evaluate the quality of training settings, including commitment 
to caring for underserved populations, and impact on addressing 
healthcare problems in the community.
    A few commenters recommended that HRSA more critically evaluate 
future QBS measures and metrics. Specifically, one commenter stated 
that they were ``particularly concerned about the proposed plans for FY 
2020. Currently, there are no ``off the shelf'' measures that can be 
used to determine the quality of training programs. We recommend a 
thorough stakeholder process be convened with pediatric experts and 
CHGME hospitals to outline the best path forward.''
    A number of commenters cautioned that it is hard to tie patient 
outcomes to resident training. A few other commenters discouraged using 
graduate outcomes as a QBS measure, suggesting that hospitals are 
unable to control the specialty choices and future practice locations 
of residents. Several commenters also cautioned against using metrics 
relating to hospital outcomes which could not be directly tied to 
training. They recommended only using measures that were within a 
hospital's control. The following chart highlights other suggested 
measures and metrics from commenters:

      Additional QBS Measures and Metrics Recommended by Commenters
------------------------------------------------------------------------
 
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                           Residency Training
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Quality of resident training.
Volume of trainee-led initiatives and participation in larger hospital
 initiatives.
Percentage of training time spent in rural and underserved locations.
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                            Graduate Outcomes
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Percentage of graduates practicing in underserved areas.
Practice patterns and competency levels of graduates.
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                 Clinical Learning Environment Outcomes
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Value of clinical care.
Number of unnecessary medical tests, treatments, and procedures.
Rates of medical complications (hospital-acquired infections, unplanned
 extubations).
Rates of surgical complications (surgical site infections).
Hospital readmission rates.
Chronic disease management (treatment compliance and percentage at
 goal).
------------------------------------------------------------------------
                  Health Care Transformation Activities
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Number of faculty and resident publications.
Number of health care transformation initiatives.
------------------------------------------------------------------------

    Commenters also identified existing sets of measure that could be 
reviewed to identify potential candidates for use in the QBS such as 
the American Board of Family Medicine's (ABFM) Certification Survey 
Questionnaire, the ABFM's National Family Medicine Residency Graduate 
Follow-up Survey, the Children's Hospital Association approved 
activities such as Solutions for Patient Safety, the American College 
of Surgeons' Pediatric National Surgical Quality Improvement Program, 
and the Accreditation Council for Graduate Medical Education's (ACGME) 
milestones and measures.
Response
    HRSA appreciates the recommendations for potential QBS measures and 
metrics and recognizes the concerns regarding appropriate measures and 
metrics expressed by the commenters. HRSA will be reviewing all the 
sets of measures that were identified, as well as individual measure 
that were suggested for potential incorporation into the next phase of 
the QBS. Following the initial baseline phase of the QBS as detailed 
above in Qualifying Initiatives for the FY 2019 QBS response section, 
HRSA plans to conduct an environmental scan of GME quality measures, 
analyze the data collected during the baseline year, develop quality 
measures for GME programs in the above areas, and manage an organized 
stakeholder engagement process on potential QBS

[[Page 29798]]

standards and measures for future iterations.

Payment Structure

Summary of Comments
    Most commenters agreed with the tiered payment method but 
highlighted the importance of clearly messaging that funding tiers are 
not indicative of different levels of quality or engagement for the 
first phase of the CHGME QBS. One commenter offered, ``the bonus 
payments would have a more significant effect in transforming the 
quality of CHGME programs if the payments were funded at a level larger 
than $3 million and were in excess of current program funding.''
Response
    HRSA will continue to message clearly that the FY 2019 CHGME QBS 
payment tiers are not reflective of the quality of the initiatives. The 
payment tiers were developed taking into account the size of the 
training programs and CHGME payments typically awarded. In future 
years, once the data sources were better developed HRSA would work to 
develop a payment structure that takes into account both the size of 
the program and quality. As noted earlier, the amount of funding 
available for the QBS is provided for in statute and the $3 million 
funding amount is an estimation, assuming funding levels and mechanisms 
remain constant.
    For FY 2019, QBS payments will be disbursed with the CHGME FY 2019 
reconciliation payments. CHGME hospitals that submit the required 
documentation with the FY 2019 reconciliation application will receive 
a portion of the available funds for the CHGME QBS payment. Amounts 
will be distributed according to a three-tiered payment structure 
detailed in the Federal Register, 82 FR 48102.
    HRSA expects that future quality measures will likely be a 
combination of both quantitative and qualitative measures, where 
payment will be directly linked to the level of achievement of an 
individual hospital. We will continue to seek additional input from 
stakeholders and experts on the appropriate measures and metrics for 
future iterations of the CHGME QBS.

Documentation, Reporting Requirements and Reducing Reporting Burden

Summary of Comments
    Several commenters indicated that HRSA already collects quite a bit 
of information through the annual report and recommended that HRSA 
build on its existing reporting requirements to minimize reporting 
burden. These commenters suggested that new reporting requirements 
would add an administrative burden and deter maximum participation in 
the QBS. One commenter questioned whether HRSA would publicly share the 
QBS data.
Response
    HRSA agrees that participation in the QBS should not be overly 
burdensome and will work to create reasonable documentation 
requirements. HRSA acknowledges that it is already collecting some 
quality-related data in the annual CHGME performance measures and is 
developing ways to improve these fields. In addition, as part of the 
further development of the QBS, HRSA will be reviewing the different 
sets of data that children's hospitals already report to identify if 
any of the measures could be used as part of the QBS. A long-term goal 
would be to have transparency regarding the QBS data and HRSA will make 
sure to include that topic in stakeholder discussions. Any new data 
collection form(s) that are developed will require Office and 
Management and Budget (OMB) approval. Stakeholders will be able to 
provide public comments on any new data collection form(s) developed.

Implementation Timeline for FY 2020 and Beyond

Summary of Comments
    Half of commenters recommended a longer timeline to phase in the 
full FY 2020 and beyond QBS proposed framework, in order to ensure a 
thorough stakeholder engagement process in which pediatric experts are 
adequately involved in establishing metrics and measures, identifying 
quality outcomes, and evaluating QBS standards.
Response
    HRSA recognizes concerns about the QBS implementation timeline. We 
understand that there are many important factors that must be taken 
into account when implementing the QBS, and each requires thorough and 
well-informed consideration. In addition, QBS-related data collection 
must align with existing reporting and payment schedules for the CHGME 
Payment Program. The first phase of the CHGME QBS is planned to start 
in FY 2019, and we have taken into consideration feedback collected 
through this FRN. The data collected during the FY 2019 QBS will give 
HRSA an indication of the current experiences across our children's 
hospitals so that we can establish reasonable parameters and measures 
moving forward. In addition, HRSA is examining using existing reporting 
requirements to establish components of the QBS for FY 2020 and beyond. 
HRSA will continue collaborating with stakeholders and experts to 
inform future phases and measures for the CHGME QBS. As new QBS 
measures will affect a fiscal year payment, any updates or changes will 
be included in that year's NOFO.

Conclusion

    HRSA appreciates the comments and recommendations received and has 
used them to guide the development of the FY 2019 CHGME QBS and inform 
future iterations of the CHGME QBS. Final guidance for the FY 2019 
CHGME QBS will be published in the FY 2019 CHGME NOFO. If you have 
questions or concerns about comments that were not addressed in this 
notice, please contact <a href="/cdn-cgi/l/email-protection#e1aca2938096878e9385a189939280cf868e97"><span class="__cf_email__" data-cfemail="4e030d3c2f3928213c2a0e263c3d2f60292138">[email protected]</span></a>.

    Dated: June 19, 2018.
George Sigounas,
Administrator.
[FR Doc. 2018-13592 Filed 6-25-18; 8:45 am]
 BILLING CODE 4165-15-P


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