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###### Department of Health and Human Services

          - [CMS-3348-N]

# AGENCY:

Office of the Secretary of Health and Human Services, HHS.

# ACTION:

Notice.

# SUMMARY:

                            This notice acknowledges the Secretary of the Department of Health and Human Services' (the Secretary) receipt and review of the National Quality Forum 2017 Annual Report to Congress and the Secretary submitted by the consensus-based entity under contract with the Secretary in accordance with the Social Security Act. The Secretary has reviewed and is publishing the report in the                             **Federal Register**                             together with the Secretary's comments on the report not later than 6 months after receiving the report in accordance with the Act.                        

# FOR FURTHER INFORMATION CONTACT:

Sophia Chan, (410) 786-5050.

# SUPPLEMENTARY INFORMATION:

## I. Background

The United States Department of Health and Human Services (HHS) has long recognized that a high functioning health care system that provides higher quality care requires accurate, valid, and reliable measurement of quality and efficiency. The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) (Pub. L. 110-275) added section 1890 of the Social Security Act (the Act), which requires the Secretary of the Department of Health and Human Services (the Secretary) to contract with the consensus-based entity (CBE) to perform multiple duties designed to help improve performance measurement. Section 3014 of the Patient Protection and Affordable Care Act (the Affordable Care Act) (Pub. L. 111-148) expanded the duties of the CBE to help in the identification of gaps in available measures and to improve the selection of measures used in health care programs.

HHS awarded a competitive contract to the National Quality Forum (NQF) in January 2009 to fulfill the requirements of section 1890 of the Act. A second, multi-year contract was awarded to NQF after an open competition in 2012. A third, multi-year contract was awarded again to NQF after an open competition in 2017. Section 1890(b) of the Act requires the following:

*Priority Setting Process: Formulation of a National Strategy and Priorities for Health Care Performance Measurement.*                         The CBE must synthesize evidence and convene key stakeholders to make recommendations on an integrated national strategy and priorities for health care performance measurement in all applicable settings. In doing so, the CBE is to give priority to measures that: (1) Address the health care provided to patients with prevalent, high-cost chronic diseases; (2) have the greatest potential for improving quality, efficiency, and patient-centered health care; and (3) may be implemented rapidly due to existing evidence, standards of care, or other reasons. Additionally, the CBE must take into account measures that: (1) May assist consumers and patients in making informed health care decisions; (2) address health disparities across groups and areas; and (3) address the continuum of care across multiple providers, practitioners and settings.                    

*Endorsement of Measures:*                         The CBE must provide for the endorsement of standardized health care performance measures. This process must consider whether measures are evidence-based, reliable, valid, verifiable, relevant to enhanced health outcomes, actionable at the caregiver level, feasible to collect and report, responsive to variations in patient characteristics such as health status, language capabilities, race or ethnicity, and income level, and are consistent across types of health care providers, including hospitals and physicians.                    

*Maintenance of CBE Endorsed Measures:*                         The CBE is required to establish and implement a process to ensure that endorsed measures are updated (or retired if obsolete) as new evidence is developed.                    

*Review and Endorsement of an Episode Grouper Under the Physician Feedback Program:*                         The CBE must provide for the review and, as appropriate, the endorsement of the episode grouper developed by the Secretary on an expedited basis.                    

*Convening Multi-Stakeholder Groups:*                         The CBE must convene multi-stakeholder groups to provide input on: (1) The selection of certain categories of quality and efficiency measures, from among such measures that have been endorsed by the entity; (2) such measures that have not been considered for endorsement by such entity but are used or proposed to be used by the Secretary for the collection or reporting of quality and efficiency measures; and (3) national priorities for improvement in population health and in the delivery of health care services for consideration under the national strategy. The CBE provides input on measures for use in certain specific Medicare programs, for use in programs that report performance information to the public, and for use in health care programs that are not included under the Act. The multi-stakeholder groups provide input on quality and efficiency measures for various federal health care quality reporting and quality improvement programs including those that address certain Medicare services provided through hospices, hospital inpatient and outpatient facilities, physician offices, cancer hospitals, end stage renal disease (ESRD) facilities, inpatient rehabilitation facilities, long-term care hospitals, psychiatric hospitals, and home health care programs.                    

*Transmission of Multi-Stakeholder Input:*                         Not later than February 1 of each year, the CBE must transmit to the Secretary the input of multi-stakeholder groups.                    

*Annual Report to Congress and the Secretary:*                         Not later than March 1 of each year, the CBE is required to submit to Congress and the Secretary an annual report. The report must describe:                    
    - The implementation of quality and efficiency measurement initiatives and the coordination of such initiatives with quality and efficiency initiatives implemented by other payers;
    - Recommendations on an integrated national strategy and priorities for health care performance measurement;
    - Performance of the CBE's duties required under its contract with the Secretary;
    - Gaps in endorsed quality and efficiency measures, including measures that are within priority areas identified by the Secretary under the national strategy established under section 399HH of the Public Health Service Act (National Quality Strategy), and where quality and efficiency measures are unavailable or inadequate to identify or address such gaps;
    - Areas in which evidence is insufficient to support endorsement of quality and efficiency measures in priority areas identified by the Secretary under the National Quality Strategy, and where targeted research may address such gaps; and
    - The convening of multi-stakeholder groups to provide input on: (1) The selection of quality and efficiency measures from among such measures that have been endorsed by the CBE and such measures that have not been considered for endorsement by the CBE but are used or proposed to be used by the Secretary for the collection or       ( print page 35319)                              reporting of quality and efficiency measures; and (2) national priorities for improvement in population health and the delivery of health care services for consideration under the National Quality Strategy.                    

                        The statutory requirements for the CBE to annually report to Congress and the Secretary of HHS also specify that the Secretary must review and publish the CBE's annual report in the                         **Federal Register**                        , together with any comments of the Secretary on the report, not later than 6 months after receiving it.                    

                        This                         **Federal Register**                         notice complies with the statutory requirement for Secretarial review and publication of the CBE's annual report. NQF submitted a report on its 2017 activities to the Secretary on March 1, 2018. Comments from the Secretary on the report are presented in section II of this notice, and the National Quality Forum 2017 Annual Report to Congress and the Secretary of the Department of Health and Human Services is provided, as submitted to HHS, in the addendum to this                         **Federal Register**                         notice in section III.                    

## II. Secretarial Comments on the National Quality Forum 2017 Annual Report to Congress and the Secretary of the Department of Health and Human Services

Once again, we thank NQF and the many stakeholders who participate in NQF projects for helping to advance the science and utility of health care quality measurement. As part of their annual recurring work to maintain a strong portfolio of endorsed measures for use across varied settings of care and health conditions, NQF reports that in 2017 it updated its measure portfolio by reviewing and endorsing or re-endorsing 120 measures and removing 109 measures. Endorsed measures are developed and implemented with input from numerous stakeholders. These measures undergo rigorous testing to ensure they are evidence-based, reliable, and valid. Continuous refinement of the measures portfolio through the measures maintenance process ensures that quality measures remain aligned with current field practices and health care goals. HHS, with the help of our partners, is committed to implementing measures that provide value to payers and actionable information that can be used to improve the health of patients.

                        NQF also undertook and continued a number of targeted projects dealing with difficult quality measurement issues. In particular, NQF has worked to help HHS address the unique challenges faced by rural communities. Nearly one in five Americans reside in rural communities.[1]                                                  HHS recognizes the unique challenges facing rural America, and with the support of partners like NQF, we are leveraging quality measurement to improve access and quality for healthcare providers serving rural patients. NQF recently completed several projects that focused on rural health, including Performance Measurement for Rural Low-Volume Providers [2]                                                  and Creating a Framework to Support Measure Development for Telehealth.[3]                                                  Our reforms in the area of rural health are part of our overall strategy to update our programs and improve access to high quality services.                    

In 2017, recognizing the need to strengthen representation of rural stakeholders in the pre-rulemaking process, HHS tasked NQF to establish a Measures Application Partnership (MAP) Rural Health Workgroup. The membership of the MAP Rural Health Workgroup, comprised of 18 organizational members, seven subject matter experts, and three federal liaisons, which reflects the diversity of rural providers and residents and allows for input from those most affected and most knowledgeable about rural measurement challenges and potential solutions. The MAP Rural Health Workgroup represents a continuation of HHS' effort to address rural health. With valuable input from our partners and stakeholders, HHS can continue to improve health care in rural America.

The MAP Rural Health Workgroup has focused on identifying a core set of the best available, “rural-relevant” measures to address the needs of the rural population. The MAP Rural Health Workgroup is also working to identify measurement gaps with respect to rural communities and provide recommendations regarding alignment and coordination of measurement efforts across both public and private programs, care settings, specialties, and sectors (both public and private). Additionally, the MAP Rural Health Workgroup provides guidance for the MAP to ensure that measures under consideration address rural provider and resident needs and challenges. The MAP Rural Health Workgroup's recommendations are also helping to address specific barriers to quality reporting faced by rural clinicians. Furthermore, the MAP Rural Health Workgroup has provided a space for rural clinicians to broadly share their valuable input. Rural physicians contribute unique and valuable perspectives critical to addressing national challenges, such as the opioid epidemic. However, rural physicians are often isolated from national discussions on relevant measures that could identify areas of need and gauge prevalence. Highlighting the valuable input from rural clinicians opens collaboration opportunities between rural providers and providers in other settings as HHS works to integrate new measures concerning the prevention and treatment of opioid and substance use disorders.

Addressing the needs of rural health communities is just one of many areas in which NQF partners with HHS in enhancing and protecting the health and well-being of all Americans. HHS greatly appreciates the ability to collaborate with diverse stakeholders and partners to help develop the strongest possible approaches to quality measurement as a key component to health care delivery system reform.

## III. Collection of Information Requirements

                        This document does not impose information collection requirements, that is, reporting, recordkeeping, or third-party disclosure requirements. Consequently, there is no need for review by the Office of Management and Budget under the authority of the Paperwork Reduction Act of 1995 (44 U.S.C. 3501*et seq.*).                    

## IV. Addendum

                        In this Addendum, we are publishing the                         *NQF Report on 2017 Activities to Congress and the Secretary of the Department of Health and Human Services,*                         as submitted to HHS.                    

Dated: June 21, 2018.

Alex M. Azar II,

Secretary, Department of Health and Human Services.

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# Footnotes

1.                                 U.S. Census Bureau, 2010 Census, Table GCTPH1.                        
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2.                                                             *https://www.qualityforum.org/​Publications/​2015/​09/​Rural_​Health_​Final_​Report.aspx.*
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3.                                                             *http://www.qualityforum.org/​Publications/​2017/​08/​Creating_​a_​Framework_​to_​Support_​Measure_​Development_​for_​Telehealth.aspx.*
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 BILLING CODE 4120-01-P

[FR Doc. 2018-15763 Filed 7-24-18; 8:45 am] 

BILLING CODE 4120-01-C