[Federal Register Volume 70, Number 193 (Thursday, October 6, 2005)]
[Notices]
[Pages 58432-58436]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 05-19904]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services


Privacy Act of 1974; Report of a New System of Records

AGENCY: Department of Health and Human Services (HHS), Centers for 
Medicare & Medicaid Services (CMS).

ACTION: Notice of a New System of Records (SOR).

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SUMMARY: In accordance with the requirements of the Privacy Act of 
1974, we are proposing to establish a new system titled ``Medicare 
Physician Group Practice Demonstration (PGPD),'' System No. 09-70-0559. 
The PGPD tests a payment methodology for physician practices that 
combines Medicare fee-for-service payments with performance-based 
payments for improvements in patient management and quality of care. 
Improvements in these areas are expected to generate savings to the 
Medicare program to offset the costs of the performance payments. 
Mandated by Section 412 of the Benefits Improvement & Protection Act of 
2000, the PGPD seeks to provide incentives for physicians to adopt care 
management strategies and to improve quality as defined by key 
measurable processes and outcomes.
    The primary purpose of the system is to establish a pay-for-
performance three year pilot with physicians to encourage the 
coordination of care, promote investment in administrative structure 
and process, and reward physicians for improving health care processes 
and outcomes. Information retrieved from this system will also be 
disclosed to: (1) Support regulatory, reimbursement, and policy 
functions performed within the agency or by a contractor or consultant; 
(2) assist another Federal or state agency with information to enable 
such agency to administer a Federal health benefits program, or to 
enable such agency to fulfill a requirement of Federal statute or 
regulation that implements a health benefits program funded in whole or 
in part with Federal funds; (3) assist an individual or organization 
for a research project or in support of an evaluation project related 
to the prevention of disease or disability, the restoration or 
maintenance of health, or payment related projects; (4) support 
constituent requests made to a congressional representative; (5) 
support litigation involving the agency; and (6) combat fraud and abuse 
in certain health benefits programs. We have provided background 
information about the new system in the ``Supplementary Information'' 
section below. Although the Privacy Act requires only that CMS provide 
an opportunity for interested persons to comment on the proposed 
routine uses, CMS invites comments on all portions of this notice. See 
Effective Dates section for comment period.

EFFECTIVE DATES: CMS filed a new system report with the Chair of the 
House Committee on Government Reform and Oversight, the Chair of the 
Senate Committee on Governmental Affairs, and the Administrator, Office 
of Information and Regulatory Affairs, Office of Management and Budget 
(OMB) on September 27, 2005. In any event, we will not disclose any 
information under a routine use until 40 days after publication. We may 
defer implementation of this system or one or more of the routine use 
statements listed below if we receive comments that persuade us to 
defer implementation.

ADDRESSES: The public should address comments to: CMS Privacy Officer, 
Division of Privacy Compliance Data Development, CMS, Mail Stop N2-04-
27, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. Comments 
received will be available for review at this location, by appointment, 
during regular business hours, Monday through Friday from 9 a.m.-3 
p.m., eastern time zone.

FOR FURTHER INFORMATION CONTACT: John Pilotte, Research Analyst, 
Division of Payment Policy, Medicare Demonstration Programs Group, 
Office of Research Development and Information, CMS, Mail Stop C4-17-
27, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. The 
telephone number is (410) 786-6558 or e-mail <a href="/cdn-cgi/l/email-protection#0c66636462227c6560637878694c6f617f2264647f226b637a"><span class="__cf_email__" data-cfemail="5b31343335752b3237342f2f3e1b38362875333328753c342d">[email protected]</span></a>.

SUPPLEMENTARY INFORMATION: The PGPD rewards physicians for improving 
the quality and efficiency of health care services delivered to 
Medicare fee-for-service beneficiaries. Mandated by Section 412 of the 
Benefits Improvement and Protection Act of 2000, the PGPD seeks to: (1) 
Encourage coordination of Part A and Part B services, (2) promote 
efficiency through investment in administrative structure

[[Page 58433]]

and process, and (3) reward physicians for improving health outcomes.
    During the three-year project, CMS will reward physician groups 
that improve patient outcomes by coordinating care for chronically ill 
and high cost beneficiaries in an efficient manner. The Demonstration 
enables CMS the ability to test physician groups' responses to 
financial incentives for improving care coordination, delivery 
processes and patient outcomes, and the effect on access, cost, and 
quality of care to Medicare beneficiaries.
    Physician groups participating in the demonstration will continue 
to be paid on a fee-for-service basis. Physician groups will implement 
care management strategies designed to anticipate patient needs, 
prevent chronic disease complications and avoidable hospitalizations, 
and improve quality of care.
    Performance payments will be derived from savings expected through 
improvements in care coordination for an assigned beneficiary 
population. Performance payments will be allocated between efficiency 
and quality, with an increasing emphasis placed on quality during the 
demonstration. The demonstration will use a total of 32 measures that 
focus on common chronic illnesses and preventive services for measuring 
and rewarding quality.
    CMS selected ten physician groups on a competitive basis to 
participate in the demonstration. The groups were selected based on a 
variety of factors including technical review panel findings, 
organizational structure, operational feasibility, geographic location, 
and demonstration implementation strategy.

I. Description of the New System of Records

A. Statutory and Regulatory Basis for System

    The statutory authority for this system is given under the 
provisions of Section 412 of the Benefits Improvement & Protection Act 
of 2000.

B. Collection and Maintenance of Data in the System

    This system will maintain individually identifiable data collected 
on the Medicare expenditures of beneficiaries assigned to the 
participating physician practices. In addition, data will be collected 
from the physician practices on their performance based on a series of 
quality measures. The collected information will include: provider 
name, unique provider identification number, clinic name, medical 
record number, health insurance claim number, first name, last name, 
gender type, birth date, as well as, background information relating to 
Medicare or Medicaid issues.

II. Agency Policies, Procedures, and Restrictions on the Routine Use

    The Privacy Act permits us to disclose information without an 
individual's consent if the information is to be used for a purpose 
that is compatible with the purpose(s) for which the information was 
collected. Any such disclosure of data is known as a ``routine use.'' 
The government will only release PGPD information that can be 
associated with an individual as provided for under ``Section III. 
Proposed Routine Use Disclosures of Data in the System.'' Both 
identifiable and non-identifiable data may be disclosed under a routine 
use.
    We will only collect the minimum personal data necessary to achieve 
the purpose of the PGPD. CMS has the following policies and procedures 
concerning disclosures of information that will be maintained in the 
system. Disclosure of information from the system will be approved only 
to the extent necessary to accomplish the purpose of the disclosure and 
only after CMS:
    1. Determines that the use or disclosure is consistent with the 
reason that the data is being collected, e.g., to collect and maintain 
data on the Medicare expenditures of the beneficiaries assigned to 
participating physician practices and making performance payments to 
participating physician practices.
    2. Determines that:
    a. The purpose for which the disclosure is to be made can only be 
accomplished if the record is provided in individually identifiable 
form;
    b. The purpose for which the disclosure is to be made is of 
sufficient importance to warrant the effect and/or risk on the privacy 
of the individual that additional exposure of the record might bring; 
and
    c. There is a strong probability that the proposed use of the data 
would in fact accomplish the stated purpose(s).
    3. Requires the information recipient to:
    a. Establish administrative, technical, and physical safeguards to 
prevent unauthorized use of disclosure of the record;
    b. Remove or destroy at the earliest time all patient-identifiable 
information; and
    c. Agree to not use or disclose the information for any purpose 
other than the stated purpose under which the information was 
disclosed.
    4. Determines that the data are valid and reliable.

III. Proposed Routine Use Disclosures of Data in the System

A. Entities Who May Receive Disclosures Under Routine Use

    The Privacy Act allows us to disclose information without an 
individual's consent if the information is to be used for a purpose 
that is compatible with the purpose(s) for which the information was 
collected. Any such compatible use of data is known as a ``routine 
use.'' The proposed routine uses in this system meet the compatibility 
requirement of the Privacy Act. We are proposing to establish the 
following routine use disclosures of information maintained in the 
system:
    1. To agency contractors or consultants who have been engaged by 
the agency to assist in the performance of a service related to this 
system of records and who need to have access to the records in order 
to perform the activity.
    We contemplate disclosing information under this routine use only 
in situations in which CMS may enter into a contractual or similar 
agreement with a third party to assist in accomplishing CMS function 
relating to purposes for this system or records.
    CMS occasionally contracts out certain of its functions when doing 
so would contribute to effective and efficient operations. CMS must be 
able to give a contractor or consultant whatever information is 
necessary for the contractor or consultant to fulfill its duties. In 
these situations, safeguards are provided in the contract prohibiting 
the contractor or consultant from using or disclosing the information 
for any purpose other than that described in the contract and requires 
the contractor or consultant to return or destroy all information at 
the completion of the contract.
    2. To another Federal or state agency to:
    a. Contribute to the accuracy of CMS's proper payment of Medicare 
benefits,
    b. Enable such agency to administer a Federal health benefits 
program, or as necessary to enable such agency to fulfill a requirement 
of a Federal statute or regulation that implements a health benefits 
program funded in whole or in part with Federal funds, and/or
    c. Assist Federal/state Medicaid programs within the state.
    Other Federal or state agencies in their administration of a 
Federal health program may require PGPD information in order to support 
evaluations and monitoring of Medicare claims

[[Page 58434]]

information of beneficiaries, including proper reimbursement for 
services provided.
    3. To an individual or organization for a research project or in 
support of an evaluation project related to the prevention of disease 
or disability, the restoration or maintenance of health, or payment 
related projects.
    The PGPD data will provide for research or in support of evaluation 
projects, a broader, longitudinal, national perspective of the status 
of Medicare beneficiaries. CMS anticipates that many researchers will 
have legitimate requests to use these data in projects that could 
ultimately improve the care provided to Medicare beneficiaries and the 
policy that governs the care.
    4. To a member of congress or to a congressional staff member in 
response to an inquiry of the congressional office made at the written 
request of the constituent about whom the record is maintained.
    Beneficiaries sometimes request the help of a member of congress in 
resolving an issue relating to a matter before CMS. The member of 
congress then writes CMS, and CMS must be able to give sufficient 
information to be responsive to the inquiry.
    5. To the Department of Justice (DOJ), court or adjudicatory body 
when:
    a. The agency or any component thereof, or
    b. Any employee of the agency in his or her official capacity, or
    c. Any employee of the agency in his or her individual capacity 
where the DOJ has agreed to represent the employee, or
    d. the United States Government is a party to litigation or has an 
interest in such litigation, and by careful review, CMS determines that 
the records are both relevant and necessary to the litigation and that 
the use of such records by the DOJ, court or adjudicatory body 
incompatible with the purpose for which the agency collected the 
records.
    Whenever CMS is involved in litigation, and occasionally when 
another party is involved in litigation and CMS' policies or operations 
could be affected by the outcome of the litigation, CMS would be able 
to disclose information to the DOJ, court or adjudicatory body 
involved.
    6. To a CMS contractor (including, but not necessarily limited to 
fiscal intermediaries and carriers) that assists in the administration 
of a CMS-administered health benefits program, or to a grantee of a 
CMS-administered grant program, when disclosure is deemed reasonably 
necessary by CMS to prevent, deter, discover, detect, investigate, 
examine, prosecute, sue with respect to, defend against, correct, 
remedy, or otherwise combat fraud or abuse in such program.
    We contemplate disclosing information under this routine use only 
in situations in which CMS may enter into a contractual relationship or 
grant with a third party to assist in accomplishing CMS functions 
relating to the purpose of combating fraud and abuse.
    CMS occasionally contracts out certain of its functions and makes 
grants when doing so would contribute to effective and efficient 
operations. CMS must be able to give a contractor or grantee whatever 
information is necessary for the contractor or grantee to fulfill its 
duties. In these situations, safeguards are provided in the contract 
prohibiting the contractor or grantee from using or disclosing the 
information for any purpose other than that described in the contract 
and requiring the contractor or grantee to return or destroy all 
information.
    7. To another Federal agency or to an instrumentality of any 
governmental jurisdiction within or under the control of the United 
States (including any State or local governmental agency), that 
administers, or that has the authority to investigate potential fraud 
or abuse in, a health benefits program funded in whole or in part by 
Federal funds, when disclosure is deemed reasonably necessary by CMS to 
prevent, deter, discover, detect, investigate, examine, prosecute, sue 
with respect to, defend against, correct, remedy, or otherwise combat 
fraud or abuse in such programs.
    Other agencies may require PGPD information for the purpose of 
combating fraud and abuse in such Federally-funded programs.

B. Additional Provisions Affecting Routine Use Disclosures

    This system contains Protected Health Information (PHI) as defined 
by HHS regulation ``Standards for Privacy of Individually Identifiable 
Health Information'' (45 CFR Parts 160 and 164, 65 FR 82462 (12-28-00), 
Subparts A and E. Disclosures of PHI authorized by these routine uses 
may only be made if, and as, permitted or required by the ``Standards 
for Privacy of Individually Identifiable Health Information.''
    In addition, our policy will be to prohibit release even of not 
directly identifiable information, except pursuant to one of the 
routine uses or if required by law, if we determine there is a 
possibility that an individual can be identified through implicit 
deduction based on small cell sizes (instances where the patient 
population is so small that individuals who are familiar with the 
enrollees could, because of the small size, use this information to 
deduce the identity of the beneficiary).

IV. Safeguards

    CMS has safeguards in place for authorized users and monitors such 
users to ensure against excessive or unauthorized use. Personnel having 
access to the system have been trained in the Privacy Act and 
information security requirements. Employees who maintain records in 
this system are instructed not to release data until the intended 
recipient agrees to implement appropriate management, operational and 
technical safeguards sufficient to protect the confidentiality, 
integrity and availability of the information and information systems 
and to prevent unauthorized access.
    This system will conform to all applicable Federal laws and 
regulations and Federal, HHS, and CMS policies and standards as they 
relate to information security and data privacy. These laws and 
regulations include but are not limited to: the Privacy Act of 1974; 
the Federal Information Security Management Act of 2002; the Computer 
Fraud and Abuse Act of 1986; the Health Insurance Portability and 
Accountability Act of 1996; the E-Government Act of 2002, the Clinger-
Cohen Act of 1996; the Medicare Modernization Act of 2003, and the 
corresponding implementing regulations. OMB Circular A-130, Management 
of Federal Resources, Appendix III, Security of Federal Automated 
Information Resources also applies. Federal, HHS, and CMS policies and 
standards include, but are not limited to, all pertinent National 
Institute of Standards and Technology publications, the HHS Information 
Systems Program Handbook, and the CMS Information Security Handbook.

V. Effects of the New System on Individual Rights

    CMS proposes to establish this system in accordance with the 
principles and requirements of the Privacy Act and will collect, use, 
and disseminate information only as prescribed therein. Data in this 
system will be subject to the authorized releases in accordance with 
the routine uses identified in this system of records.
    CMS will take precautionary measures (see item IV. above) to 
minimize the risks of unauthorized access to the records and the 
potential harm to individual privacy or other personal or property 
rights of patients whose data is maintained in the system.

[[Page 58435]]

CMS will collect only that information necessary to perform the 
system's functions. In addition, CMS will make disclosure from the 
proposed system only with consent of the subject individual, or his/her 
legal representative, or in accordance with an applicable exception 
provision of the Privacy Act.
    CMS, therefore, does not anticipate an unfavorable effect on 
individual privacy as a result of maintaining this system of records.

    Dated: September 27, 2005.
Charlene Brown,
Acting Chief Operating Officer, Centers for Medicare & Medicaid 
Services.
System No.: 09-70-0559.

SYSTEM NAME:
    ``Medicare Physician Group Practice Demonstration (PGPD)'' HHS/CMS/
ORDI.

SECURITY CLASSIFICATION:
    Level 3 Privacy Act Sensitive.

SYSTEM LOCATION:
    CMS Data Center, 7500 Security Boulevard, North Building, First 
Floor, Baltimore, Maryland 21244-1850 and CMS contractors and agents at 
various locations.

CATEGORIES OF INDIVIDUALS COVERED BY THE SYSTEM:
    This system will maintain individually identifiable data collected 
on the Medicare expenditures and quality of care of beneficiaries 
assigned to the participating physician practices.

CATEGORIES OF RECORDS IN THE SYSTEM:
    This system will maintain individually identifiable data collected 
on the Medicare expenditures of beneficiaries assigned to the 
participating physician practices. In addition, data will be collected 
from the physician practices on their performance based on a series of 
quality measures. The collected information will include: provider 
name, unique provider identification number, clinic name, medical 
record number, health insurance claim number (HICN), first name, last 
name, gender type, birth date, as well as, background information 
relating to Medicare or Medicaid issues.

AUTHORITY FOR MAINTENANCE OF THE SYSTEM:
    The statutory authority for this system is given under the 
provisions of Section 412 of the Benefits Improvement & Protection Act 
of 2000.

PURPOSE(S) OF THE SYSTEM:
    The primary purpose of the system is to establish a pay-for-
performance three year pilot with physicians to encourage the 
coordination of care, promote investment in administrative structure 
and process, and reward physicians for improving health care processes 
and outcomes. Information retrieved from this system will also be 
disclosed to: (1) Support regulatory, reimbursement, and policy 
functions performed within the agency or by a contractor or consultant; 
(2) assist another Federal or state agency with information to enable 
such agency to administer a Federal health benefits program, or to 
enable such agency to fulfill a requirement of Federal statute or 
regulation that implements a health benefits program funded in whole or 
in part with Federal funds; (3) assist an individual or organization 
for a research project or in support of an evaluation project related 
to the prevention of disease or disability, the restoration or 
maintenance of health, or payment related projects; (4) support 
constituent requests made to a congressional representative; (5) 
support litigation involving the agency; and (6) combat fraud and abuse 
in certain health benefits programs.

ROUTINE USES OF RECORDS MAINTAINED IN THE SYSTEM, INCLUDING CATEGORIES 
OF USERS AND THE PURPOSES OF SUCH USES:
A. Entities Who May Receive Disclosures Under Routine Use
    The Privacy Act allows us to disclose information without an 
individual's consent if the information is to be used for a purpose 
that is compatible with the purpose(s) for which the information was 
collected. Any such compatible use of data is known as a ``routine 
use.'' The proposed routine uses in this system meet the compatibility 
requirement of the Privacy Act. We are proposing to establish the 
following routine use disclosures of information maintained in the 
system:
    1. To agency contractors or consultants who have been engaged by 
the agency to assist in the performance of a service related to this 
system and who need to have access to the records in order to perform 
the activity.
    2. To another Federal or state agency to:
    a. Contribute to the accuracy of CMS's proper payment of Medicare 
benefits,
    b. Enable such agency to administer a Federal health benefits 
program, or as necessary to enable such agency to fulfill a requirement 
of a Federal statute or regulation that implements a health benefits 
program funded in whole or in part with Federal funds, and/or
    c. Assist Federal/state Medicaid programs within the state.
    3. To an individual or organization for a research project or in 
support of an evaluation project related to the prevention of disease 
or disability, the restoration or maintenance of health, or payment 
related projects.
    4. To a member of Congress or to a congressional staff member in 
response to an inquiry of the congressional office made at the written 
request of the constituent about whom the record is maintained.
    5. To the Department of Justice (DOJ), court or adjudicatory body 
when:
    a. The agency or any component thereof, or
    b. Any employee of the agency in his or her official capacity, or
    c. Any employee of the agency in his or her individual capacity 
where the DOJ has agreed to represent the employee, or
    d. The United States Government

is a party to litigation or has an interest in such litigation, and by 
careful review, CMS determines that the records are both relevant and 
necessary to the litigation and that the use of such records by the 
DOJ, court or adjudicatory body is incompatible with the purpose for 
which the agency collected the records.
    6. To a CMS contractor (including, but not necessarily limited to 
fiscal intermediaries and carriers) that assists in the administration 
of a CMS-administered health benefits program, or to a grantee of a 
CMS-administered grant program, when disclosure is deemed reasonably 
necessary by CMS to prevent, deter, discover, detect, investigate, 
examine, prosecute, sue with respect to, defend against, correct, 
remedy, or otherwise combat fraud or abuse in such program.
    7. To another Federal agency or to an instrumentality of any 
governmental jurisdiction within or under the control of the United 
States (including any State or local governmental agency), that 
administers, or that has the authority to investigate potential fraud 
or abuse in, a health benefits program funded in whole or in part by 
Federal funds, when disclosure is deemed reasonably necessary by CMS to 
prevent, deter, discover, detect, investigate, examine, prosecute, sue 
with respect to, defend against, correct, remedy, or otherwise combat 
fraud or abuse in such programs.
B. Additional Provisions Affecting Routine Use Disclosures
    This system contains Protected Health Information (PHI) as defined 
by HHS regulation ``Standards for Privacy of Individually Identifiable 
Health Information'' (45 Code of Federal Regulations (CFR)) Parts 160 
and 164, 65 Fed. Reg. 82462 (12-28-00), Subparts A and E. Disclosures 
of PHI authorized

[[Page 58436]]

by these routine uses may only be made if, and as, permitted or 
required by the ``Standards for Privacy of Individually Identifiable 
Health Information.''
    In addition, our policy will be to prohibit release even if not 
directly identifiable, except pursuant to one of the routine uses or if 
required by law, if we determine there is a possibility that an 
individual can be identified through implicit deduction based on small 
cell sizes (instances where the patient population is so small that 
individuals who are familiar with the enrollees could, because of the 
small size, use this information to deduce the identity of the 
beneficiary).

POLICIES AND PRACTICES FOR STORING, RETRIEVING, ACCESSING, RETAINING, 
AND DISPOSING OF RECORDS IN THE SYSTEM:
STORAGE:
    All records are stored on magnetic media.

RETRIEVABILITY:
    Information collected will be retrieved by the name or other 
identifying information of the participating provider, and may also be 
retrievable by HICN at the individual beneficiary record level.

SAFEGUARDS:
    CMS has safeguards in place for authorized users and monitors such 
users to ensure against excessive or unauthorized use. Personnel having 
access to the system have been trained in the Privacy Act and 
information security requirements. Employees who maintain records in 
this system are instructed not to release data until the intended 
recipient agrees to implement appropriate management, operational and 
technical safeguards sufficient to protect the confidentiality, 
integrity and availability of the information and information systems 
and to prevent unauthorized access.
    This system will conform to all applicable Federal laws and 
regulations and Federal, HHS, and CMS policies and standards as they 
relate to information security and data privacy. These laws and 
regulations include but are not limited to: the Privacy Act of 1974; 
the Federal Information Security Management Act of 2002; the Computer 
Fraud and Abuse Act of 1986; the Health Insurance Portability and 
Accountability Act of 1996; the E-Government Act of 2002, the Clinger-
Cohen Act of 1996; the Medicare Modernization Act of 2003, and the 
corresponding implementing regulations. OMB Circular A-130, Management 
of Federal Resources, Appendix III, Security of Federal Automated 
Information Resources also applies. Federal, HHS, and CMS policies and 
standards include, but are not limited to, all pertinent National 
Institute of Standards and Technology publications, the HHS Information 
Systems Program Handbook, and the CMS Information Security Handbook.

RETENTION AND DISPOSAL:
    CMS will retain identifiable information maintained in the PGPD 
system of records for a period of 6 years. Data residing with the 
designated claims payment contractor shall be returned to CMS at the 
end of the project, with all data then being the responsibility of CMS 
for adequate storage and security. All claims-related records are 
encompassed by the document preservation order and will be retained 
until notification is received from the DOJ.

SYSTEM MANAGER AND ADDRESS:
    Director, Medicare Demonstration Programs Group, CMS, 7500 Security 
Boulevard, Mail stop C4-17-27, Baltimore, Maryland, 21244-1850.

NOTIFICATION PROCEDURE:
    For purpose of access, the subject individual should write to the 
system manager who will require the system name, and for verification 
purposes, the subject individual's name, provider identification 
number, and the patient's Medicare number.

RECORD ACCESS PROCEDURE:
    For purpose of access, use the same procedures outlined in 
Notification Procedures above. Requestors should also reasonably 
specify the record contents being sought. (These procedures are in 
accordance with Department regulation 45 CFR 5b.5 (a)(2)).

CONTESTING RECORD PROCEDURES:
    The subject individual should contact the system manager named 
above, and reasonably identify the record and specify the information 
to be contested. State the corrective action sought and the reasons for 
the correction with supporting justification. (These procedures are in 
accordance with Department regulation 45 CFR 5b.7).

RECORD SOURCE CATEGORIES:
    Information maintained in this system will be collected from 
physicians voluntarily participating through claims data requesting 
payment for services. The PGPD information will also be collected from 
the reporting of ambulatory care data by participating physician 
groups.

SYSTEMS EXEMPTED FROM CERTAIN PROVISIONS OF THE ACT:
    None.

[FR Doc. 05-19904 Filed 10-5-05; 8:45 am]
BILLING CODE 4120-03-P


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