[Federal Register Volume 75, Number 232 (Friday, December 3, 2010)]
[Notices]
[Pages 75469-75471]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2010-30262]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Agency for Healthcare Research and Quality


Priority Setting for the Children's Health Insurance Program 
Reauthorization Act (CHIPRA) Pediatric Quality Measures Program

AGENCY: Agency for Healthcare Research and Quality, HHS.

ACTION: Request for public comments.

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SUMMARY: Section 401(a) of the Children's Health Insurance Program 
Reauthorization Act of 2009 (Pub. L. 111-3) amended title Xl of the 
Social Security Act by inserting after section 1139 the new section 
1139A, ``Child Health Quality Measures.'': Subsection 1139A(b), 
``Advancing and Improving Pediatric Quality Measures,'' directs the 
Secretary to establish a pediatric quality measures program to: improve 
and strengthen the initial core child health care quality measures 
established by the Secretary under section 1139A(a); expand on existing 
pediatric quality measures used by public and private health care 
purchasers and advance the development of new quality measures; and 
increase the portfolio of evidence-based, consensus pediatric quality 
measures available to public and private purchasers of children's 
healthcare services, providers, and consumers. Section 1139A(b)(3) 
requires the Secretary to consult with a broad range of stakeholders to 
set these priorities. To meet the requirement for extensive stakeholder 
consultation, we are seeking general public comment on these draft 
priorities, and asking the public to identify additional priorities as 
needed.

DATES: Comments on this notice must be received by January 14, 2010. 
The

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public comment period will close on January 14, 2010 at 5 p.m. EST. Any 
comments received after the close of the comment period will not be 
considered.

ADDRESSES: You may submit comments by any of the following methods:
    1. Electronic Mail_[email protected].
    2. Mail--Agency for Healthcare Research and Quality, Attention: 
Office of Extramural Research, Education, and Priority Populations-
Public Comment, CHIPRA PQMP Priorities, 540 Gaither Rd., Rockville, MD 
20850.
    Comments cannot be sent by facsimile transmission, because of staff 
and resource limitations. Please note that all submissions may be 
posted without change to http://www.AHRQ.gov/chipra, including any 
personal information provided.

FOR FURTHER INFORMATION CONTACT: 
    Denise Dougherty, PhD, Senior Advisor, Child Health and Quality 
Improvement, Office of Extramural Research, Education, and Priority 
Populations, Agency for Healthcare Research and Quality, 540 Gaither 
Rd., Rockville, MD. 301-427-1868. [email protected].
    For information regarding this Notice, please contact: 
[email protected].

SUPPLEMENTARY INFORMATION: On February 4, 2009, the Congress enacted 
the Children's Health Insurance Program Reauthorization Act (CHIPRA) of 
2009 (Pub. L. 111-3)., Section 401(a) of the legislation amended title 
XI of the Social Security Act (the Act) to establish section 1139A (42 
U.S.C. 1320b-9a). Subsection 1139A(b)(E) requires the Secretary to 
consult with a wide spectrum of national stakeholders to identify gaps 
in existing pediatric quality measures and establish priorities for 
development and advancement of such measures. The Secretary delegated 
CHIPRA implementation to the Centers for Medicare & Medicaid Services 
(CMS). A ``Memorandum of Understanding ``was entered into with the 
Agency for Healthcare Research and Quality (AHRQ), by which AHRQ would 
conduct several activities in Title IV. These included the 
identification of an initial, recommended core set of children's 
healthcare quality measures for voluntary use by Medicaid and CHIP 
programs and establishment of the Pediatric Quality Measures Program 
(PQMP), both in collaboration with CMS.
    Pediatric Quality Measures Program (PQMP). The PQMP was required to 
be established by January 1, 2011, and authorized to award grants and 
contracts. The PQMP will consist of 7-9 cooperative agreement awards to 
successful applicants to HS11-001 (http://grants.nih.gov/grants/guide/rfa-files/RFA-HS-11-001.html), and a contract award to a CHIPRA 
Coordinating and Technical Assistance Center (http://www.ahrg.gov/chipra/#CTAC), both supervised by AHRQ and CMS. As required by CHIPRA, 
successful applicants will work on priorities for measurement methods 
and topics set by HHS and informed by the input of multiple 
stakeholders.
    Multi-stakeholder consultation. Section 1139A(b)(3) requires a 
consultation process for establishing priorities for the pediatric 
quality measures program that requires consultation with multiple 
stakeholders, as follows:

    `` * * * the Secretary shall consult with:
    ``(A) States;
    (B) pediatricians, children's hospitals, and other primary and 
specialized pediatric health care professionals (including members 
of the allied health professions) who specialize in the care and 
treatment of children, particularly children with special physical, 
mental and developmental health care needs;
    (C) dental professionals, including pediatric dental 
professionals;
    (D) health care providers that furnish primary health care to 
children and families who live in urban and rural medically 
underserved communities or who are members of distinct population 
sub-groups at heightened risk for poor health outcomes;
    (E) national organizations representing children, including 
children with disabilities and children with chronic conditions;
    (F) national organizations representing consumers and purchasers 
of children's health care;
    (G) national organizations and individuals with expertise in 
pediatric health quality measurement; and
    (H) voluntary consensus standards setting organizations and 
other organizations involved in the advancement of evidence-based 
measures of health care.''

    Measure topics: Section 1139A(b)(2)(E) requires that the improved 
core measure sets include (but not necessarily be limited to) the 
following topics and types of healthcare quality measures:

    ``(A) The duration of children's health insurance coverage over 
a 12-month time period.
    ``(B) The availability and effectiveness of a full range of--
    ``(i) preventive services, treatments, and services for acute 
conditions, including services to promote healthy birth, prevent and 
treat premature birth, and detect the presence or risk of physical 
or mental conditions that could adversely affect growth and 
development; and
    ``(ii) treatments to correct or ameliorate the effects of 
physical and mental conditions, including chronic conditions, in 
infants, young children, school-age children, and adolescents.
    ``(C) The availability of care in a range of ambulatory and 
inpatient health care settings in which such care is furnished.
    ``(D) The types of measures that, taken together, can be used to 
estimate the overall national quality of health care for children, 
including children with special needs, and to perform comparative 
analyses of pediatric health care quality and racial, ethnic, and 
socioeconomic disparities in child health and health care for 
children.

    CHIPRA Section 1139A(b)(2)) requires that the measures developed 
under the pediatric quality measures program shall, at a minimum, be:

    ``(A) evidence-based and, where appropriate, risk adjusted;
    ``(B) designed to identify and eliminate racial and ethnic 
disparities in child health and the provision of health care;
    ``(C) designed to ensure that the data required for such 
measures is collected and reported in a standard format that permits 
comparison of quality and data at a State, plan, and provider level;
    ``(D) periodically updated; and
    ``(E) responsive to the child health needs, services, and 
domains of health care quality described in clauses (i), (ii), and 
(iii) of subsection (a)(6)(A).

    Definition of healthcare quality measure. For purposes of this 
notice, a healthcare quality measure is defined as a mechanism that 
enables a user to quantify the quality of a selected aspect of care by 
comparing it to a criterion (adapted from http://www.qualitymeasures.AHRQ.gov/resources/measure use.aspx).
    Definition of healthcare quality. An Institute of Medicine 
Committee on a Future Vision for the National Healthcare Quality and 
Disparities Reports has recently updated the IOM recommended framework 
for assessing and improving quality so that 6 components of quality 
care are identified (safety, timeliness, effectiveness, patient/family-
centeredness, access, efficiency), as well as 2 crosscutting dimensions 
(equity and value), three types of care (preventive care, acute 
treatment, and chronic condition management), and two additional 
elements (care coordination, health systems infrastructure 
capabilities). (http://iom.edu/Reports/2010/Future-Directions-for-the-National-Healthcare-Quality-and-Disparities-Reports.aspx). We adopt 
this framework for purposes of this public notice.
    Prior work to identify priorities for the POMP. The first phase of 
CHIPRA required a process for developing recommendations for an initial 
core set of quality measures for voluntary use by Medicaid and CHIP 
programs. As

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discussed in the Federal Register Notice and background paper that 
accompanied the public posting of the initial, recommended core set 
(http://www.ahrq.gov/chip/chipraact.htm#Core), not all CHIPRA criteria 
were able to be met for the initial core set. Public comments on the 
initial, recommended core set, and an expert meeting on measure 
criteria for the CHIPRA PQMP (http://www.AHRQ.gov/chipra/#Expert) 
provided additional insights into potential priorities for the PQMP. 
The combination of these efforts and events led to the identification 
of the following potential priorities for measure enhancement and 
development of new measures:
    1. Development or enhancement of methods to:
    a. Standardize measures across all payers, programs, and providers, 
public and private, as appropriate, to ensure that comparisons are 
valid.
    b. Assess disparities in quality by race, ethnicity, socioeconomic 
status, geographic region and residence, and special health care needs, 
for example by developing new measurement methods or enhancing existing 
measurement methods.
    c. Adjust for risk by enrollment duration.
    d. Stratify or adjust for risk by depth and breadth of coverage.
    e. Stratify or adjust for risk by medical conditions, including 
severity and acuity.
    f. Capitalize on current and coming investments in health 
information technology (e.g., patient and procedure registries, 
electronic health records, health information exchanges, 
interoperability), including meaningful use criteria under the American 
Recovery and Reinvestment Act (ARRA).
    g. Increase State programs' and CMS's ability to rely on non-
Medicaid and CHIP data sources through improvement in public health 
sector measurement (e.g., birth certificate data; immunization 
surveys).
    h. Come to consensus on the meaning and application of ``evidence-
based'' in the context of healthcare quality measurement for children.
    i. Incorporate patient and family perspectives into measurement to 
increase understandability.
    2. Development or enhancement of measures in key topic areas:
    a. Most integrated healthcare settings.
    b. Availability of services.
    c. Duration of enrollment as a standalone measure.
    d. Measures of the content (quality) of care now typically measured 
as broad utilization categories (e.g., prenatal, postpartum, newborn 
care (including breastfeeding support), well-child and adolescent well-
care visits, screening services, and follow-up visits for chronic 
conditions and related medications).
    e. Specific care settings and conditions:
    i. Perinatal care (e.g., family planning clinics, obstetric and 
gynecological care, birth centers).
    ii. Quality of mental/behavioral health and substance abuse 
services, including prevention and treatment services, across all 
settings.
    iii. Quality of care in settings beyond traditional medical care 
settings (e.g., for screening, diagnostic services and therapies).
    iv. Inpatient settings (including specialty inpatient settings).
    v. Specialty care for child conditions and diseases.
    vi. Care transitions for patients transitioning within and across 
health care settings.
    vii. Additional measures related to family experiences of care 
(e.g., child or adolescent self-reports; perinatal experiences of care; 
inpatient experiences)
    viii. Health outcome measures (e.g., measures of patient and 
population health or other outcomes of healthcare).\2\
    ix. Structural measures (e.g., measures of system design features 
that are causally linked to improved healthcare processes and 
outcomes).
    Those submitting comments are encouraged to include a summary of 
evidence for the readiness of a topic for quality measurement and the 
importance of a topic or method. Additional background information may 
be attached. Commenters may wish to address these issues using the 
following questions. Commenters may also wish to include in their 
comments a summary score based on a scale of 1-5, where 1 is a high 
score, 3 is a medium score, and 5 is a low score.
    Validity/Underlying Scientific Soundness: To what extent is there a 
demonstrated causal relationship between the element of quality to be 
measured (as a structure, process, or health outcome of healthcare 
delivery) and another element of the healthcare delivery system (e.g., 
structure and process; process and outcome). Commenters may wish to use 
as a guide to assessing underlying scientific soundness the method and 
criteria used by the AHRQ National Advisory Council Subcommittee on 
Children's Healthcare Quality Measures for Medicaid and CHIP, where 
appropriate http://www.AHRQ.gov/chipra/corebackground/corebacktab.htm#note5).
    Importance: Importance has several dimensions:
     To what extent is the topic important to children's health 
outcomes, family functioning, or societal functioning, including but 
not necessarily limited to high monetary costs of poor quality 
healthcare to children, families, or Society?
     To what extent is the topic important to reducing 
disparities in the quality of care for particular racial and ethnic 
groups of children, socioeconomic groups, geographically underserved 
groups, and children with special healthcare needs?
     To what extent is the topic important as a sentinel 
measure that could have spillover effects to the rest of the children's 
healthcare delivery system?
     To what extent is the proposed methodology important for 
addressing current shortcoming of healthcare quality measurement?
    We strongly encourage comments to be as succinct as possible (250 
words or less per topic, with additional supporting data allowed).

3. Collection of Information Requirements

    This voluntary request does not impose information collection and 
recordkeeping requirements. Consequently, it need not be reviewed by 
the Office of Management and Budget under the authority of the 
Paperwork Reduction Act of 1995 (44 U.S.C. 35).

4. Regulatory Impact Analysis

    As this notice does not meet the significance criteria of Executive 
Order 12866, it was not reviewed by the Office of Management and 
Budget.

    Dated: November 24, 2010.
Carolyn M. Clancy,
AHRQ Director.
[FR Doc. 2010-30262 Filed 12-2-10; 8:45 am]
BILLING CODE 4160-90-M