[Federal Register Volume 77, Number 228 (Tuesday, November 27, 2012)]
[Notices]
[Pages 70786-70788]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2012-28473]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[CMS-9962-NC]


Request for Information Regarding Health Care Quality for 
Exchanges

AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION: Request for Information.

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SUMMARY: This notice is a request for information to seek public 
comments regarding health plan quality management in Affordable 
Insurance Exchanges.

DATES: To be assured consideration, comments must be received at one of 
the addresses provided below, no later than 5 p.m. on December 27, 
2012.

ADDRESSES: In commenting, refer to file code CMS-9962-NC. Because of 
staff and resource limitations, we cannot accept comments by facsimile 
(FAX) transmission.
    You may submit comments in one of four ways (please choose only one 
of the ways listed):
    1. Electronically. You may submit electronic comments on this 
regulation to http://www.regulations.gov. Follow the ``Submit a 
comment'' instructions.
    2. By regular mail. You may mail written comments to the following 
address ONLY:
    Centers for Medicare & Medicaid Services, Department of Health and 
Human Services, Attention: CMS-9962-NC, P.O. Box 8010, Baltimore, MD 
21244-8010.
    Please allow sufficient time for mailed comments to be received 
before the close of the comment period.
    3. By express or overnight mail. You may send written comments to 
the following address ONLY:
    Centers for Medicare & Medicaid Services, Department of Health and 
Human Services, Attention: CMS-9962-NC, Mail Stop C4-26-05, 7500 
Security Boulevard, Baltimore, MD 21244-1850.
    4. By hand or courier. Alternatively, you may deliver (by hand or 
courier) your written comments ONLY to the following addresses:
    a. For delivery in Washington, DC--Centers for Medicare & Medicaid 
Services, Department of Health and Human Services, Room 445-G, Hubert 
H. Humphrey Building, 200 Independence Avenue SW., Washington, DC 
20201.
    (Because access to the interior of the Hubert H. Humphrey Building 
is not readily available to persons without

[[Page 70787]]

Federal government identification, commenters are encouraged to leave 
their comments in the CMS drop slots located in the main lobby of the 
building. A stamp-in clock is available for persons wishing to retain a 
proof of filing by stamping in and retaining an extra copy of the 
comments being filed.)
    b. For delivery in Baltimore, MD--Centers for Medicare & Medicaid 
Services, Department of Health and Human Services, 7500 Security 
Boulevard, Baltimore, MD 21244-1850.
    If you intend to deliver your comments to the Baltimore address, 
call telephone number (410) 786-9994 in advance to schedule your 
arrival with one of our staff members.
    Comments erroneously mailed to the addresses indicated as 
appropriate for hand or courier delivery may be delayed and received 
after the comment period.
    For information on viewing public comments, see the beginning of 
the ``SUPPLEMENTARY INFORMATION'' section.

FOR FURTHER INFORMATION CONTACT: Rebecca Zimmermann, (301) 492-4396.

SUPPLEMENTARY INFORMATION: Inspection of Public Comments: All comments 
received before the close of the comment period are available for 
viewing by the public, including any personally identifiable or 
confidential business information that is included in a comment. We 
post all comments received before the close of the comment period on 
the following Web site as soon as possible after they have been 
received: http://www.regulations.gov. Follow the search instructions on 
that Web site to view public comments.
    Comments received timely will also be available for public 
inspection as they are received, generally beginning approximately 3 
weeks after publication of a document, at the headquarters of the 
Centers for Medicare & Medicaid Services, 7500 Security Boulevard, 
Baltimore, Maryland 21244, Monday through Friday of each week from 8:30 
a.m. to 4 p.m. To schedule an appointment to view public comments, 
phone 1-800-743-3951.

I. Background

    Last year, the Department of Health and Human Services (HHS) 
adopted the National Strategy for Quality Improvement in Health Care 
(National Quality Strategy) to create national aims and priorities that 
would guide local, state, and national efforts to improve the quality 
of health care in the United States. The priorities of the National 
Quality Strategy include making care safer; ensuring person- and 
family-centered care; promoting effective communication and 
coordination of care; promoting the most effective prevention and 
treatment for the leading causes of mortality, starting with 
cardiovascular disease; working with communities to promote wide use of 
best practices to enable healthy living; and making quality care more 
affordable.\1\ As discussed in the National Quality Strategy, ``[t]he 
Affordable Care Act seeks to increase access to high-quality, 
affordable health care for all Americans.'' To that end, the Affordable 
Care Act contains several provisions that help to foster and support 
health care quality improvement across the insurance marketplace, 
including section 2717 of the Public Health Service Act (PHS Act). The 
Affordable Care Act places additional quality-related requirements on 
health insurance issuers offering qualified health plans (QHPs) in the 
new Exchange marketplace, including section 1311 which directs QHP 
issuers to implement quality improvement strategies, enhance patient 
safety through specific contracting requirements, and publicly report 
quality data. The Affordable Care Act also directs the Secretary of HHS 
to develop and administer a quality rating system and an enrollee 
satisfaction survey system, the results of which will be available to 
Exchange consumers shopping for insurance plans. In addition, section 
10329 of the Affordable Care Act, which relates to plans both inside 
and outside the Exchange, directs the Secretary, in consultation with 
relevant stakeholders, to develop a methodology for calculating the 
value of a health plan.
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    \1\ See Report to Congress: National Strategy for Quality 
Improvement in Health Care available at http://www.healthcare.gov/law/resources/reports/quality03212011a.html.
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    HHS's strategy for establishing quality reporting requirements to 
ensure that quality health care is delivered through the Exchange 
marketplace includes the consideration of existing relevant quality 
measure sets and quality improvement initiatives in conjunction with 
other factors, such as characteristics of the Exchange population. 
States, employers, health insurance issuers, and other stakeholders, in 
addition to the Centers for Medicare and Medicaid Services (CMS) and 
other HHS agencies, are currently engaged in health plan quality 
reporting and improvement initiatives. As indicated in the National 
Quality Strategy, HHS is interested in promoting effective quality 
measurement while minimizing the burden of data collection by aligning 
measures across programs. These efforts would also ease comparability 
across plans, providers, and insurance markets, and promote delivery of 
high-quality and high-value health care.
    As set forth in the May 2012 General Guidance on Federally-
facilitated Exchanges, HHS intends to propose a phased approach to 
quality reporting and display standards for all Exchanges and QHP 
issuers. No new quality reporting standards would be in place until 
2016 (other than those related to accreditation, if applicable), which 
allows time to develop standards appropriately matched to the Exchange 
enrollee population and plan offerings. Until final regulations are 
issued, state-based Exchanges would have the choice of adopting a 
similar approach or implementing their own quality reporting standards 
immediately and over time.\2\
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    \2\ See ``General Guidance on Federally-facilitated Exchanges,'' 
available at http://cciio.cms.gov/resources/files/FFE_Guidance_FINAL_VERSION_051612.pdf.
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    In preparation for the implementation of the quality provisions 
affecting QHPs in the new Exchange marketplace under the Affordable 
Care Act, HHS is requesting information through this notice from 
stakeholders regarding existing quality measures and rating systems, 
strategies and requirements for quality improvement, purchasing 
strategies to promote care redesign and patient safety, as well as 
effective methodologies to measure health plan value. This notice also 
offers the opportunity to provide recommendations on the most effective 
ways to enhance and align the quality reporting and display 
requirements for QHPs starting in 2016 in conjunction with existing 
quality improvement initiatives, such as the National Quality Strategy. 
We note that this notice should not be viewed as final policy that will 
be adopted pursuant to rulemaking.

II. Solicitation of Comments

    CMS is requesting information regarding the following:

Understanding the Current Landscape

    1. What quality improvement strategies do health insurance issuers 
currently use to drive health care quality improvement in the following 
categories: (1) Improving health outcomes; (2) preventing hospital 
readmissions; (3) improving patient safety and reducing medical errors; 
(4) implementing wellness and health promotion activities; and (5) 
reducing health disparities?
    2. What challenges exist with quality improvement strategy metrics 
and

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tracking quality improvement over time (for example, measure selection 
criteria, data collection and reporting requirements)? What strategies 
(including those related to health information technology) could 
mitigate these challenges?
    3. Describe current public reporting or transparency efforts that 
states and private entities use to display health care quality 
information.
    4. How do health insurance issuers currently monitor the 
performance of hospitals and other providers with which they have 
relationships? Do health insurance issuers monitor patient safety 
statistics, such as hospital acquired conditions and mortality 
outcomes, and if so, how? Do health insurance issuers monitor care 
coordination activities, such as hospital discharge planning 
activities, and outcomes of care coordination activities, and if so, 
how?

Applicability to the Health Insurance Exchange Marketplace

    5. What opportunities exist to further the goals of the National 
Quality Strategy through quality reporting requirements in the Exchange 
marketplace?
    6. What quality measures or measure sets currently required or 
recognized by states, accrediting entities, or CMS are most relevant to 
the Exchange marketplace?
    7. Are there any gaps in current clinical measure sets that may 
create challenges for capturing experience in the Exchange?
    8. What are some issues to consider in establishing requirements 
for an issuer's quality improvement strategy? How might an Exchange 
evaluate the effectiveness of quality improvement strategies across 
plans and issuers? What is the value in narrative reports to assess 
quality improvement strategies?
    9. What methods should be used to capture and display quality 
improvement activities? Which publicly and privately funded activities 
to promote data collection and transparency could be leveraged (for 
example, Meaningful Use Incentive Program) to inform these methods?
    10. What are the priority areas for the quality rating in the 
Exchange marketplace? (for example, delivery of specific preventive 
services, health plan performance and customer service)? Should these 
be similar to or different from the Medicare Advantage five-star 
quality rating system (for example, staying healthy: screenings, tests 
and vaccines; managing chronic (long-term) conditions; ratings of 
health plan responsiveness and care; health plan members' complaints 
and appeals; and health plan telephone customer service)? \3\
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    \3\ For more information on Medicare Advantage rating system 
domains see http://www.cms.gov/Medicare/Health-Plans/HealthPlansGenInfo/Downloads/2013-Call-Letter.pdf; http://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/PerformanceData.html.
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    11. What are effective ways to display quality ratings that would 
be meaningful for Exchange consumers and small employers, especially 
drawing on lessons learned from public reporting and transparency 
efforts that states and private entities use to display health care 
quality information?
    12. What types of methodological challenges may exist with public 
reporting of quality data in an Exchange? What suggested strategies 
would facilitate addressing these issues?
    13. Describe any strategies that states are considering to align 
quality reporting requirements inside and outside the Exchange 
marketplace, such as creating a quality rating for commercial plans 
offered in the non-Exchange individual market.
    14. Are there methods or strategies that should be used to track 
the quality, impact and performance of services for those with 
accessibility and communication barriers, such as persons with 
disabilities or limited English proficiency?
    15. What factors should HHS consider in designing an approach to 
calculate health plan value that would be meaningful to consumers? What 
are potential benefits and limitations of these factors? How should 
Exchanges align their programs with value-based purchasing and other 
new payment models (for example, Accountable Care Organizations) being 
implemented by payers?

    Dated: November 6, 2012.
Marilyn Tavenner,
Acting Administrator, Centers for Medicare & Medicaid Services.
    Approved: November 16, 2012.
Kathleen Sebelius,
Secretary.
[FR Doc. 2012-28473 Filed 11-23-12; 11:15 am]
BILLING CODE 4120-01-P