[Federal Register Volume 82, Number 161 (Tuesday, August 22, 2017)]
[Notices]
[Pages 39797-39874]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2017-17734]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

[CMS-3340-N]


Secretarial Review and Publication of the National Quality Forum 
Report of 2016 Activities to Congress and the Secretary of the 
Department of Health and Human Services

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

ACTION: Notice.

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SUMMARY: This notice acknowledges that in accordance with section 
1890(b)(5)(B) of the Social Security Act (the Act) the Secretary of the 
Department of Health and Human Services (the Secretary) has received 
and reviewed the National Quality Forum (NQF) Report of 2016 Activities 
to Congress and the Secretary of the Department of Health and Human 
Services submitted by the consensus-based entity with whom the 
Secretary has a contract under section 1890(a) of the Act. The purpose 
of this Federal Register notice is to publish the report, together with 
the Secretary's comments on such report.

FOR FURTHER INFORMATION CONTACT: Sophia Chan, (410) 786-5050.

I. Background

    The Secretary of the Department of Health and Human Services (the 
Secretary) 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. Section 1890(a) of the 
Social Security Act (the Act), as added by section 183(a)(1) of the 
Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) 
(Pub. L. 110-275), requires the Secretary to identify and have in 
effect a contract with a consensus-based entity (CBE) to perform 
multiple duties described in subsection (b) that are designed to help 
improve performance measurement. The duties described in subsection (b) 
originally included a priority setting process, measure endorsement, 
measure maintenance, electronic health record promotion, and the 
preparation of an annual Report to Congress and the Secretary. Section 
3003(b) of the Patient Protection and Affordable Care Act (Pub. L. 111-
148) as amended by the Health Care and Education Reconciliation Act 
(Pub. L. 111-152) (collectively, the Affordable Care Act) expanded the 
duties of the CBE to require the CBE to review and, as appropriate, 
endorse the episode grouper developed by the Secretary under the 
Physician Feedback Program. Section 3014(a)(1) of the Affordable Care 
Act further expanded the duties to require the CBE to convene multi-
stakeholder groups to provide input on the selection of quality and 
efficiency measures and national priorities for improvement in 
population health and in the delivery of health care services for 
consideration under the national strategy, and to transmit such input 
to the Secretary. Section 3014(a)(2) of the Affordable Care Act 
expanded the requirements for the annual report that must be submitted 
under section 1890(b)(5)(A) of the Act.
    To meet the requirements of section 1890(a) of the Act, in January 
of 2009, the Department of Health and Human Services (HHS) awarded a 
competitive contract to the National Quality Forum (NQF). A second, 
multi-year contract was awarded to NQF after an open competition in 
2012. This contract includes the following duties:
    Priority Setting Process: Formulation of a National Strategy and 
Priorities for Health Care Performance Measurement. The CBE is required 
to 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-centeredness of 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 a patient receives, including 
across multiple providers, practitioners and settings.
    Endorsement of Measures. The CBE is required to 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 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. ``Episode-based'' performance measurement is an 
approach to better understanding the utilization and costs associated 
with a certain condition by grouping together all the care related to 
that condition. ``Episode groupers'' are software tools that combine 
data to assess such condition-specific utilization and costs over a 
defined period of time. The CBE is required to provide for the review, 
and as appropriate, endorsement of an episode grouper as 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; and 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 (2) 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 
use in certain federal programs including

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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. For Medicaid and the 
Children's Health Insurance Program (CHIP), the multi-stakeholder 
groups provide input on measures to be included as part of the Medicaid 
and CHIP Child and Adult Core Sets.
    Transmission of Multi-Stakeholder Input. Not later than February 1 
of each year, the CBE is required to 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 of HHS an annual report. The report is required to describe 
the following:
     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 by the CBE on the duties required under its 
contract with HHS;
     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 those 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 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 by 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 2016 activities to the Secretary 
on March 1, 2017. Comments of the Secretary on this report are 
presented below in section II and the actual 2017 Annual Report to 
Congress is provided as an addendum to this Federal Register notice.

II. Secretarial Comments on the NQF Report of 2016 Activities to 
Congress and the Secretary of the Department of Health and Human 
Services

    Once again we thank the National Quality Forum (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 its 
annual recurring work to maintain a strong portfolio of endorsed 
measures for use across varied providers, settings of care, and health 
conditions, NQF reports that in 2016 it updated its portfolio of 
approximately 600 endorsed measures by reviewing and endorsing or re-
endorsing 197 measures and removing 87 measures. Endorsed measures 
facilitate the goals of improving care for highly prevalent conditions, 
fostering better care and coordination, and making the healthcare 
system more responsive to patient and family needs. These endorsed 
measures address a wide range of health care topics relevant to HHS 
programs, including: Person- and family-centered care; care 
coordination; palliative and end-of-life care; cardiovascular care; 
behavioral health; pulmonary/critical care; perinatal care; cancer 
treatment; patient safety; and cost and resource use.
    In addition to adding and re-endorsing new and existing measures, 
some measures were also removed from the portfolio for a variety of 
reasons (for example, no longer meeting endorsement criteria; 
harmonization with other similar measures; retirement by the measures 
developers; replacement with improved measures; and lack of continued 
need because providers consistently perform at the highest level on 
those measures). This 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. NQF 
also reports that in 2016 it continued to support the National Quality 
Strategy (NQS) by endorsing measures linked to the NQS priorities and 
convening diverse stakeholder groups to reach consensus on key 
strategies for performance measurement.
    In addition, in 2016 NQF undertook and continued a number of 
projects to address difficult quality measurement issues and reduce the 
burden of quality measures for clinicians. An important area that NQF 
continued to address was the issue of attribution, or the process used 
to assign accountability for a patient and his or her quality outcomes 
to a clinician, a group of clinicians, or a facility. HHS agrees that 
engaging clinicians and clearly communicating the methods and 
benchmarks used to determine attribution are foundational principles in 
quality measurement. Having clear methods for attribution helps 
clinicians understand the information given to them from quality 
measures, and allows for clinicians to make actionable changes to their 
clinical practices. When clinicians receive meaningful feedback 
regarding performance measurement, they can use it to implement best 
practices. Clear performance data reduce clinicians' burden in 
deciphering quality measurement information and allows them to focus on 
how best to improve care. While attribution models may differ, 
clinician engagement, transparency, and clear, usable data remain 
fundamental to quality measurement.
    NQF's work on attribution began in 2015 when NQF convened a multi-
stakeholder committee to examine attribution models and recommend 
principles to guide the selection and implementation of approaches. 
This work has resulted in a thorough list of potential approaches to 
validly and reliably attribute performance measurement results to one 
or more clinicians under different delivery models and to identify 
models of attribution for potential testing. The committee first 
convened in December 2015 and performed an environmental scan to 
identify attribution models currently in use and models that have been 
proposed but not implemented. The environmental scan identified 171 
unique attribution models, 27 of which have been implemented and 144 of 
which remain proposals only. The models differed across care settings, 
payment models, and in methodology, but there were also areas of 
similarity. After reviewing and discussing the scan, the committee 
defined several guiding principles to inform the development of

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successful attribution models. In addition, the committee developed an 
Attribution Model Selection Guide and outlined their findings in a 
report published in December 2016. See ``Attribution--Principles and 
Approaches'', National Quality Forum, December 2016, https://www.qualityforum.org/Publications/2016/12/Attribution_-_Principles_and_Approaches.aspx.
    Attribution is just one of many areas in which NQF partners with 
HHS in enhancing and protecting the health and well-being of all 
Americans. Quality measurement is essential to a high-functioning 
healthcare system, as evidenced in many of the targeted projects that 
NQF is being asked to undertake. HHS greatly appreciates the ability to 
bring many and diverse stakeholders to the table to help develop the 
strongest possible approaches to quality measurement as a key component 
of our healthcare system. We look forward to a continued strong 
partnership with the National Quality Forum in this ongoing endeavor.

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 2016 
Activities to Congress and the Secretary of the Department of Health 
and Human Services.

    Dated: August 16, 2017.
Thomas E. Price,
Secretary, Department of Health and Human Services.
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[FR Doc. 2017-17734 Filed 8-21-17; 8:45 am]
 BILLING CODE 4150-28-C