[Federal Register Volume 82, Number 198 (Monday, October 16, 2017)]
[Notices]
[Pages 48102-48103]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2017-22381]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Resources and Services Administration


Proposed Standards for the Children's Hospitals Graduate Medical 
Education Payment Program's Quality Bonus System

AGENCY: Health Resources and Services Administration (HRSA), Department 
of Health and Human Services.

ACTION: Request for public comment.

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SUMMARY: This notice seeks public comment on establishing a quality 
bonus system for the Children's Hospitals Graduate Medical Education 
(CHGME) Payment Program. The CHGME Support Reauthorization Act of 2013 
states that the Secretary may establish a quality bonus system, whereby 
the Secretary distributes bonus payments to hospitals participating in 
the program that meet standards specified by the Secretary. The goal of 
this notice is to seek comment to assist HRSA in the development of the 
standards, payment structure, and outcome measures for the CHGME 
Quality Bonus System.

DATES: Submit written comments no later than December 15, 2017.

ADDRESSES: Written comments should be submitted to Malena Crawford, 
Public Health Analyst, HRSA, by email ([email protected]) or by fax 
(301-443-0162).

FOR FURTHER INFORMATION CONTACT: Malena Crawford, Public Health 
Analyst, HRSA, 5600 Fishers Lane, Rockville, MD, 20852, (301) 443-7334.

SUPPLEMENTARY INFORMATION: The CHGME Program supports graduate medical 
education (GME) in freestanding children's hospitals. The program 
supports the training of primary care pediatricians and pediatric 
medical and surgical subspecialists. The CHGME Support Reauthorization 
Act of 2013 makes up to 25 percent of the total amount appropriated 
annually in excess of $245 million, but not to exceed $7,000,000, 
available to provide payments to newly qualified hospitals, as defined 
in section 340E(h) of the Public Health Service Act. The statute 
additionally states that the Secretary may establish a quality bonus 
system for CHGME hospitals using any remaining funds after payments are 
made to newly qualified hospitals. In FY 2017, Congress appropriated 
$300 million to the CHGME Program. Of this, approximately $4 million in 
payments were made to newly qualified hospitals. If funding levels and 
mechanisms remain constant, it is estimated that approximately $3 
million may be available annually for the CHGME Quality Bonus System. 
If the total amount available for the CHGME Quality Bonus System in a 
fiscal year is less than $2 million, HRSA does not plan to implement 
the CHGME Quality Bonus System in that year to minimize administrative 
burden on the hospitals. In this case, the funds would be disbursed to 
all eligible hospitals (including those newly qualified) according to 
the CHGME formula payment methodology.
    HRSA understands the complexities involved in designing a GME 
quality improvement initiative. The CHGME Quality Bonus System would be 
the first of its kind for any federal GME payment program and responds 
to changes occurring in the larger health care arena. For example, the 
Accreditation Council for GME, one of the prevailing GME accrediting 
bodies, recently implemented new GME program requirements around 
patient safety and quality improvement. Many GME programs and 
stakeholders are working towards establishing GME quality related 
outcome metrics, but currently no widely accepted metrics exist that 
have the ability to distinguish between the quality of training 
provided at different hospitals and training programs. Additionally, 
clinical outcomes alone may not be appropriate measures for 
establishing a GME quality improvement initiative. HRSA would like to 
begin to develop approaches to measure and assess the quality of GME 
programs using existing data sources initially and then develop new and 
improved data sources as we learn which are most informative and 
useful.

Quality Bonus Payment in FY 2019--Proposal for Public Comment

    HRSA is proposing a multi-step implementation in recognition of the 
changing landscape and the need for additional data. For FY 2019, HRSA 
proposes a quality bonus system that will initially recognize high-
level engagement of CHGME hospitals in state and regional health care 
transformation, as well as engagement of resident trainees in these 
activities. HRSA is seeking public comment on the timeline, 
eligibility, standards, documentation, and payment structure as 
described below. HRSA is also proposing areas for comment for FY 2020 
and beyond.
    Timeline: HRSA anticipates implementing the proposed CHGME Quality 
Bonus System standards in FY 2019 payments (project period October 1, 
2018, through September 30, 2019).
    CHGME Hospital Eligibility: HRSA proposes to include all eligible 
CHGME hospitals, including those newly qualified, as eligible entities 
for the CHGME Quality Bonus System.
    Quality Bonus System Standards: The proposed standards are: (1) 
Demonstration of engagement in state- or regional-level initiatives by 
a children's hospital to transform pediatric health care to improve 
access, quality, and cost effectiveness of health care; and (2) 
demonstration of resident trainee engagement in these activities.
    HRSA has identified several initiatives involving CHGME hospitals 
that require a significant level of engagement. These include federally 
funded efforts such as: Participation in a state Medicaid initiative to 
improve access, quality, and cost effectiveness of pediatric health 
care (e.g., a Centers for Medicare & Medicaid Services State Innovation 
Model Award or other Health Care Innovation Award with a state or 
regional impact); participation in the HRSA Maternal and Child Health 
Bureau's Health Care Delivery System Innovations for Children with 
Medical Complexity Collaborative Improvement and Innovation Network 
(CoIIN); or, participation in HRSA's Federal Office of Rural Health 
Policy Rural Health Network Development Grant Program.

[[Page 48103]]

In addition to the partnerships above, HRSA is seeking comment on state 
or regional initiatives to consider when establishing the qualifying 
standards for the CHGME Quality Bonus System, as well as suggestions 
for how to distinguish between levels of engagement and performance in 
a meaningful way.
    Documentation: To receive a quality bonus payment based upon 
engagement in state- or regional-level pediatric health care 
transformation, CHGME hospitals would be required to submit a letter 
from the lead organization, which could include the project director 
for a HRSA-supported program or the state Medicaid Director, confirming 
participation by the children's hospital in the program and delineating 
the roles and responsibilities of the children's hospital in the 
program activities. In addition, CHGME hospitals would be required to 
submit a brief narrative statement describing how CHGME trainees are 
integrated into state- or regional-level pediatric health care 
transformation activities and the expected benefits for trainees and 
the health systems served by the children's hospital. HRSA is seeking 
comment on this proposed approach including opportunities to limit 
burden and streamline the documentation to determine whether applicants 
meet standards and distinguish among levels of engagement and 
performance.
    Payment Structure: HRSA proposes that CHGME hospitals that meet the 
standards receive a portion of the available funds for the CHGME 
Quality Bonus System. HRSA proposes a three tiered payment structure to 
recognize the different annual payment levels received by CHGME 
hospitals. Hospitals that meet the Quality Bonus Systems standards will 
be evenly divided into three tiers based on their combined direct and 
indirect fiscal year payment amounts, as calculated per the established 
CHGME program formulas:
    Tier 1: Hospitals that qualify for the quality bonus payment that 
are in the lowest third among hospitals that qualify for the quality 
bonus payment of calculated CHGME annual payments will receive a base 
payment.
    Tier 2: Hospitals that qualify for the quality bonus payment that 
are in the middle third will receive two times the base payment.
    Tier 3: Hospitals that qualify for the quality bonus payment that 
are in the highest third will receive three times the base payment.
    The base payment rate would be determined from the total amount 
available and the number of hospitals that qualify for the CHGME 
Quality Bonus System in a fiscal year. HRSA would also seek to 
recognize the hospital's level of engagement or performance in the 
bonus amount. HRSA is also interested in gathering views and 
suggestions on whether any of the existing information that hospitals 
already report to the Centers of Medicare and Medicaid Services, HRSA, 
accrediting bodies, and others could be used to measure the performance 
of GME programs and related health outcomes for FY 2019 or subsequent 
years. This could be individual measures or combinations of measures 
that are reported to different entities.

Quality Bonus Payment in FY 2020 and Beyond--Areas for Public Comment

    In future years, HRSA will refine the CHGME Quality Bonus System to 
reflect the feedback received from stakeholders, as well as 
advancements in the development of standardized GME quality measures. 
To that end, HRSA also is requesting comments on several areas of the 
Quality Bonus System that will be implemented in FY 2020 and beyond. 
For long-term implementation, HRSA seeks public comments on the 
following areas:
    CHGME Hospital Eligibility: HRSA proposes to include all eligible 
CHGME hospitals, including those newly qualified, as eligible entities 
for the CHGME Quality Bonus System.
    Quality Bonus System Measures: HRSA is seeking comment on 
appropriate GME outcome measures that can assess and distinguish 
performance in meaningful ways. HRSA is considering several GME outcome 
measures including resident specialty outcomes (e.g., number of 
graduates in high need pediatric specialties), resident service 
outcomes (e.g., service to high need rural or underserved communities), 
and children's hospital quality outcomes. As noted above, these 
measures could be existing measures that hospitals already report or 
new ones that would be developed or improved for use in determining 
quality bonuses.
    Data Sources: HRSA is seeking comment on available data sources on 
which to base the Quality Bonus System. HRSA is requesting comment on 
data sources that are publicly available, will streamline reporting 
requirements, and will limit burden on CHGME programs.
    Tiering of Quality Bonus Payments: HRSA is requesting comments on 
payment structures to recognize hospitals according to their level of 
engagement and/or outcomes while also taking into account the different 
size of GME programs. The goal is for payment structures to recognize 
the quality of hospitals' programs considering the different 
circumstances in which different children's hospitals operate (e.g., 
patient severity, size of training programs, number of specialties 
trained, etc.)
    Frequency of Review: HRSA plans to review and update the CHGME 
Quality Bonus System standards regularly to reflect changes in GME and 
advances in measuring GME outcomes.

    Dated: October 5, 2017
George Sigounas,
Administrator.
[FR Doc. 2017-22381 Filed 10-13-17; 8:45 am]
 BILLING CODE 4165-15-P