[Federal Register Volume 74, Number 248 (Tuesday, December 29, 2009)]
[Notices]
[Pages 68846-68849]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: E9-30802]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Office of the Secretary

[CMS-2474-NC]


Medicaid and CHIP Programs; Initial Core Set of Children's 
Healthcare Quality Measures for Voluntary Use by Medicaid and CHIP 
Programs

AGENCY: Office of the Secretary, HHS.

ACTION: Notice with comment period.

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SUMMARY: This notice identifies and solicits public comments on the 
initial, recommended core set of children's health care quality 
measures for voluntary use by State programs administered under titles 
XIX and XXI of the Social Security Act, health insurance issuers and 
managed care entities that enter into contracts with Medicaid and 
Children's Health Insurance Programs, and providers of items and 
services under these programs, in accordance with the Children's Health 
Insurance Program Reauthorization Act of 2009 (Pub. L. 111-3). This 
notice also discusses steps already underway to facilitate the 
programs' voluntary use of the children's health care quality measures. 
In addition, this notice solicits comments on how the steps might be 
enhanced, and recommendations for additional steps to facilitate use of 
the measures.

DATES: To be assured consideration, comments must be received at one of 
the addresses provided below, no later than 5 p.m. on March 1, 2010.

ADDRESSES: Because of staff and resource limitations, we cannot accept 
comments by facsimile (FAX) transmission.
    You may submit comments in one of two ways (please choose only one 
of the ways listed):
    1. Electronic Mail. CHIPRAqualitymeasures@ahrq.hhs.gov.
    2. Regular Mail. Agency for Healthcare Research and Quality, 
Attention: Office of Extramural Research, Education, and Priority 
Populations--Public Comment, CHIPRA Core Measures, 540 Gaither Rd., 
Rockville, MD 20850.
    Please note that all submissions may be posted without change to 
http://www.AHRQ.gov, including any personal information provided.

FOR FURTHER INFORMATION CONTACT: CHIPRAqualitymeasures@AHRQ.hhs.gov.

SUPPLEMENTARY INFORMATION:

I. Background

    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 the Social Security Act (the 
Act), to establish section 1139A (42 U.S.C. 1320b-9a). This section 
requires the Secretary to identify and publish for general comment an 
initial, recommended core set of child health quality measures for use 
by State programs administered under titles XIX and XXI of the Act, 
health insurance issuers and managed care entities that enter into 
contracts with such programs, and providers of items and services under 
such programs. The statute requires that the

[[Page 68847]]

Secretary identify and publish these measures by January 1, 2010. The 
Secretary delegated this task to the Centers for Medicare & Medicaid 
Services (CMS). A ``Memorandum of Understanding'' was signed with the 
Agency for Healthcare Research and Quality (AHRQ), by which CMS and 
AHRQ would collaborate to make recommendations for the initial core set 
of children's health care quality measures to be posted for public 
comment. The initial core set is intended to be used voluntarily by 
Medicaid and the Children's Health Insurance Program (CHIP).
    The initial core set of children's health care quality measures for 
voluntary use by Medicaid and CHIP programs was developed in 
consultation with organizations representing the stakeholder categories 
set out at section 1139A(b)(3) of the Act (including States; health 
care providers specializing in pediatric health and dentistry; 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; national organizations representing children 
and families; individuals and organizations with health care quality 
measurement expertise; and other organizations involved in the 
advancement of evidence-based measures of health care).
    Measures for consideration for the initial core set were compiled 
from ``existing quality of care measures for children that are in use 
under public and privately sponsored health care coverage arrangements, 
or that are part of reporting systems that measure both the presence 
and duration of health insurance coverage over time'' as required by 
section 1139A(a)(2) of the Act.
    The statute requires that the initial core set of child health 
quality measures include the following:
    1. The duration of children's health insurance coverage over a 12-
month time period.
    2. The availability and effectiveness of a full range of 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 treatments to 
correct or ameliorate the effects of physical and mental conditions, 
including chronic conditions in infants, young children, school-age 
children, and adolescents.
    3. The availability of care in a range of ambulatory and inpatient 
health care settings in which such care is furnished.
    4. 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.
    To help facilitate an evidence-informed and transparent process for 
making recommendations, AHRQ's National Advisory Council on Healthcare 
Research and Quality created a Subcommittee on Children's Healthcare 
Quality Measures for Medicaid and CHIP programs (the ``Subcommittee''). 
The Subcommittee held public meetings, and considered public comments 
and measure nominations throughout their deliberations. Subcommittee 
members were provided with standard definitions, criteria, and 
objective information to facilitate scoring of measures for validity, 
feasibility, and importance over several iterations of measure 
consideration. The Subcommittee's recommendations were reported to the 
Chair of AHRQ's National Advisory Council on Healthcare Research and 
Quality and subsequently considered further by Medicaid and CHIP 
officials, as well as staff in the Office of the Secretary of the 
Department of Health and Human Services (HHS) prior to this public 
posting. Extensive details regarding the process, the measures 
recommended, and other considerations regarding the initial core set 
can be found at http://www.ahrq.gov/chip/corebackgrnd.htm. We are now 
soliciting additional comments from the public to help determine which 
measures should remain in the core set, which measures may need further 
development to enhance their validity and feasibility, and the nature 
of technical assistance and other resources required before State 
Medicaid and CHIP programs and health care providers can be expected to 
implement and report on these measures. In submitting comments, it is 
important to consider the kinds of activities already under way at HHS 
to facilitate making the measures more feasible and valid for use by 
the States for reporting across all Medicaid and CHIP programs (for 
example, managed care, fee-for-service and enrollees).
    HHS will be making improvements and enhancements to the core set of 
measures as a result of the following:
     Public comment on the initial, recommended core measure 
set.
     Products developed by a pediatric quality measures program 
of grants and contracts to begin in 2010 (section 1139A(b) of the Act).
     Products stimulated by CMS's CHIPRA Quality Demonstration 
Grants, including evaluation and experimentation with the measures and 
development of an electronic health record format for children's health 
care (section 1139A(d) of the Act).
     Other advancements and improvements to children's health 
care quality measures (such as annual quality reporting as required 
under section 1139A(a)(4) of the Act).
    Section 1139A(b)(5) of the Act directs that an improved, evidence-
based core measure set is to be available by January 1, 2013, to be 
feasible for use by a broad range of providers, payers, and programs, 
both public and private (42 U.S.C. 1320b-9a).
    To further these efforts, AHRQ and CMS are currently working to 
continue or implement the following initiatives:
    1. Establishing methodologies to create measure specifications that 
are applicable to all Medicaid and CHIP enrollees, and suitable for 
identifying disparities in quality by race, ethnicity, socioeconomic 
status, and special health care needs status, as required by CHIPRA.
    2. Providing technical assistance to States to facilitate 
implementation of the initial, recommended core measure set.
    3. Using a public process for the pediatric quality measures grants 
and contracts program to build on priorities identified during the 2009 
identification of the initial, recommended core set. Priority topics 
already identified include quality measures for: mental health and 
substance abuse services for children, other specialty services, 
inpatient care, duration of enrollment and coverage, medical home and 
other integrated health care delivery mechanisms, and availability of 
services.
    4. Considering ways to align State reporting requirements across 
CHIPRA provisions, with Early and Periodic Screening, Diagnostic and 
Treatment Services (EPSDT) via CMS 416 reporting, and with annual 
reporting requirements for CHIP.
    5. Coordinating quality measurement efforts with payment reform 
strategies, health information technology and electronic health record 
initiatives, and
    6. Working with States to identify the best formats for sharing 
Medicaid and CHIP quality measurement data, including when and how 
state reports should be made publicly available.
    7. Continuing to work with States and national stakeholders to 
develop

[[Page 68848]]

national intervention strategies for improving health care quality and 
outcomes for children (for example, Medicaid Transformation Grants and 
the CHIPRA Quality Demonstration Grants).
    8. Continuing development and implementation of the Federal-State 
National Quality Framework in alignment with CHIPRA initiatives for 
improving the quality of care for children.
    9. Due to the concurrent CHIPRA and American Recovery and 
Reinvestment Act (ARRA) HIT implementation activities, CMS will align 
the two programs and strive to create efficiencies for States and 
pediatric providers, where applicable, by prioritizing consistency in 
measure selection for pediatric providers.

II. Categories of the Initial, Recommended Core Set of Children's 
Healthcare Quality Measures

    The basic categories of the initial, recommended core set of 
children's health care quality measures are set forth below. For full 
specifications of each measure and summaries of the rationales behind 
each recommended measure, see the background paper for this Federal 
Register notice at http://www.ahrq.gov/chip/corebackgrnd.htm. Measures 
that have received National Quality Forum (NQF) endorsement are 
indicated with the relevant number.

   Measures Recommended for Initial Core Set of Children's Healthcare
 Quality for Voluntary Reporting by Medicaid and CHIP Programs, Measure
                     Labels by Legislative Category
------------------------------------------------------------------------
                                     Legislative measure topic/Subtopic/
          Measure number                    Current measure label
------------------------------------------------------------------------
                     PREVENTION AND HEALTH PROMOTION
                           Prenatal/Perinatal
------------------------------------------------------------------------
1.................................  Frequency of ongoing prenatal care.
2.................................  Timeliness of prenatal care--the
                                     percentage of deliveries that
                                     received a prenatal care visit as a
                                     member of the organization in the
                                     first trimester or within 42 days
                                     of enrollment in the organization.
3.................................  Percent of live births weighing less
                                     than 2,500 grams.
4.................................  Cesarean Rate for low-risk first
                                     birth women [NQF 0471].
------------------------------------------------------------------------
                              Immunizations
------------------------------------------------------------------------
5.................................  Childhood immunization status [NQF
                                     0038].
6.................................  Immunizations for adolescents.
------------------------------------------------------------------------
                                Screening
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7.................................  BMI documentation 2-18 year olds
                                     [NQF 0024].
8.................................  Screening using standardized
                                     screening tools for potential
                                     delays in social and emotional
                                     development--Assuring Better Child
                                     Health and Development (ABCD)
                                     initiative measures.
9.................................  Chlamydia screening for women [NQF
                                     0033].
------------------------------------------------------------------------
                      Well-child Care Visits (WCV)
------------------------------------------------------------------------
10................................  WCVs in the first 15 months of life.
11................................  WCVs in the third, fourth, fifth and
                                     sixth years of life.
12................................  WCV for 12-21 yrs of age--with PCP
                                     or OB-GYN.
------------------------------------------------------------------------
                                 Dental
------------------------------------------------------------------------
13................................  Total eligibles receiving preventive
                                     dental services (EPSDT measure Line
                                     12B).
------------------------------------------------------------------------
                     MANAGEMENT OF ACUTE CONDITIONS
            Upper Respiratory--Appropriate Use of Antibiotics
------------------------------------------------------------------------
14................................  Appropriate testing for children
                                     with pharyngitis [NQF 0002].
15................................  Otitis Media with Effusion--
                                     avoidance of inappropriate use of
                                     systemic antimicrobials--ages 2-12.
------------------------------------------------------------------------
                                 Dental
------------------------------------------------------------------------
16................................  Total EPSDT eligibles who received
                                     dental treatment services (EPSDT
                                     CMS Form 416, Line 12C).
------------------------------------------------------------------------
                          Emergency Department
------------------------------------------------------------------------
17................................  Emergency Department (ED)
                                     Utilization--Average number of ED
                                     visits per member per reporting
                                     period.
------------------------------------------------------------------------
                            Inpatient Safety
------------------------------------------------------------------------
18................................  Pediatric catheter-associated blood
                                     stream infection rates (PICU and
                                     NICU) [NQF 0139].
------------------------------------------------------------------------
                    MANAGEMENT OF CHRONIC CONDITIONS
                                 Asthma
------------------------------------------------------------------------
19................................  Annual number of asthma patients (>=
                                     1 year old) with >= 1 asthma
                                     related ER visit (S/AL Medicaid
                                     Program).
------------------------------------------------------------------------

[[Page 68849]]

 
                                  ADHD
------------------------------------------------------------------------
20................................  Follow-up care for children
                                     prescribed attention-deficit/
                                     hyperactivity disorder (ADHD)
                                     medication (Continuation and
                                     Maintenance Phase) [NQF 108].
------------------------------------------------------------------------
                              Mental Health
------------------------------------------------------------------------
21................................  Follow up after hospitalization for
                                     mental illness.
------------------------------------------------------------------------
                                Diabetes
------------------------------------------------------------------------
22................................  Annual hemoglobin A1C testing (all
                                     children and adolescents diagnosed
                                     with diabetes).
------------------------------------------------------------------------
                       FAMILY EXPERIENCES OF CARE
------------------------------------------------------------------------
23................................  CAHPS[supreg] Health Plan Survey
                                     4.0, Child Version including
                                     Medicaid and Children with Chronic
                                     Conditions supplemental items.
------------------------------------------------------------------------
                              AVAILABILITY
------------------------------------------------------------------------
24................................  Children and adolescents' access to
                                     primary care practitioners (PCP),
                                     by age and total.
------------------------------------------------------------------------

    Comments on the measures themselves are encouraged to:
     Specify which of the measures are being addressed with 
each comment.
     Explain views and reasoning clearly.
    In addition, comments are invited on the AHRQ and CMS plans to 
enhance the initial, recommended core measure set so that they can be 
collected most efficiently and accurately across all Medicaid and CHIP 
programs, providers, and enrollees.
    We strongly encourage comments to be as succinct as possible (250 
words or less recommended, with additional supporting data allowed).

III. Collection of Information Requirements

    This document 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).

IV. 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.

    Authority: Section XIX and XXI of the Social Security Act (42 
U.S.C. 13206 through 9a)

(Catalog of Federal Domestic Assistance Program No. 93.778, Medical 
Assistance Program)

    Dated: December 22, 2009.
Kathleen Sebelius,
Secretary.
[FR Doc. E9-30802 Filed 12-28-09; 8:45 am]
BILLING CODE 4120-01-P