[Federal Register: July 22, 2005 (Volume 70, Number 140)]
[Notices]
[Page 42331-42336]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr22jy05-60]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[CMS-3142-FN]
Medicare Program; Evaluation Criteria and Standards for Quality
Improvement Program Contracts
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Final notice.
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SUMMARY: This final notice describes the evaluation criteria we will
use to evaluate the Quality Improvement Organizations (QIOs) under
their contracts with us, for efficiency and effectiveness in accordance
with the Social Security Act. These evaluation criteria are based on
the tasks and related subtasks set forth in the QIO's Scope of Work
(SOW). The current 7th SOW includes Tasks 1 through 4, with subtasks
included under all tasks,
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excluding Task 4. QIOs were awarded contracts for the 7th SOW, or 7th
Round, for 3 years, with staggered starting dates beginning August
2002, November 2002, and February 2003. This final notice also responds
to the public comments received regarding the evaluation criteria
published in July 2004.
DATES: Effective August 22, 2005.
FOR FURTHER INFORMATION CONTACT: Maria Hammel, (410) 786-1775.
SUPPLEMENTARY INFORMATION:
I. Background
The Peer Review Improvement Act of 1982 (Title I, Subtitle C of
Public Law 97-248) amended Part B of Title XI of the Social Security
Act (the Act) to establish the Peer Review Organization (PRO) program.
The PRO program (now called the Quality Improvement Organization (QIO)
program) was established to redirect, simplify, and enhance the cost-
effectiveness and efficiency of the medical peer review process.
Sections 1152 and 1153 of the Act define the types of organizations
eligible to become QIOs, and establish certain limitations and
priorities regarding QIO contracting.
The Secretary enters into contracts with QIOs to perform three
broad functions:
Improve quality of care for beneficiaries by ensuring that
beneficiary care meets professionally recognized standards of health
care;
Protect the integrity of the Medicare Trust Fund by
ensuring that Medicare only pays for services and items that are
reasonable and medically necessary and that are provided in the most
economical setting;
Protect beneficiaries by expeditiously addressing
individual cases such as beneficiary quality of care complaints,
contested hospital issued notices of noncoverage (HINNs), alleged
Emergency Medical Treatment and Labor Act (EMTALA) violations (patient
dumping), and other statutory responsibilities.
Section 1154 of the Act requires that QIOs review those services
furnished by physicians; other health care practitioners; and
institutional and non-institutional providers of health care services,
including health maintenance organizations and competitive medical
plans. Section 109 of the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 (MMA), Pub. L. 108-173, amended section
1154(a)(1) of the Act to expand the scope of review of QIOs to include
Medicare Advantage Organizations and prescription drug sponsors.
Section 109 of the MMA also created a new section 1154(a)(17) of the
Act, which requires QIOs to offer to providers, practitioners, Medicare
Advantage Plans, and prescription drug sponsors quality improvement
assistance pertaining to prescription drug therapy. We will not
evaluate QIOs on these provisions in the current Scope of Work (SOW)
because these provisions of sections 1154(a)(1) and (a)(17) of the Act
were not included in the contract.
Section 1153(h)(2) of the Act requires the Secretary to publish in
the Federal Register the general criteria and standards that would be
used to evaluate the efficient and effective performance of contract
obligations by QIOs and to provide the opportunity for public comment.
The QIO contracts for the 7th SOW were awarded for 3 years with
starting dates staggered into three approximately equal groups (rounds)
starting August 2002, November 2002, and February 2003, respectively.
II. Provisions of the Notice With Comment
On July 23, 2004, we published a notice with comment in the Federal
Register titled ``Medicare Program; Evaluation Criteria and Standards
for Quality Improvement Organizations.'' The comment period for this
notice closed on August 23, 2004. The evaluation criteria published in
the notice are currently being used to evaluate QIO performance on the
7th SOW. The evaluation criteria is listed here for the reader's
convenience. No modifications were made to the evaluation criteria
based on comments provided in response to the notice.
A. Measuring QIO Performance
Under the 7th Round contracts, QIOs are responsible for completing
tasks in the following four areas, with additional subtasks contained
in the first three areas:
Task 1--Improving Beneficiary Safety and Health Through Clinical
Quality Improvement
a. Nursing Home
b. Home Health
c. Hospital
d. Physician Office
e. Underserved and Rural Beneficiaries
f. Medicare+Choice Organizations (M+COs), now called Medicare Advantage
Organizations (MAs)
Task 2--Improving Beneficiary Safety and Health Through Information and
Communications
a. Promoting the Use of Performance Data
b. Transitioning to Hospital-Generated Data
c. Other Mandated Communications Activities
Task 3--Improving Beneficiary Safety and Health Through Medicare
Beneficiary Protection Activities
a. Beneficiary Complaint Response Program
b. Hospital Payment Monitoring Review Program
c. All Other Beneficiary Protection Activities
Task 4--Improving Beneficiary Safety and Health Through
Developmental Activities (Special Studies defined as work that we
direct a QIO to perform or work that a QIO elects to perform with our
approval that is not currently defined in the Tasks, but falls within
the scope of the contract and section 1154 of the Act).
Under this contract, to merit having its contract renewed non-
competitively, the QIO must meet the performance criteria (including a
score of 1.0 or greater for Tasks 1a through 1e and 2b) on 10 of 12
subtasks (9 of 11 for States with no MA plans) of Tasks 1 through 3 of
the 7th SOW. To renew the QIO's contract non-competitively for both of
the subtasks that do not meet the criteria, the QIO must have: (1)
Achieved a score of 0.6 or better on all quantitative subtasks, and (2)
for the remaining subtasks only, in the judgment of the Project
Officer, the QIO expended a reasonable effort to address these
subtasks, and developed and implemented an appropriate initial work
plan. The work plan must have been assessed by the Project Officer
during the contract period to determine if it was achieving results
likely to lead to success in meeting contractual performance
expectations and had made appropriate adjustments to its work plan
based on these results.
To be considered successful (that is, meeting the criteria outlined
in the J-7 found at http://www.cms.hhs.gov/qio/2.asp), though not
meriting a non-competitive renewal, the QIO must meet the performance
criteria (including a score of 1.0 or greater for Tasks 1a through 1e
and 2b) on 9 of 12 subtasks (8 of 11 for States with no MA plans) of
Tasks 1 through 3 of the 7th Round Contract. For the subtasks that do
not meet the criteria, the QIO must--
Achieve a score of 0.6 or better on all quantitative
subtasks;
For the remaining subtasks only, in the judgment of the
Project Officer, the QIO has expended a reasonable effort to address
these subtasks, developed and implemented an appropriate initial work
plan that was assessed by the Project Officer during the contract
period to determine if it was achieving
[[Page 42333]]
results likely to lead to success in meeting contractual performance
expectations, and had made appropriate adjustments to its work plan
based on these results; and
Failed to meet the criteria in no more than two subtasks
of any one task.
For Task 4, except as provided in Task 3b that is evaluated by the
Task Leader, all special studies approved under this task will be
evaluated individually, based on study-specific evaluation criteria.
The QIO's success or failure on a special study will not be factored
into the evaluation of the QIO's work under Tasks 1 through 3.
However, meeting the minimum performance standards does not
guarantee a noncompetitive renewal of the QIO's contract. For example,
an organization within a particular State meeting the definition of a
QIO may express interest in competing for a contract currently held by
a QIO from outside that State, according to section 1153(i) of the Act.
In this case, we will compete the contract despite acceptable
performance by the current QIO. We will make a final decision on
renewal/non-renewal by the end of the 30th month of the 7th Round
contract. We will issue a ``Notice of Intent to Non-renew the QIO
Contract'' letter to all QIOs that do not meet the minimum performance
standards no later than the end of the 33rd month of the contract. The
QIO will be considered to have met minimum performance standards if the
QIO had demonstrated acceptable performance in each Task area as
specified in section III of this notice, Standards for Minimum
Performance.
If the QIO has not met the criteria to merit a noncompetitive
renewal, it will be notified of our intention not to renew its contract
and will be informed of its right to request an opportunity to provide
information about its performance under the contract to a CMS-wide
panel. The panel includes representatives from each of the four QIO
Regional Offices and the Central Office. The QIO's Project Officer will
not be eligible to represent the Regional Office on the panel when it
reviews the work of his or her QIO. However, the Project Officer will
be available to answer any questions. Also, the QIO will be given the
opportunity to provide additional information. The panel will have the
right to create its own procedures, but must apply them consistently to
all QIOs. At a minimum, the panel will use the criteria listed below
for all Tasks:
The degree of collaboration the QIO exhibited with the
Quality Improvement Organization Support Centers (QIOSCs) and other
QIOs, both by sharing the lessons and tools it developed and by
adopting practices and tools developed by other QIOs.
Whether the QIO was a new contractor in the 7th SOW.
Whether specific identifiable circumstances uniquely
interfered with the QIO's efforts.
Evidence suggesting that the QIO has done exceptional work
in one or more of the other Task areas.
Any other issues that the panel may deem relevant.
Upon completion of its review, the panel will recommend a final
disposition of the QIO's contract renewal to the Director of CMS'
Office of Clinical Standards and Quality (OCSQ).
B. Standards for Minimum Performance
General Criteria
We will evaluate the QIO's performance on each sub-task by some
combination of the following elements:
Statewide improvement on the quality measure(s).
Improvement on the quality of care measure(s) among a
group of identified participants as defined within each subtask.
Satisfaction among providers and practitioners regarding
their interaction with the QIO.
Satisfaction will be assessed using a survey, the purpose of which
will be to:
Measure satisfaction as one component of the QIO's
evaluation.
Identify opportunities where the QIO can improve
satisfaction.
Task 1 (including subtasks a through e) and subtask 2b will be
evaluated quantitatively. The QIO's success will be measured by
assessing its relative improvement on each evaluation criterion. The
term ``improvement'' as used in the 7th Round Contract will be defined
mathematically to mean the relative reduction in the failure rate. The
expected minimum improvement level, as determined by our management and
defined in the J-7 at http:http://www.cms.hhs.gov/qio/2.asp, will serve as the
reference point for each calculated relative improvement.
In a number of the Task 1 subtasks, statewide improvement will be
averaged with the improvement among a set of identified participant
providers. In these cases, we have set a target percentage of
identified participant providers. The relative weights of the statewide
improvement and of identified participants' improvement will combine to
equal 80 percent of the subtask's weight, and will be a function of the
percentage of the target percentage (up to 150 percent) that the QIO
identifies as participants. Tasks 1f, 2a, 2c and all of Task 3 will be
evaluated by the Project Officer using qualitative measures based on
information provided in reports developed from data provided by the
QIOs on the QIO's status to date.
C. Task Specific Standards
1. Task 1--Improving Beneficiary Safety and Health Through Clinical
Quality Improvement
a. Task 1a--Nursing Home Quality Improvement
The QIO will be held accountable for improvement in the quality of
care measure rates for all nursing homes in the State and for
identified participant nursing homes. QIOs will be evaluated based on
the following components: Statewide improvement on the set of three to
five publicly reported quality of care measures that the QIO has
selected in consultation with stakeholders, improvement in the selected
nursing home publicly reported quality of care measures for identified
participants, and nursing home satisfaction based on a survey of
identified participating nursing homes. To view the weighting criteria
for each component, go to http://www.cms.hhs.gov/qio/2.asp for a copy
of the J-7.
b. Task 1b--Home Health Quality Improvement
The QIO will be held accountable for improvement in the Outcome
Based Quality Improvement (OBQI) quality of care measure rates for a
set of home health agencies that are identified participants. The QIOs
will be evaluated based on the following components: The extent to
which the number of participating home health agencies, with
significant improvement in a targeted outcome, equals or exceeds 30
percent of the total number of home health agencies in the State, and
the identified participant satisfaction that will be measured by a
survey of identified participant home health agencies using a composite
measure of satisfaction that reflects the type of activities that QIOs
are expected to have undertaken with these providers.
c. Task 1c--Hospital Quality Improvement
QIOs will be evaluated on the following criteria: Statewide
improvement on the quality of care measures listed in the 7th Round
Contract, and hospital satisfaction based on feedback from the
hospitals in the State. To view the specific criteria, go to http://www.cms.hhs.gov/qio/2.asp
for a copy of the J-7.
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d. Task 1d--Physician Office Quality Improvement
QIOs will be evaluated based on the following general criteria:
statewide improvement on quality of care measures, improvement on
diabetes and cancer screening quality of care measures for identified
participant physicians, and physician satisfaction based on feedback
from physician designees in the State who participated with the QIO. To
view the specific criteria for this task, go to http://www.cms.hhs.gov/qio/2.asp
for a copy of the J-7.
e. Task 1e--Underserved and Rural Beneficiaries Quality Improvement
The QIO's work on this task will be primarily evaluated on the
success of the QIO's efforts to reduce disparity between the targeted
underserved group and their geographically relevant non-underserved
reference group from baseline to re-measurement. To be judged to have
performed minimally successful on this task, the QIO must demonstrate
disparity reduction. QIOs will also be evaluated on three factors that
collectively demonstrate knowledge generated by the QIO about the
underserved target group, the interventions planned upon the basis of
that knowledge, the use of literature on effective interventions, and
by demonstrating the effectiveness of their interventions through
analyses comparing the intervention group and a contrast group. To view
the specific criteria for this task, go to http://www.cms.hhs.gov/qio/2.asp
for a copy of the J-7.
f. Task 1f--Medicare + Choice Organizations (M+COs) (Now Called
Medicare Advantage Organizations (MAs)) Quality Improvement
QIOs will be expected to have demonstrated appropriate activity to
include MAs in Tasks 1a to 1e as determined by the Project Officer. We
will survey MAs that have worked with the QIO using a composite measure
of satisfaction that reflects the types of activities that QIOs are
expected to have undertaken with these organizations. We will further
use the results of the Medicare+Choice Quality Review Organizations
(M+CQRO) or accreditation organization evaluation of the Quality
Assessment and Performance Improvement (QAPI) projects to determine if
expected improvement was demonstrated.
2. Task 2--Improving Beneficiary Safety and Health Through Information
and Communications
a. Task 2a--Promoting the Use of Performance Data
QIO success will be assessed on the timely completion and
submission of a project work plan, timely completion and submission of
all required reports and deliverables, and the extent to which the QIO
uses information we have provided as well as any other feedback the QIO
receives to refine its project activities to achieve the desired
outcome.
b. Task 2b--Transitioning to Hospital-Generated Data
The evaluation for this task will be based on the following
elements:
We will determine the completeness of the assessment
survey information for each hospital.
We will review hospital data submitted to the national
repository via QualityNet Exchange to determine the proportion of
hospitals within the State that have implemented a data abstraction
system to abstract quality of care measures.
We will review hospital satisfaction with the QIO data
abstraction support. To view specific criteria for this task, go to
http://www.cms.hhs.gov/qio/2.asp for a copy of the J-7.
c. Task 2c--Other Mandated Communication Activities
QIO success on this task will be assessed on the following
elements: The establishment and use of a Consumer Advisory Council to
advise and provide guidance regarding consumer related activities, the
QIO's success at broadening consumer representation on the QIO Board of
Directors, the successful operation of a beneficiary helpline, and the
publication and distribution of an annual report.
3. Task 3--Improving Beneficiary Safety and Health Through Medicare
Beneficiary Protection Activities
a. Task 3a--Beneficiary Complaint Response Program
QIO success will be assessed by the timeliness of completed
reviews, quality improvement activities as the result of beneficiary
complaints, reliability of the review of cases as determined by QIO
assessment of the review determinations, and beneficiary satisfaction
with the complaint process.
b. Task 3b--Hospital Payment Monitoring Review Program
The QIO must complete reviews within the prescribed timeframes. The
QIO must also meet one of the following criteria: with respect to the
absolute payment error rate, the follow-up payment error rate must be
no greater than 1.5 standard errors above the baseline error rate, or
the QIO must have made acceptable progress in improving provider
performance in relation to all projects approved or directed by us.
c. Task 3c--Other Beneficiary Protection Activities
The QIO will be assessed on the timeliness of reviews for HINN/
NODMAR, EMTALA review, other case review activities and post review
activities.
III. Analysis of and Responses to Public Comments and Provisions of the
Final Notice
We received several public comments on the 2004 Federal Register
notice with comment period.
Comment: One commenter expressed concern over the hospital
satisfaction survey in Task 1c. The commenter noted that some hospitals
have changed to acute care hospitals late in the SOW. The commenter
believes this does not provide the QIO ample opportunity to work with
the hospital before the hospital completes the satisfaction survey. The
commenter recommended that we establish a cut-off date for new entries
as acute care hospitals participating in the satisfaction survey.
Response: While we understand the concern that hospitals with only
recent experience in acute care could have an impact on the hospital
satisfaction survey, we do not believe that it would be a significant
impact for the 7th SOW. The Task 1c satisfaction scores from the first
two rounds appear to support our position. All QIOs in the first two
rounds received scores that met or exceeded the 80 percent passing
threshold. The suggestion to include a cut-off date is a reasonable one
that we can consider for subsequent Scopes of Work. We intend to
evaluate all rounds for the current SOW identically.
Comment: One commenter expressed concern about the project plan
requirements in Task 2a. Specifically, the commenter stated that the
task only required a project plan for the Nursing Home Quality
Initiative. The commenter requested more specific language in the
evaluation criteria to address this issue.
Response: For the 7th SOW, we are requiring only one formal project
plan for the Nursing Home Quality Initiative. A deliverable has not
been added for subsequent plans. QIOs will not be held accountable for
failing to deliver project plans that are not required deliverables for
the task.
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Comment: One commenter stated that there are no historical data to
demonstrate that nursing homes' thresholds and home health thresholds
are achievable or realistic.
Response: We believe that the thresholds are achievable for most
QIOs. The results of the 1st Round 28-month evaluations show that the
majority of the QIOs (87 percent) achieved or exceeded the target
performance. Therefore, there is no indication that these thresholds
should be changed.
Comment: One commenter stated that the tasks to be evaluated
subjectively would be less ambiguous if the components of the
evaluation were known before the start of the SOW.
Response: We agree with this comment. However, QIOs were provided a
copy of the J-7 before the start of the SOW. The tool used to do the
actual evaluation was based on the materials provided in the J-7, and
did not include any criteria or standards not in the SOW. We will
produce the tool for the 8th SOW early in the contract period. It will
be distributed to QIOs as soon as it is available.
Comment: Three commenters questioned how statistical significance
could be calculated for home health agencies with a small number of
episodes of care.
Response: We use the Fisher's exact test to calculate statistical
significance for agency outcomes with 10 to 30 episodes of care. This
test does not require a large sample to estimate statistical
significance. More information on this test can be found in Categorical
Data Analysis by Alan Agresti. Additionally, we tested the impact of
small HHAs by recalculating evaluation results. Excluding all HHAs with
fewer than 30 episodes of care did not substantively improve the
overall evaluation results. Based on this information, we decided not
to modify the 1b evaluation criteria.
Comment: One commenter questioned how we determined the home health
task denominator for the 30 percent.
Response: The home health denominator is made up of two components.
It includes identified participants and non-identified participants.
Identified participants are defined as all home health agencies that
submitted an OBQI plan of action (POA) and have at least a one 3-bar
OBQI report for any reporting period ending at least 12 months after
the POA submission date. A 3-bar report allows the HHA to compare
current outcome rates to prior year outcome rates and national outcome
rates. Non-identified participants are defined as having no OBQI plan
of action submitted, but with a 3-bar OBQI report for the reporting
period ending in the 24th month of the contract. This definition
recognizes the dynamic nature of the home health industry, and counts
only agencies with sufficient caseload during the 24 months included in
the 3-bar report. We believe that this definition provides QIOs with
the best opportunity to successfully pass the evaluation, while
including all agencies operating with a sufficient caseload during a
large part of the SOW.
Comment: One commenter stated that many of the Task 1c hospital
indicators will have a small number in the denominator. The commenter
stated that by collecting the same number of cases for all States, the
precision and confidence interval is much smaller for a large State,
thereby making the evaluation of the QIO less accurate.
Response: The assumption on the part of the commenter is not
completely accurate. The evaluation score equally weights the four
conditions for hospital public reporting (see http://www.cms.hhs.gov/quality/hospital
for list of conditions) to provide a more robust
estimate of quality improvement. Three of the four conditions have
large enough samples so that sample size (not population size) is the
primary determinant driving the precision of the estimates. Acute
Myocardial Infarction measures, one of the four conditions, with
systematically small samples are weighted accordingly to minimize the
impact of any unreliable estimates on the overall evaluation. AMI is
the only one of the four conditions with systematically small samples.
It is weighted accordingly to minimize the impact of any unreliable
estimates on the overall evaluation.
Comment: One commenter stated that the Task 2b evaluation should
not be considered under the quantitative evaluation criteria. The
commenter stated that the largest weighted criterion for this task is
related to the Reporting Hospital Quality Data for Annual Payment
Update (RHQDAPU), which does not have a quantitative measurement.
Response: The RHQDAPU criterion for this subtask is dichotomous in
nature and requires that QIOs contact all hospitals in their State and
assist them in their data submission into the Standard Data Processing
System Clinical Warehouse. QIOs must also document their communication
and assistance with all hospitals, participating and non-participating.
Although this task does involve some activities that may be evaluated
in a qualitative manner, the majority of the activities are
quantitative in nature. Therefore, we have chosen to evaluate this task
quantitatively.
Comment: One commenter expressed concern over the lateness of data
for Task 1d. The commenter believes that this has made it nearly
impossible to assess the effectiveness of the QIO interventions, or to
identify other areas for intervention.
Response: We recognize that time lags can hinder the QIO's
technical assistance to providers in the outpatient setting. We have
set the baseline period to allow QIOs to work with providers during the
transition period between SOWs. Much of this work is reflected in the
next SOW's evaluation results. The relative stability of QIOs in their
States lessens the impact of the time lag.
Comment: One commenter suggested that we change the evaluation
criteria in the J-7 for Task 1e to make them the same as the evaluation
criteria that were originally developed for their QIO's improvement
project.
Response: We assume the commenter is referring to the use of sub-
county targeting in the evaluation of this Task. We have already
modified the evaluation on this Task to allow sub-county targeting.
This modification to the evaluation was approved by the Project
Officers in the beginning of the SOW. We do not anticipate any further
changes at this point.
Comment: One commenter suggested that Task 3 activities be elevated
to a higher position in the SOW. This commenter believes the current
Task 3 should be Task 1 or Task 2 to increase its importance in the
contract.
Response: We agree that all of the Tasks performed by the QIOs are
important to foster quality improvement in the health care delivered to
Medicare beneficiaries. The evaluation criteria reflect this belief.
Task 3 comprises 3 out of 12 subtasks evaluated by us. QIOs must
successfully perform Task 3 work in order to be granted non-competitive
contract renewal. We believe that the stringent evaluation criteria in
place for this task reflect the importance of the work.
Comment: One commenter asked about the provider satisfaction survey
and how we plan to use the survey if the QIO does not have a sufficient
sample size.
Response: Identifying opportunities for improvement is part of a
quality improvement feedback cycle. We believe that the results of the
satisfaction survey are useful to QIOs in identifying quality
improvement opportunities. CMS and its statistical contractor have
provided all QIOs with detailed information about their satisfaction
survey results. The
[[Page 42336]]
statistical contractor will also write a national analysis of the
survey results to identify opportunities for QIO program improvement as
a whole. In the few instances with insufficient sample size, we use the
actual satisfaction rate to evaluate QIO performance. However, we grant
QIOs a passing evaluation score when the overall evaluation status
(that is, pass vs. fail) is sensitive to this potentially unreliable
rate. Usually this rate does not affect a QIO's overall evaluation
status on a particular subtask, since its relative weight is small in a
subtask's evaluation.
Comment: One commenter stated that, with the development of the
Excel spreadsheet to evaluate the qualitative tasks, these tasks are no
longer qualitative. They are now being evaluated in a quantitative way.
Response: The Excel tool allows Project Officers to subjectively
evaluate QIO performance in the qualitative tasks. It was developed in
response to concerns from QIOs about inter-region variation in the 6th
SOW. It uses the same evaluation criterion provided in the J-7, and is
not intended to make the evaluation quantitative in nature. Rather, it
gives some consistency to the subjective review by the Project
Officers. We agree that this tool should be provided to QIOs as early
as possible in the contract cycle. We will strive to provide this tool
to the QIOs as early as possible for the 8th SOW.
Comment: One commenter stated that a great deal of effort was put
into the National Voluntary Hospital Reporting Initiative (NVHRI), but
this effort was not included in the evaluation criteria.
Response: We appreciate the fact that the NVHRI did require some
additional effort on the part of the hospitals. However, participation
could not be included in the evaluation criteria because this was a
voluntary program on the part of hospitals. The voluntary nature of the
program requires a different approach by the QIO than is required by
the other subtasks and deliverables of the contract.
Comment: One commenter stated that for those States with 100
percent participation in hospital public reporting, the Hospital
Generated Data (HGD) Survey is redundant. The commenter stated that the
same information may be obtained through both sources.
Response: We have been careful to avoid redundant activities for
both providers and QIOs. The HGD Survey does not determine if a
hospital is a reporting hospital. Instead, it assesses the hospital's
ability to collect data. Therefore both the survey and the actual
hospital reporting are necessary and provide different information to
us.
Comment: One commenter questioned the evaluation criteria for Task
3b. In the J-7, the term ``reliability'' is used. The guidance document
states that the QIO will be evaluated based on both ``reliability'' and
``validity of review.'' This commenter also requested clarification as
to why Tasks 3a and 3b require reliability while Task 3c does not
require validity for evaluation.
Response: The reliability of the review is the primary criterion
for evaluating this component of the task. We will ensure consistency
in documents released for the 8th SOW. The evaluation criteria were
chosen for each subtask in Task 3 based on the appropriateness for the
task.
Comment: One commenter expressed concern over using Medicare
physician billing as the method to measure the rate of statewide and
identified participants' improvement in quality care measures for Task
1d.
Response: We are investigating this method of measuring improvement
for the Round 1 evaluations, and have so far found nothing large-scale
or systematic that would alter evaluation results for Task 1d. We
believe that the evaluation measures are relatively stable and reliable
estimates, and that billing issues as a whole do not contribute
significant bias to these estimates. We understand the limitations of
using billing information to estimate quality improvement, and are
working to minimize its impact by identifying these problems and
reporting questionable billing issues to the appropriate parties.
We are adopting the provisions of the notice with comment as final.
IV. Executive Order 12866 Statement
In accordance with the provisions of Executive Order 12866, this
notice with comment period was not reviewed by the Office of Management
and Budget.
Authority: Section 1153 of the Social Security Act (42 U.S.C.
1320c-2).
(Catalog of Federal Domestic Assistance Program No. 93.774,
Medicare--Supplementary Medical Insurance Program)
Dated: March 14, 2005.
Mark B. McClellan,
Administrator, Centers for Medicare & Medicaid Services.
[FR Doc. 05-14505 Filed 7-21-05; 8:45 am]
BILLING CODE 4120-01-P