CHGME Program Quality Bonus Payment System Initiatives Supporting Statement A_4-4-19_CLEAN

Supporting Statement A

Children’s Hospitals Graduate Medical Education Quality Bonus System (QBS) Initiative Response Form

OMB Control No. 0906-xxxx-New

Terms of Clearance: None

A. Justification

1. Circumstances Making the Collection of Information Necessary

This is a request for Office of Management and Budget (OMB) approval to utilize the Children’s Hospitals Graduate Medical Education Quality Bonus System (QBS) Initiative Response Form. The CHGME QBS Initiative Response Form will be used to collect required responses from CHGME Hospitals that are applying for QBS award funds.

The CHGME Payment Program provides federal funds to the nation’s freestanding children's hospitals to help them maintain their graduate medical education (GME) programs that train resident physicians and dentists. The Children’s Hospital GME Support Reauthorization Act of 2013 states that the Secretary may establish a QBS, whereby the Secretary distributes bonus payments to hospitals participating in the CHGME Payment Program that meet standards specified by the Secretary. In order to qualify for the QBS payment in Fiscal Year (FY) 2019, CHGME award recipients must submit documentation as an attachment in the FY 2019 reconciliation application, describing the hospital’s initiatives, resident curriculum, and direct resident involvement in the following areas:

1. Integrated care models (e.g., integrated behavioral and mental health, care coordination across providers and settings);

2. Telehealth and/or Health Information Technology;

3. Population health;

4. Social determinants of health; and

5. Additional initiatives to improve access and quality of care to rural and/or underserved communities.

These five areas have been identified as priorities in HRSA’s FY 19-22 Strategic Plan Goals and Objectives. Integrated care models is an area in alignment with Objective 1.2, to enhance the quality of care by enhancing care integration and coordination. Telehealth and/or Health Information Technology aligns with the Objectives 1.1, 1.14, and 1.2.6, to increase access to and improve the quality of patient care through the use of telehealth and innovative technology solutions. The area of population and social determinants of health align with the Goal 3, to enhance population health and address health disparities through community partnerships, along with Objective 3.1 and 1.3, to leverage community partnerships and stakeholder collaboration to improve population health and address health disparities, and connect HRSA patient populations to primary care and preventive services.

As specified in the CHGME statute, the QBS payment shall be remitted to qualified hospitals participating in the CHGME Payment Program that meet standards set forth by the Secretary of HHS. To demonstrate the fulfillment of such standards, it will be necessary for applicants to complete the QBS Response Initiative form and submit it as an attachment to the FY 2019 reconciliation application. This form will be used to gather information relating to the hospitals’ engagement in quality initiatives.

2. Purpose and Use of Information Collection

The main purpose for this response form is to establish eligibility for QBS award funds through documentation of the applicant’s participation and engagement in various quality initiatives.

In addition to the QBS Response Initiative Form, under Section 340E of the Public Health Service (PHS) Act, CHGME award recipients have the following existing reporting requirements, and risk losing twenty-five percent of their funding if they fail to meet them:

• types of resident training programs,

• the number of training positions,

• types of training related to health care needs of different populations, such as children who are underserved for reasons of family income or geographic location,

• changes in residency training, including curricula, training experiences, and types of training programs and benefits, in addition to changes in training in measurement and improvement in the quality and safety of patient care, and

• number of residents who completed training and care for children within the borders of the service area of the hospital or within the state.

The CHGME Annual Performance Report (APR) (OMB 0915-0061 expiration Date 3/31/2022 consists of both the data that are statutorily required to be included in the “Annual Report” pursuant to section 340E(b)(3)(B) of the PHS Act as well as additional performance data, the collection of which is authorized by the Government Performance and Results Act (GPRA). The additional performance data collected includes individual-level characteristics of the residents, including demographics, whether they are from a rural or disadvantaged background, training hours and encounters in primary care, underserved and/or rural settings, employment outcomes after 1 year, intention at graduation and training site information. CHGME programs also report hospital information, including the hospital discharges by payer type, zip code, and patient safety initiatives within the hospital.

On October 16, 2017, through a Federal Register Notice (FRN), HRSA solicited input on the CHGME QBS proposed standards. HRSA proposed a multi-step implementation beginning in FY 2019 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 sought public comment on the timeline, eligibility, standards, documentation, and payment structure as described in the FRN. HRSA also requested comment on proposed QBS measures, potential data sources, and tiering of QBS payments for FY 2020 and beyond. HRSA received 17 responses to the CHGME QBS FRN. Comments were generally supportive of implementing a QBS for the CHGME program. HRSA received comments during the QBS FRN process that it is currently unclear how CHGME awardees are training and engaging residents in health care transformation areas and recommended that HRSA start by documenting the programs in which CHGME awardees are currently implementing. The current annual performance report and funding applications lack measures on transformative high-level engagement of CHGME hospitals in state and regional health care transformation, as well as engagement of resident trainees in these activities. The QBS Initiative Response Form will allow CHGME hospitals the opportunity to document the health care transformation activities being implemented in their hospitals.

CHGME funding applications and audit requests, Initial, Reconciliation and Resident FTE Assessment (OMB No. 0915-0247 Expiration Date 02/29/2020), collect information on and documentation supporting the weighted and unweighted FTE counts used to determine Direct Medical Education data and inpatient days, discharges, case mix index and bed count to determine Indirect Medical Education data related to the teaching of residents.

CHGME also collects GPRA data on the Reconciliation Application including: the number of FTE residents enrolled in approved residency programs supported by or rotating at the children’s hospital; hospital’s total and operating margins; hospital’s allowable operating expenses; and hospital’s revenue, gross revenue and expenses attributed to patient care.

The QBS Initiative Response Form will be a required document for all QBS applicants, to be included as part of the Reconciliation application.

3. Use of Improved Information Technology and Burden Reduction

HRSA will collect responses via the Electronic Handbooks (EHB) as an attachment to the CHGME Payment Program Reconciliation application to reduce grantee burden and improve data quality. Every effort was taken to design the form to collect only pertinent responses needed to meet the QBS award requirements.

4. Efforts to Identify Duplication and Use of Similar Information

The information gathered in the QBS Initiative Response form is not collected by other HHS agencies or data collection systems. CHGME published a FRN with the QBS proposed plan in October of 2018, and although the Association of American Medical Colleges (AAMC) and Children’s Hospital Association (CHA) did respond, there was no mention of duplicative efforts from other agencies or data collection systems. A QBS contract is expected to be awarded in FY 2020 which will address any redundancy between QBS data requirements and data that is already being collected in the APR. The information will be requested annually in accordance with the statue.

5. Impact on Small Businesses or Other Small Entities

No small businesses will be involved.

6. Consequences of Collecting the Information Less Frequently

There are no legal consequences to collecting the information less frequently.

7. Special Circumstances Relating to the Guidelines of 5 CFR 1320.5

The request fully complies with the regulation.

8. Comments in Response to the Federal Register Notice/Outside Consultation

Section 8A:

A 60-day Federal Register Notice was published in the Federal Register on October 23, 2018, Vol. 83, No. 205; pp. 53487-53488. Two public comments were received.

The AAMC addressed the concern that the QBS Initiative Response Form may be time consuming exercise and AAMC’s lack of access to the form for their review. The QBS Initiative Response Form was made available to AAMC and any other entities or individuals who requested it. HRSA recognizes the complexity in describing the hospitals initiatives, resident curriculum and involvement and created the form and instructions to support the grantee in this endeavor. In efforts to reduce the burden, the QBS Initiative Response Form limits the narrative required from the grantees in the following ways:

• In 250 words or less, a brief narrative discussing the initiative’s purpose and goals for each of the areas listed in the FRN.

• In 200 words or less, the grantee is asked to provide a brief narrative discussing any outcomes and/or highlights of this initiative.

• In 200 words or less, the grantee is asked to provide a brief narrative describing current or future benefits of this initiative for CHGME trainees.

Each of these requests contains a “Not Applicable” option. The QBS Initiative Response Form Instructions also contain definitions and instructions to offer further clarity to the grantee. In addition, assistance will be readily available from CHGME Project Officers.

Similarly, the CHA addressed their concern that the additional administrative burdens associated with completing the QBS Initiative Response Form may not be relative and reasonable to the benefit of the QBS award received. HRSA recognizes that although the award range may be considered modest, hospitals may use the funds creatively to bolster initiatives currently in place or otherwise. CHA also noted that participating hospitals are already subject to existing reporting obligations throughout the year and urged HRSA to streamline the QBS Initiative Response Form to the maximum extent possible. HRSA is aware of this reporting burden and is planning on minimizing any redundancy between the QBS Initiative Response Form and the CHGME Annual Report.

Section 8B: The following CHGME Payment Program award recipients were consulted on the burden of completing the QBS Initiative Response Form. The requests for responses were administered August 17, 2018.

Name	Title	Telephone Number	Email	Organization
Rani Geriege	Director	(305) 662-8327	Rani.Gereige@Nicklaushealth.org	Variety Children’s AKA Nicklaus Children’s Hospital
Pamela Simms-Mackey & Terry Oertel	Director	510-428-3885 ext. 4146	PSimms@mail.cho.org & TOertel@mail.cho.org	Oakland Children’s AKA Benioff Children’s Hospitals
Laura Lynch Bush	Associate Director, 3rd Party Reimbursement	(575)388-1511 ext. 2744	llbusg@health.southalabama.edu	South Alabama Women & Children’s Hospital
Art Kutner	Program Coordinator	404-785-7893	Art.Kutner@choa.org	Egleston & Scottish Rite Children’s Hospitals

9. Explanation of any Payment/Gift to Respondents

HRSA proposes that CHGME hospitals that submit the required documentation will receive a portion of the available funds for the CHGME QBS payment. Amounts will be distributed according to a three tiered payment structure that recognizes 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 of calculated CHGME annual payments among hospitals that qualify for the quality bonus payment will receive two times the base payment.

Tier 3: Hospitals that qualify for the quality bonus payment that are in the highest third of calculated CHGME annual payments among hospitals that qualify for the quality bonus payment 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 QBS in a fiscal year.

10. Assurance of Confidentiality Provided to Respondents

The information collected is secure and protected. Data will be collected via the EHB which is built on a secure web-based enterprise framework.

11. Justification for Sensitive Questions

There are no sensitive questions on the QBS Initiative Response Form and no personal identifiable information (PII) is collected.

12. Estimates of Annualized Hour and Cost Burden

The hour burden estimates were derived by survey of CHGME Payment Program award recipients. The recipients were asked to estimate the amount of time it took to complete the QBS Initiative Response form and instructions within their institution.

12A. Estimated Annualized Burden Hours

Type of Respondent	Form Name	No. of Respondents	No. Responses per Respondent	Average Burden per Response (in hours)	Total Burden Hours
QBS Response Initiative Form	58	1	58	32.41	1,880
Total	58		58		1,880

12B. Estimated Annualized Burden Costs

Type of Respondent	Total Burden Hours	Hourly Wage Rate	Total Respondent Costs
Administrative Assistant	1,880	$18.21/hr.	$34,235
Total			$34,235

The hourly wage rates were taken from the Bureau of Labor Statistics, 2017 National Industry-Specific Occupational Employment and Wage Estimates, Sector 62 – Secretaries and Administrative Assistants. (https://www.bls.gov/ooh/office-and-administrative-support/secretaries-and-administrative-assistants.htm)

13. Estimates of other Total Annual Cost Burden to Respondents or Recordkeepers/Capital Costs

Other than their time, there is no cost to respondents. All data are reported through a web-based enterprise system owned by, and maintained at, HRSA.

14. Annualized Cost to Federal Government

An estimated 0.1 FTE at the GS 12 Step level 3 is needed to serve as the coordinator for data evaluation. As coordinator, the Federal employee will provide technical assistance to awardees regarding the data collection process and subsequent evaluation at an estimated cost of $8,698.40 annually. Using 2018 as a base year, the annual salary of a GS 12 Step 3 is $86,984.

HRSA will award a contract in FY 2019 for $1.2 million that will 1) conduct an environmental scan of GME measures; 2) analyze data collected on changes in residency training in transformed healthcare delivery in FY 2019; 3) manage a stakeholder engagement process on QBS standards and measures; 4) develop Graduate Medical Education quality measures, and 5) study the challenges and opportunities for developing a cross-cutting set of quality measures for CHGME and other Federal GME programs. A statistician from the QBS contract staff will be receiving and analyzing QBS data from this form which will inform the development of the CHGME quality measures and stakeholder engagement process. There is an estimated $122.27 hourly wage for this position referenced from the Acquisition Gateway for labor rates.  The proposed labor hours for this position for the 12 month contract is 1,035 hours at a cost of $126,549.48. This contract is now slated to be awarded in FY 2020.

15. Explanation for Program Changes or Adjustments

This is a new information collection.

16. Plans for Tabulation, Publication, and Project Time Schedule

Data collected in the FY 2019 baseline year will be used by HRSA for qualitative analysis to develop a core set of quality measures for the CHGME Payment Program. Data collected in FY 2020 and beyond will be used to confirm awardee eligibility. HRSA may compile an annual summary of quality initiative data to be published on the CHGME website, which will only be used to highlight the QBS program and the exemplary work of its awardees.

17. Reason(s) Display of OMB Expiration Date is Inappropriate

No exemption is requested. The OMB number and Expiration date will be displayed on every page of the instrument.

18. Exceptions to Certification for Paperwork Reduction Act Submissions

There are no exceptions to the certification.

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