Federal Register: October 22, 2003 (Volume 68, Number 204)
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration
Children's Hospitals Graduate Medical Education Payment Program:
Final Policies on Withholding and Reconciliation Process and
Methodology for Calculating Reconciliation Payments, Use of Wage Index
in Calculating Indirect Medical Education Payments, Dissemination of
Program Data, and Audit; Updates on Calculation of National Per
Resident Amount and Government Performance and Results Act Measures
ACTION: Final notice
Final Notice in printer-friendly Acrobat/pdf
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SUMMARY: This notice adopts policies for the Children's Hospitals
Graduate Medical Education Payment Program (CHGME PP) regarding the
CHGME PP withholding and reconciliation process and calculation of
reconciliation payments, use of the wage index to calculate CHGME PP
indirect medical education (IME) payments, dissemination of CHGME PP
data, and audits. This notice also provides updates and clarification
on the CHGME PP calculation of a national per resident amount and CHGME
PP compliance with Government Perfornance and Results Act (GPRA)
measures.
DATES: This notice is effective November 21, 2003. See discussion under
Supplemental Information.
FOR FURTHER INFORMATION CONTACT: Ayah E. Johnson, Ph.D., Chief,
Graduate Medical Education Branch, Division of Medicine and Dentistry,
Bureau of Health Professions, Health Resources and Services
Administration, Room 9A-05, Parklawn Building, 5600 Fishers Lane,
Rockville, Maryland 20857; telephone (301) 443-1058 or e-mail address ChildrensHospitalGME@hrsa.gov.
SUPPLEMENTARY INFORMATION: The CHGME PP, as authorized by section 340E
of the Public Health Service Act (42 U.S.C. 256e) (the Act), provides
funds to children's hospitals that operate graduate medical education
(GME) programs. Pub. L. 106-310 amended the CHGME PP statute to
continue the program through Federal fiscal year (FFY) 2005.
On September 25, 2002, the Secretary published a notice in the
Federal Register (67 FR 60241) clarifying hospital eligibility criteria
for the CHGME PP. That notice also sought public comments on proposals
for (1) establishing a methodology to determine direct medical
education (DME) and IME payments during the withholding and
reconciliation processes stipulated in the CHGME PP statute; (2)
updating the wage index used in the calculation of IME payments; (3)
disseminating CHGME PP data; and (4) auditing.
During the comment period, the Department received comments from
six interested parties, including hospitals and professional
associations. The Secretary thanks the respondents for the quality and
thoroughness of their comments. As a result of these comments, the
Department has made revisions and clarifications in this final notice.
The comments and Department's responses to the comments, as well as the
final rules are set forth below. Subsequent to the publication of this
notice, CHGME PP policies will be codified.
As indicated in the September 25 Federal Register notice, an
updated listing of children's hospitals potentially eligible to
participate in the CHGME PP will be posted on the CHGME PP Web site
(http://bhpr.hrsa.gov/childrenshospitalgme), during the third quarter
of each year.
Effective dates. To the extent this notice reiterates or clarifies
past practices of the CHGME program, those policies continue in effect.
To the extent this notice creates new duties and obligations which cannot be directly
drawn from the statute, the effective date shall be November 21, 2003.
Final Provisions
The Department is finalizing the following provisions: (1)
Methodology for withholding DME and IME payments and determining
reconciliation payments as stipulated in the CHGME PP statute; (2)
updating of the wage index used in calculating lIME payments; (3)
dissemination of CHGME PP data; and (4) audit.
In its September 25, 2002 Federal Register notice, the Department
proposed for public comment its methodology for the withholding and
reconciliation of CHGME PP payments as stipulated by statute. The
Department proposed to withhold up to 25% of both DME and lIME payments
to ensure that hospitals did not receive overpayment. It also proposed
a methodology to determine reconciliation payments using changes in FTE
resident counts that occur during the Federal fiscal year (FFY) for
which payments are being made.
In the same Federal Register notice, the Department also proposed
that the most recently available wage index (WI) be used in the
determination of IME payments. To date, the Department had been using
the FY 1999 WI published by the Centers for Medicare and Medicaid
Services (CMS) to determine IME since its use is statutorily mandated
in the determination of DME.
The Department also proposed that each hospital could request its
own information (i.e., its application information and information used
to determine payments) from the CHGME PP but would need to request all
other information (e.g., information for other hospitals or for all
hospitals) through the HRSA Freedom of Information Act (FOIA).
Finally, the Department proposed that the 0MB A-133 review
requirements originally imposed on hospitals participating in the CHGME
PP be replaced with an assessment conducted by an outside contractor
familiar with Medicare policies of the FTE resident counts.
A description of the Department's final policies on these issues as
well as the public comments and the Department's response is included
in the following sections.
I. Withholding and Reconciliation Processes and Methodology for
Calculating Reconciliation Payments
The Department is finalizing the methodology for withholding
children's hospitals DME and IME payments to reduce the likelihood that
a hospital is overpaid on an interim basis, determining revised full
time equivalent (FTE) resident counts, and calculating reconciliation
payments described in the September 25, 2002 Federal Register notice.
The CHGME PP began implementing this methodology beginning with the
payments it awarded to children's hospitals issued in Federal Fiscal
Year (FFY) 2002.
Withholding Process
The CHGME PP statute, as amended, states that ``the Secretary shall
withhold up to 25% from each interim (payment) installment for direct
and indirect graduate medical education * * * as necessary to ensure a
hospital will not be overpaid on an interim basis.'' The statute also
indicates that, prior to the end of each FFY, the Secretary must
determine any changes to the number of FTE residents reported by a
hospital in its annual initial application for CHGME PP funding. This
determination by the Secretary will be used to calculate the final
amount payable to that hospital for the FFY. Funding withheld during
the interim period will be allocated to children's hospitals following
the determination by the Secretary of any changes to the number of FTE
residents reported by participating hospitals. The Secretary has
statutory authority to reconcile FTE resident counts only. It should be
noted, however, that the Secretary does have the discretion to audit
any and all variables used to determine CHGME PP payments to children's
hospitals.
Reporting Revised Resident Counts
To assess the impact of payment resulting from the FTE assessment
process, during the third quarter (March 1-June 30) of each FFY for
which payments are being made, the CHGME PP will release a
reconciliation application for use by participating hospitals to report
changes in the FTE resident counts reported in their initial
applications. The reconciliation application will include forms HRSA-99
(Hospital Demographics), HRSA-99-1 (Reconciliation of FTE resident
counts), HRSA 99-2 (Determination of Indirect Medical Education Data),
HRSA-99-3 (Certification), and HRSA-99-4 (Required Data Reporting for
Government Performance and Results Act). This collection of information
has been approved under 0MB Information Collection No. 09 5-0247.
Hospitals will have 30 days to complete and return the reconciliation
application. If a hospital fails to complete and return the
reconciliation application according to the terms and conditions of the
CHGME PP, the Department may suspend the award, pending corrective
action, or may terminate the award for cause.
Hospitals that were not eligible to participate or did not apply
for funding during the initial application cycle are not eligible to
apply for and receive funding during the reconciliation process. These
hospitals must wait until the next initial application cycle to apply.
Determining Changes in FTE Resident Counts
Hospitals will report revised FTE resident counts to the CHGME PP
by submitting a complete reconciliation application. Any changes to
resident FTE counts reported on the reconciliation application must be
for the same Medicare cost report (MCR) period(s) identified in the
hospital's initial application for the FFY. Hospitals whose resident
counts have not changed are not exempt from completing and submitting a
CHGME PP reconciliation application. For purposes of clarification, an
FTE resident is measured in terms of time worked during a residency
training year. It is not a measure of individual residents who are
working.
Prior to FFY 2003, assessment of FTE resident counts was done by
the Medicare fiscal intermediaries (FIs) for the subset of children's
hospitals that filed full MCRs. The Secretary has established an
assessment process that will ensure this determination is made for FTE
resident counts submitted by all children's hospitals. Beginning in FFY
2003, the CHGME PP is contracting with FIs to assess the FTE resident
counts submitted by participating hospitals in their FFY 2003 initial
CHGME PP application. This assessment of FTE resident counts will be
performed for all hospitals regardless of the type of MCR they file
(e.g., full, low or no utilization). This process is designed to assess
FTE resident counts for all children's hospitals within the CHGME PP
time constraints in an equitable fashion. The resident FTE counts
reported by the hospitals in their reconciliation application must be
consistent with those reported by the hospital's CHGME FI to be
accepted by the Department. The Department will provide final review
and determination of the hospitals' FTE counts. The reconciliation
process requires that participating hospitals comply with requests from
the CHGME PP FI. The CHGME PP has placed a guidance document providing
further information about the FTE resident count assessment on the
program's Web site(http://bhpr.hrsa.gov/childrenshospitalgme).
Comment: One respondent noted that the Department should seek FI
review of hospitals' resident counts and reporting of those counts
consistent with the review for a given point in time and that the FIs
should not be required to attest to hospitals' resident counts. The
respondent noted that such an attestation suggests that the FI could be
held legally liable for a hospital's error in resident counts even
though the FI is not responsible for the maintenance and accuracy of
the hospital's records. In addition, the review of resident counts
reflects those counts at a point in time: The counts may be subject to
change over time due to a variety of factors such as a cost report re-
opening.
Response: The Department will not require the CHGME FIs to attest
to a hospital's FTE resident count but instead will require a review of
the FTE resident counts. This review will be based on the FTE resident
counts submitted by the hospitals with their initial application for
funding in a particular FFY. It will reflect the hospitals' FTE
resident counts at a point in time just prior to the submission of the
hospitals' reconciliation application. The hospital's reconciliation
application must be consistent with the results of this CHGME PP FI FTE
resident count assessment. The Department also recognizes that these
FTE resident counts may change over time.
Comment: One respondent commented that although the Department
should contract with FIs to provide independent review of resident
counts for the CHGME PP, the hospitals should be able to have the same
FI providing both the review and processing of their MCR and the
assessment of resident FTE counts for their CHGME PP application.
Response: In developing a contract with the FIs to assess the FTE
resident counts training in children's hospitals, the Department made
every effort to ensure that the same FI would work with the hospital on
both their MCR and their CHGME PP application. However, not all FIs
chose to participate in the CHGME PP FTE resident assessment contract
and, as a result, some hospitals will have different FIs reviewing
their MCR and their CHGME PP application. It is important to note that
the prime contractor for Medicare and the CHGME PP is the same. As a
result, communications are facilitated between the Medicare and CHGME
PP FIs in instances where the two are different entities. In those
instances where a children's hospital has one FI for Medicare and one
for CHGME PP, information and FTE assessment results will be shared
between both FIs.
Determining Revised Resident Counts for "New Children's Teaching
Hospitals"
"New children's teaching hospitals," as defined by the CHGME PP in
its July 20, 2001 Federal Register notice, do not include those
hospitals with a newly approved residency training program as described
in 42 CFR 413.86(g)(6)(i). These ``new children's teaching hospitals''
will calculate FTE resident counts for the reconciliation application
process using the methodology proposed in the September 25 Federal
Register notice. This proposed methodology provides that the hospital
would calculate its FTE resident counts in one of two ways:
1. If a hospital has filed a Medicare cost report (MCR) by the
CHGME PP reconciliation application deadline, the hospital would report
the actual number of resident FTEs trained during that cost reporting
period;
2. If a hospital has not filed an MCR by the CHGME PP
reconciliation application deadline, the hospital would determine the
FTE residents training at the hospital from the beginning of the FFY
for which payments are being made up to the reconciliation application
deadline. The revised FTE resident count will equal the average number
of FTE residents trained per day during this period multiplied by the
total number of days the hospital will be training residents during the
FFY for which payments are being made. In the event that a ``new
children's teaching hospital'' counts residents in excess of its FTE
resident cap as a result of an affiliation agreement with one or more
other hospitals, it is important to note that the total number of FTE
residents counted by members of the affiliated group cannot exceed the
aggregate FTE cap for member hospitals. ``New children's teaching
hospitals'' will report these updated FTE resident counts on form HRSA
99-1 of the reconciliation application.
Determining IME Payments for "New Children's Teaching Hospitals"
All hospitals, including "new children's teaching hospitals,"
must submit a complete reconciliation application. In completing form
HRSA 99-2 (Indirect Medical Education) in the reconciliation
application, ``new children's teaching hospitals'' will use the
methodology described in the September 25 Federal Register notice.
Those hospitals that have not filed an MCR or completed a full Medicare
cost reporting period will use the timeframe from the beginning of the
FFY for which payments are being made up to the reconciliation
application deadline date to determine the estimates needed to complete
the form.
Reconciliation Payment Process
The Secretary will determine any balance due or any overpayment
made to individual hospitals following the determination of changes, if
any, to the number of residents reported by hospitals in their
reconciliation applications. Hospitals will be notified, in writing, of
the Secretary's final reconciliation payment determination during the
fourth quarter (July 1-September 30) of the FFY in which payments are
being made.
Hospitals that have been notified of an overpayment will have 30
days to return the overpayment to the Department without accrual of
interest. Hospitals that fail to return overpayments within the
specified timeframe will accrue and be responsible for any interest.
Reconciliation payments will be made to individual hospitals on or
before the end of the FFY (September 30) in which payments are being
made. The Secretary will include in the reconciliation payments all
funding initially withheld from the hospital as a result of withholding
required by statute. At the end of the FFY, the CHGME PP may make a
final payment to distribute any remaining funds, including those funds
that have been returned to the Department during the course of the FFY
as a result of overpayment or hospitals' loss of eligibility.
All hospitals, whether or not they report changes to their resident
FTE resident counts during the reconciliation process, can expect
changes to their final payment determination as a result of FTE
resident count changes reported by other participating hospitals. This
is due to the methodology used to determine CHGME PP payments. Payments
to individual hospitals are based upon the hospital's share of the
total amount of DME and IME funding available for a given FFY. A
hospital's portion of the total DME and IME funding available is
calculated based on payment variables in the CHGME PP statute and
regulations. This individual hospital portion (the numerator) is then
divided by the sum of all hospitals' portions (the denominator) to
determine the share of the total available funding to be distributed to
the hospital. Hence, although an individual hospital's FTE resident
count and subsequent portion (numerator) may not change at the time of the reconciliation application process, the denominator of the
payment calculation may change as a result of changes in FTE resident
counts reported by other hospitals. More detailed information is
available on the CHGME PP payment formulas in the June 19, 2000 Federal
Register notice (DME payment formula) and the July 20, 2001 Federal
Register notice (IME payment formula). Information on the payment
formulas is also available on the CHGME PP Web site http://bhpr.hrsa.gov/childrenshospitalgme/
.
As provided by statute, for disputes greater than $10,000, a
hospital may request a hearing on the Secretary's payment determination
by the Provider Reimbursement Review Board under section 1878 of the
Social Security Act (42 U.S.C. 1395oo), implemented by regulations at
42 CFR part 405, subpart R.
It should also be noted that the reconciliation process does not
take the place of a separate audit process to which the hospitals may
be subject. Participating children's hospitals are subject to audit
(other than OMB Circular A-133 as described in section IV below) to
determine whether the applicant hospital has complied with applicable
laws, regulations, and its application for funding.
Comment: One respondent requested that the interest rate charged by
the Government be published.
Response: Interest will be accrued at a rate set on a quarterly
basis by the Secretary of the Treasury pursuant to 45 CFR 30.13.
II. Updating the Wage Index in Calculation of Indirect Medical
Education Payment
The Department has determined that it will continue to use the wage
index (WI) determined by the Centers for Medicare and Medicaid Services
(CMS) for fiscal year (FY) 1999 to calculate the indirect medical
education (IME) payment for children's hospitals. In its September 25,
2002 Federal Register notice, the CHGME PP proposed that the wage index
(WI) from the most recent fiscal year available be used to calculate
IME payments. Although the CHGME PP statute states that the factor
applied under section 1886(d)(3)(E) of the Social Security Act (i.e.,
the wage index calculated by the Centers for Medicare and Medicaid
Services) for discharges occurring during fiscal year 1999 for the
hospital's area be used in the calculation of direct medical education
(DME) payments, the Secretary has discretion to choose the WI used in
the calculation of IME payments. Since the statute specifies the use of
the FY 1999 WI to determine DME, however, the use of the WI from the
most recent fiscal year available to calculate IME payments would
result in two different WI being used to determine the CHGME PP
payments to children's hospitals. After consideration of the public
comments on this topic, the Department has determined that it will
continue to use the wage index (WI) determined by the Centers for
Medicare and Medicaid Services (CMS) for fiscal year (FY) 1999 to
calculate the indirect medical education (IME) payment for children's
hospitals. In using the WI to determine CHGME PP payments for both DME
and IME, the Secretary will use the most recently available Medicare
PPS labor-related (and non-labor-related) share; currently, the PPS
labor-related share is 71.1%.
Comment: Several respondents expressed concern regarding use of the
updated CMS WI because of current Congressional efforts to make
substantive changes in the determination of the CMS WI. As the outcome
of these efforts (i.e., if and when a bill is passed) and the resulting
implications for recalculation of the WI by CMS are not clear, the
respondents encouraged the CHGME PP to postpone implementation of this
policy.
Response: Since its inception, determination of the WI has been
subject to change both at the Congressional and Department level. Given
this ongoing iterative process and the lack of statutory directive
regarding the use of WI in the calculation of IME, the Department has
determined that it will continue to use the WI from FY 1999 to
calculate the IME payment.
Comment: One respondent was concerned about the potential confusion
that could result from using two different WI values, one for DME and
one for lIME, to determine payments for the participating hospitals.
Response: The Department recognizes the potential confusion that
using two different WI values could create among hospitals
participating in the CHGME PP. In order to prevent such confusion, the
WI from FY 1999 will continue to be used to calculate IME.
Comment: One respondent commented that it may be more appropriate
to postpone the implementation of the proposed WI policy until it could
be assessed in light of the findings of the ongoing analytic activities
related to the CHGME PP IME payment formula.
Response: The Department agrees that it may be best to introduce
any changes to the IME payment formula simultaneously and not in an
incremental fashion. It should be noted, however, that the payment
formulas used by the program may be subject to statutory amendment.
III. Dissemination of CHGME PP Data
The Department considers all CHGME PP information obtained by the
program in hospital applications and generated by the program to
determine payments to be fully disclosable; that is, its release to the
public poses no potential harm to the hospital(s) that originally
submitted the Program application. The Department is finalizing the
following procedure for the dissemination of information related to the
CHGME PP.
Each hospital participating in the CHGME PP may request its own
hospital-specific data related to the CHGME PP through a written
request to the CHGME PP. Contact information is provided earlier in
this notice.
All other requests for information (e.g., information requested
about another participating hospital or all participating hospitals)
must be submitted to the Freedom of Information Act (FOIA) Officer for
the Health Resources and Services Administration (HRSA). The HRSA FOIA
Office address is 5600 Fishers Lane, Room 14-45, Rockville Maryland
20857.
In addition, the CHGME PP will follow the policies regarding fees
and charges associated with release of information as stated in 45 CFR
part 5, subpart D.
IV. Audit
In the March 1, 2001 Federal Register notice, the Department
announced that awards under the CHGME PP must be audited under Office
of Management and Budget (OMB) Circular A-133. The Department has
reconsidered its position with respect to this requirement, and is
making final the policy proposed in the September 25 Federal Register
notice that CHGME PP awards are not subject to review/audit under OMB
Circular A-133. This policy will be in effect beginning with the FFY
2003 CHGME PP application.
The relevant compliance requirements that the Department needs for
the CHGME PP are the FTE resident counts reported on the initial and
reconciliation applications for the Program. Since the Secretary must
account for change in the number of FTE residents prior to the close of
each FFY, the Department is required to assess FTE resident counts per
the applications prior to the end of each FFY for all CHGME PP
participating hospitals. The Department has established a process to
assess the FTE resident counts submitted by children's
hospitals in their applications for funds from the CHGME PP. The
process is based on the assessment process utilized by CMS in their
review of FTE resident counts submitted on MCR. The process will be
implemented by Department contractors familiar with both CMS procedures
and CHGME PP requirements.
The Department believes this approach is more effective than an
audit/review under OMB Circular A-133, as it provides the Department
up-front assurance on the reconciliation of FTE resident counts as
mandated in statute. Excluding the CHGME PP from the definition of
Federal awards expended under OMB Circular A-133 removes a potential
duplication of effort that would result from an auditor testing FTE
counts that the Department has already verified, and may allow these
audit resources to be used to test other Federal programs of higher
risk.
Comment: Several respondents commented that the elimination of the
requirement for compliance with OMB Circular A-133 should be made
retroactive.
Response: The compliance reviews under OMB Circular A-133 will have
been initiated and/or completed for FFYs 2000-2002 prior to the
finalization of the Department's policy on this issue. As a result, the
Department is not in a position to make the elimination of this
compliance requirement retroactive. The Department policy will become
effective with the FFY 2003 funding cycle. Furthermore, the
comprehensive FTE resident count assessment process undertaken by the
Department was not in place prior to FFY 2003.
Clarification of Provisions
The Department wishes to clarify its current rules related to the
calculation of a national per resident amount for determining CHGME PP
payments and the measures used by the CHGME PP to be in compliance with
the Government Performance and Results Act (GPRA).
V. Calculation of National Per Resident Amount
The CHGME PP statute specifies the calculation of a baseline
national per resident amount (NPRA) using FFY 1997 data. As amended,
the statute also specifies that this baseline amount should be updated
annually using the estimated percentage increase in the consumer price
index (CPI) for all urban consumers during the period beginning October
1997 and ending with the midpoint of the federal fiscal year for which
payments are made. The NPRA is used in the calculation of DME payments.
The March 1, 2001 Federal Register notice indicated that the NPRA
for cost reporting periods ending in FFY 1997, using the methodology
prescribed by the CHGME PP statute, is $67,688. This amount has only
been updated by the program once to date. As published in the March 1,
2001 Federal Register notice, the updated amount for FFY 2000 was
estimated at $71,709. Since the NPRA appears as the same number in both
the individual hospital portion (numerator) and the sum of all
hospitals' portions (denominator) used to determine DME payments, it
doesn't affect the calculation of payments; as a result, the update has
not been performed annually.
Beginning with FFY 2002, the NPRA will be updated annually using
the methodology included in the statute. The updated amount will be
posted on the CHGME PP Web site (http://bhpr.hrsa.gov/childrenshospitalgme
) in the third quarter of each year. For FFY 2002,
the updated NPRA is estimated at $74,890--determined by applying the
percent increase in CPI from October 1997 to April 2002 to the baseline
NPRA from FFY 1997.
VI. Government Performance and Results Act (GPRA) Measures
In order to be in compliance with the GPRA, the CHGME PP collects
information on a series of measures determined by the Department in its
annual performance plan. These performance measures are developmental
and are subject to periodic modification. In the future, the CHGME PP
will post annual updates of its GPRA performance measures on the CHGME
PP Web site (http://bhpr.hrsa.gov/childrenshospitalgme).
The following measures are being used by the Department to evaluate
the performance of the CHGME PP for FFY 2003: (1) Maintain the number
of FTE residents in training in eligible children's teaching hospitals;
(2) Report the percentage of hospitals funded by the program with
negative total margins; and (3) Report the proportion of hospitals'
gross revenue from patient care attributed to public insurance
(Medicaid, Medicare, SCHIP) and uninsured patients.
Other Applicable Laws, Executive Orders, and Policies
Economic and Regulatory Impact: Executive Order 12866 directs
agencies to assess all costs and benefits of available regulatory
alternatives, and when rulemaking is necessary, to select regulatory
approaches that provide the greatest net benefits (including potential
economic, environmental, public health, safety, distributive, and
equity effects). In addition, under the Regulatory Flexibility Act
(RFA) of 1980, if a rule has a significant economic effect on a
substantial number of small entities, the Secretary must specifically
consider the economic effect of the rule on small entities and analyze
regulatory options that could lessen the impact of the rule.
Executive Order 12866 requires that all regulations reflect
consideration of alternatives of costs, benefits, incentives, equity,
and available information. Regulations must meet certain standards,
such as avoiding an unnecessary burden. Regulations which are
``significant'' because of cost, adverse effects on the economy,
inconsistency with other agency actions, effects on the budget, or
novel legal or policy issues, require special analysis.
In accordance with the RFA and the Small Business Regulatory
Enforcement Act of 1996, which amended the RFA, the Secretary certifies
that this action will have a significant effect on a substantial number
of small entities, in that this action will provide significant funding
to eligible children's hospitals. The Department has determined that
the only burden this action will impose on children's hospitals is the
allocation of resources required to submit an application to the CHGME
PP. Since this action will not impose a significant burden on a
substantial number of small entities, the Department has not examined
any alternatives for reducing the burden on children's hospitals. The
Secretary has also determined that this action does not meet criteria
for a major rule as defined by Executive Order 12866 and would have no
major effect on the economy or Federal expenditures.
The Department has determined that the proposed rule is not a major
rule within the meaning of the statute providing for Congressional
Review of Agency Rulemaking, 5 U.S.C. 801. Similarly, the proposed rule
will not have effects on State, local and tribal governments and on the
private sector such as to require consultation under the Unfunded
Mandates Reform Act of 1995.
Further, Executive Order 13132 establishes certain requirements
that an agency must meet when it promulgates a rule that imposes
substantial direct compliance costs on State and local governments,
preempts State law, or otherwise has Federalism implications. The
Department has reviewed this action under the threshold criteria of
Executive Order 13132, Federalism, and has determined that this action
would not have substantial direct effects on the rights, roles, and responsibilities of States.
Paperwork Reduction Act of 1995
In accordance with section 3507(a) of the Paperwork Reduction Act
(PRA) of 1995, the Department is required to solicit public comments
and receive final 0MB approval on collections of information. In order
to implement the CHGME PP, certain information is required, as set
forth in this notice, in order to determine eligibility for payment and
amount of payment. In accordance with the PRA, we have received final
0MB approval on the collection of information for the reconciliation
procedures beginning in the FFY 2002 cycle (0MB No. 0915-0247).
Collection of Information: The Children's Hospitals Graduate
Medical Education Payment Program.
Description: Data is collected on the number of full-time
equivalent residents in applicant children's hospitals' training
programs to determine the amount of direct and indirect medical
education payments to be distributed to participating children's
hospitals. Indirect medical education payments will also be derived
from a formula that requires the reporting of discharges, beds, and
case mix index information from participating children's hospitals.
Hospitals will be requested to submit such information in an annual
application. Hospitals will also be requested to submit data on the
number of full-time equivalent residents a second time during the
Federal fiscal year to participate in the reconciliation payment
process.
Description of Respondents: Children's hospitals operating approved
graduate medical residency training programs.
Estimated Annual Reporting: The estimated average annual reporting
for this data collection is approximately 150 hours per hospital. The
estimated annual burden is as follows:
| Form |
Number
of Respondents |
Responses
per Respondent |
Hours
per Response |
Total
Burden Hours |
| HRSA 99-1 |
54 |
1 |
99.9 |
5,395 |
HRSA 99-1
(reconciliation of FTE counts) |
54 |
1 |
8 |
432 |
| HRSA 99-2 |
54 |
1 |
14 |
756 |
| HRSA 99-4 |
54 |
1 |
28 |
1,512 |
| Totals |
54 |
|
|
8,095 |
Education and Service Linkage: As part of its long-range planning,
HRSA will be targeting its efforts to strengthen linkages between
Department education programs and programs that provide comprehensive
primary care services to the underserved.
Smoke-Free Workplace: The Department strongly encourages all award
recipients to provide a smoke-free workplace and promote abstinence
from all tobacco products, and Pub. L. 103-227, the ProChildren Act of
1994, prohibits smoking in certain facilities that receive Federal
funds in which education, library, day care, health care, and early
childhood development services are provided to children.
This program is not subject to the Public Health Systems Reporting
Requirements.
Dated: September 2, 2003.
Elizabeth M. Duke,
Administrator, Health Resources and Services Administration.
Dated: October 16, 2003.
Tommy G. Thompson,
Secretary.
[FR Doc. 03-26626 Filed 10-21-03; 8:45 am]
BILLING CODE 4165-15-P
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