Evaluation of the Medicare Care Management Performance Demonstration (CMS-10256): Physician Survey

Evaluation of the Medicare Care Management Performance Demonstration

MCMP-OMB-Combined Final (5-29-08)

Evaluation of the Medicare Care Management Performance Demonstration (CMS-10256): Physician Survey

OMB: 0938-1057

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Contract No.:
500-00-0033/T.O.05
MPR Reference No.: 6138-145

Evaluation of the
Medicare Care
Management
Performance (MCMP)
Demonstration:
Supporting Statement for
Paperwork Reduction Act
Submission
Final
May 28, 2008

Julita Milliner-Waddell
Eric Grau
Jillian Stein
Lorenzo Moreno

Submitted to:
U.S. Department of Health and Human Services
Centers for Medicare & Medicaid Services
Office of Research, Development, and Information
C3-23-04 Central Bldg.
7500 Security Blvd.
Baltimore, MD 21244-1850
Project Officer:
Lorraine Johnson

Submitted by:
Mathematica Policy Research, Inc.
P.O. Box 2393
Princeton, NJ 08543-2393
Telephone: (609) 799-3535
Facsimile: (609) 799-0005
Project Director:
Lorenzo Moreno

CONTENTS

Section
A

Page
BACKGROUND .....................................................................................................1
1.
2.
3.

Rationale for the Demonstration ......................................................................1
Demonstration Design .....................................................................................2
Evaluation Design ............................................................................................4

JUSTIFICATION ....................................................................................................9
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.

Need and Legal Basis.......................................................................................9
Information Users ............................................................................................9
Use of Information Technology.....................................................................10
Duplication of Effort......................................................................................10
Small Businesses............................................................................................11
Less-Frequent Collection ...............................................................................11
Special Circumstances ...................................................................................11
Federal Register/Outside Consultation ..........................................................11
Payments/Gifts to Respondents .....................................................................12
Confidentiality ...............................................................................................12
Sensitive Questions ........................................................................................13
Burden Estimates (Hours and Wages) ...........................................................13
Capital Costs ..................................................................................................14
Cost to Federal Government ..........................................................................14
Changes to Burden .........................................................................................15
Publication/Tabulation Dates.........................................................................15
a. Cost Neutrality Monitoring Report ........................................................15
b. Interim and Final Evaluation Reports.....................................................16
c. Report to Congress .................................................................................17
17. Expiration Date ..............................................................................................18
18. Certification Statement ..................................................................................18
C

COLLECTION OF INFORMATION EMPLOYING STATISTICAL
METHODS ............................................................................................................19
1.
2.

Respondent Universe and Sampling Methods ...............................................19
a. Respondent Universe..............................................................................19
b. Sampling Methods..................................................................................20
Procedures for the Collection of Information ................................................22
a. Beneficiary Survey .................................................................................22
b. Physician Survey ....................................................................................25

iii

CONTENTS (continued)
Section
C
(con’t)

Page
3.
4.
5.
6.

Methods to Maximize Response Rates ..........................................................27
a. Beneficiary Survey .................................................................................27
b. Physician Survey ....................................................................................28
Tests of Procedures or Methods.....................................................................28
a. Beneficiary Pretest..................................................................................29
b. Physician Pretest.....................................................................................29
Individuals Involved in Design ......................................................................30
Additional Information ..................................................................................30
a. Safeguarding Personally Identifiable Identifiable (PII)
Information .............................................................................................31
b. Social Security Numbers (SSN) ............................................................31

REFERENCES ......................................................................................................32

TABLES

Table

Page

A.1

MEASURES COLLECTED ON THE BENEFICIARY SURVEY........................... 6

A.2

MEASURES COLLECTED ON THE PHYSICIAN SURVEY................................ 7

B.1

RESPONSE BURDEN FOR THE BENEFICIARY AND PHYSICIAN
SURVEYS ................................................................................................................ 14

B.2

DELIVERY SCHEDULE FOR EVALUATION REPORTS .................................. 16

C.1

DISTRIBUTION OF ELIGIBLE PRACTICES, BY SIZE, IN
DEMONSTRATION STATES ................................................................................ 21

C.2

DISTRIBUTION OF MEDICARE BENEFICIARIES BY CHRONIC
CONDITION AND STATE ..................................................................................... 23

C.3

DATA COLLECTION SCHEDULE ....................................................................... 27

APPENDICES

Appendix

Page

LEGISLATION ...................................................................................................A.1

FEDERAL REGISTER NOTICE........................................................................B.1

MEDICARE CARE MANAGEMENT PERFORMANCE (MCMP)
DEMONSTRATION: ADVANCE LETTER—MEDICARE
BENEFICIARIES ................................................................................................C.1

MEDICARE CARE MANAGEMENT PERFORMANCE (MCMP)
DEMONSTRATION: FACT SHEET FOR BENEFICIARIES .........................D.1

MEDICARE CARE MANAGEMENT PERFORMANCE
(MCMP) DEMONSTRATION: BENEFICIARY SURVEY............................. E.1

MEDICARE CARE MANAGEMENT PERFORMANCE (MCMP)
DEMONSTRATION: PHYSICIAN SURVEY—DEMONSTRATION
PHYSICIANS ...................................................................................................... F.1

MEDICARE CARE MANAGEMENT PERFORMANCE (MCMP)
DEMONSTRATION: PHYSICIAN SURVEY—COMPARISON
PHYSICIANS ......................................................................................................G.1

MEDICARE CARE MANAGEMENT PERFORMANCE (MCMP)
DEMONSTRATION: ADVANCE LETTER—DEMONSTRATION
PHYSICIANS ......................................................................................................H.1

MEDICARE CARE MANAGEMENT PERFORMANCE (MCMP)
DEMONSTRATION: ADVANCE LETTER—COMPARISON
PHYSICIANS ....................................................................................................... I.1

MEDICARE CARE MANAGEMENT PERFORMANCE (MCMP)
DEMONSTRATION: FACT SHEET—COMPARISON PHYSICIANS........... J.1

vii

A. BACKGROUND

Mathematica Policy Research, Inc. (MPR) is conducting an independent evaluation of the
Medicare Care Management Performance (MCMP) Demonstration on behalf of the Centers for
Medicare & Medicaid Services (CMS). The demonstration, which began operations on July 1,
2007, will run for three years, ending June 2010.
1.

Rationale for the Demonstration
Section 649 of the Medicare Prescription Drug, Improvement, and Modernization Act of

2003 (MMA) requires the Secretary of the U.S. Department of Health and Human Services to
establish a pay-for-performance demonstration program with physicians to meet the needs of
eligible beneficiaries through the adoption and use of health information technology (HIT) and
evidence-based outcome measures. The goals of the three-year demonstration are to improve
quality of care to eligible fee-for-service Medicare beneficiaries and encourage the
implementation and use of HIT. The specific objectives are to promote continuity of care, help
stabilize medical conditions, prevent or minimize acute exacerbations of chronic conditions, and
reduce adverse health outcomes. CMS is responsible for designing and operating the MCMP
demonstration.
Under the demonstration, physician practices that meet or exceed performance standards
established by CMS in clinical performance process and outcome measures will receive a bonus
payment for managing the care of eligible Medicare beneficiaries.

Practices that submit

performance data electronically using a certified electronic medical record (EMR) system to
CMS will also be eligible for an increase in the incentive payment. The bonuses will be in
addition to the normal fee-for-service Medicare payment they receive for services delivered. In a
predemonstration (baseline) year, the demonstration will be a pay-for-reporting initiative to help
1

physicians become familiar with the process of reporting quality measures. The demonstration
builds on models used in the private sector, most notably Bridges to Excellence™ (Bodenheimer
et al. 2005; de Brantes 2005; Iglehart 2005).
2.

Demonstration Design
The MCMP demonstration will target practices serving at least 50 traditional fee-for-service

Medicare beneficiaries with selected chronic conditions for whom they provide primary care.
Under this demonstration, physicians practicing primary care1 in solo or small- to medium-sized
group practices (practices with 10 or fewer physicians, although there may be exceptions) will be
eligible to earn incentive payments for (1) reporting quality measures for congestive heart failure
(CHF), coronary artery disease (CAD), diabetes, and the provision of preventive health services
during a baseline (predemonstration) period; (2) achieving specified standards on clinical
performance measures during the three-year demonstration period; and (3) submitting clinical
quality measures to CMS electronically using an EMR system that meets industry standards
specified by the Certification Commission for Healthcare Information Technology (CCHIT).
The legislation authorizes up to four demonstration sites to include both urban and rural
areas.2 The states of Arkansas, California, Massachusetts, and Utah were chosen as the four
sites.

The Quality Improvement Organizations (QIOs) in these four states recruited

demonstration practices on relationships built through CMS’s Doctor’s Office Quality—

The following physician specialties will be eligible to participate in the MCMP demonstration if they provide
primary care: general practice, allergy/immunology, cardiology, family practice, gastroenterology, internal
medicine, pulmonary disease, geriatric medicine, osteopathic medicine, nephrology, infectious disease,
endocrinology, multispecialty clinic or group practice, hematology, hematology/oncology, preventive medicine,
rheumatology, and medical oncology.
2

In addition, the statute requires that one site be “in a state with a medical school with a Department of
Geriatrics that manages rural outreach sites and is capable of managing patients with multiple chronic conditions,
one of which is dementia.”

Information Technology (DOQ-IT) project.

Demonstration practices represent many

organizational structures, and serve at least 50 Medicare beneficiaries.

Recruitment of

demonstration practices began in January 2007.
Demonstration practices were defined by one or more tax identification numbers (TINs).
Physicians were linked to each practice using individual Medicare provider identification
numbers (PINs). Medicare beneficiaries who live in a demonstration state and who are treated
by primary care providers, or those medical subspecialties likely to provide primary care, for the
targeted conditions and who are covered under traditional fee-for-service Medicare for both Part
A and Part B coverage were linked to these practices.3 Demonstration practices are submitting
performance data to CMS on up to 26 clinical measures covering treatment related to CHF,
CAD, diabetes, and the provision of specific preventive and screening services for all
beneficiaries assigned with a chronic condition.4 Through several contractors, CMS is collecting
data on all the clinical measures for the baseline period and all three years of the demonstration.
The demonstration practices will be eligible to receive up to three incentive payments. First,
demonstration practices will receive an incentive of $20 per beneficiary per category (up to
$1,000 per physician to a maximum of $5,000 per practice) for reporting baseline clinical quality
measures. The payment will not be contingent on the practice’s score on any of these measures.
Second, for each of the three demonstration years, based on the clinical measures data that the
practices report, CMS will calculate a composite score for each chronic condition (as well as the
3

Beneficiaries for whom Medicare is not the primary source of insurance coverage or whose care a hospice
program manages will be excluded from the demonstration.
4

In addition to three primary target chronic conditions—congestive heart failure, coronary artery disease, and
diabetes mellitus—the other eligible conditions are Alzheimer’s disease or other mental, psychiatric, or neurological
disorders; any heart condition (such as arteriosclerosis, myocardial infarction, or angina pectoris/stroke); any cancer;
arthritis and osteoporosis; kidney disease; and lung disease. These conditions will be identified through ICD-9-CM
diagnosis codes available in Medicare claims data (Wilkin et al. 2007).

preventive measures) and compare it against performance thresholds. Physicians will be eligible
for payments of up to $70 per beneficiary for meeting standards related to a specific chronic
condition. Beneficiaries who have more than one condition will be counted in each of the
relevant groups. For preventive services, physicians will be eligible for a payment of up to $25
per beneficiary with any chronic condition. Physicians will be eligible to earn up to $10,000 per
year for performance on all clinical measures. The maximum annual payment to any single
practice will be $50,000, regardless of the number of physicians in the practice. Third, practices
with a CCHIT certified EMR system that can extract and submit performance data to CMS
electronically will be eligible to increase the incentive payment by up to 25 percent, or $2,500
per physician (up to $12,500 per practice) per year during the demonstration period for electronic
submission.

Thus, practices could receive up to $192,500 over the three years of the

demonstration (including the baseline period).
Finally, Congress also mandated an independent evaluation of the MCMP demonstration.
The evaluation must include an assessment of the impacts of pay-for-performance on improving
quality of care, care coordination, and continuity of care; reducing Medicare expenditures; and
improving health outcomes. The legislation specified that a final evaluation report must be
submitted to Congress within 12 months of the demonstration’s conclusion. CMS, with funding
from the Agency for Healthcare Research and Quality (AHRQ), has contracted with MPR to
conduct this evaluation.
3.

Evaluation Design
The main goal of the evaluation is to provide CMS and AHRQ with valid estimates of the

incremental effect, or impact, of providing performance-based financial incentives on the quality
of care, continuity of care, use of Medicare-covered services, and Medicare costs of the
chronically ill Medicare beneficiaries served by demonstration practices.
4

To provide this

information, the evaluation must generate rigorous quantitative estimates of the intervention’s
impacts.
The impact analysis for the evaluation will use a matched comparison (quasi-experimental)
group design. Comparison practices will be chosen from practices that participated in the DOQIT project in selected non-demonstration states. Each demonstration state was matched to a nondemonstration state based on specific criteria that included demographics and degree of
electronic health records and pay for performance programs going on in the state. Alternate
comparison states were chosen in the event that the selected state does not have a sufficient
number of practices for matching. The demonstration and comparison practices will be matched
on key factors likely to be associated with outcomes of interest. The impact analysis will use a
difference-in-differences approach to estimate impacts. With this approach, changes in quality
measures and other outcomes of practices in the demonstration states and comparison states will
be compared before and after the start of the demonstration. The unit of analysis will be the
practice, which also is the unit of intervention.
Data for impact analysis will be collected from four sources: (1) a beneficiary survey, (2) a
physician survey, (3) an Office Systems Survey, and (4) Medicare claims and eligibility data.
This request for OMB clearance only relates to the beneficiary and physician surveys.
The survey of eligible Medicare beneficiaries will measure their well being (using such
indicators as health status, burden of illness, and quality of life); access to care; adherence to
self-care management principles; continuity of care; and satisfaction with care (Table A.1).
The survey of physicians will measure barriers to transforming the practices’ clinical
encounters with beneficiaries and other office procedures, barriers to adoption of HIT,
experience implementing this type of technology, satisfaction with HIT, and experience with
other pay-for-performance programs (in the demonstration states only) (Table A.2).
5

TABLE A.1
MEASURES COLLECTED ON THE BENEFICIARY SURVEY
Health Status
Self-rated health status
List of diagnosed chronic conditions
Self-rated knowledge of chronic conditions
Self-rated knowledge of risk factors or symptoms of worsening conditions
Access to Care
Regular source of medical care
Frequency of physician or clinic visits in past year
Frequency of emergency room visits in past year
Health Care Processes
Measures taken, exams given, and education provided during last visit to health care
professional
Discussion of exercise, smoking, drinking, diet with health care professional in past year
Colon cancer screening in past five years
Flu vaccination in past two years
Frequency of self-examination of feet and self-weigh during past year
Satisfaction with Care
Level of satisfaction with several dimensions of the care received from the health care
professional (for example, the amount of time spent with the doctor during a visit)
Level of satisfaction with the ability to get appointments and reminders for appointments
Level of satisfaction with communication among physicians regarding patient’s medical care
Overall quality of health care and services
Background Information
Level of education
Primary language spoken
Marital status
Living arrangements
Household size
House ownership status
Employment status
Household income

TABLE A.2
MEASURES COLLECTED ON THE PHYSICIAN SURVEY

Use of Electronic Medical Records (EMRs)
Availability of EMR system
Use of EMR system to perform functions (for example, documenting office visits, eprescribing, polypharmacy, or issuing patient reminders)
Level of satisfaction with EMR system training
Level of satisfaction with ability of EMR system to meet practice needs
Barriers to Adoption and Use of EMRs
Start-up and maintenance costs
Time to acquire or setup the system
Staff computer skills, skepticism, and reluctance to change
Patient privacy concerns
Time and ability to incorporate legacy records into the new system
Interoperability
Caring for Medicare Patients with Chronic Illnesses
Issue routine care reminders electronically or manually
Change in number of office visits, telephone conversations, and email exchanges with
Medicare patients
Number of encounters with polypharmacy, unnecessary or duplicate tests, lack of timely
information from other providers or after hospitalization
Level of satisfaction with overall quality of care, coordination of care, physician and patient
knowledge of recommended preventive care
Frequency of producing reports on patients
Frequency of availability of patient care-related information during office visits
Experiences with the MCMP Demonstration (only Physicians in Demonstration Practices)
Success targeting important medical conditions, use of appropriate quality measures, and
promoting EMR adoption and use
Effect of demonstration on processes of care
Recommendation of MCMP to colleagues
Experience with other pay-for-performance programs
Demographic and Socioeconomic Characteristics
Number of Medicare beneficiaries with chronic conditions seen in an average week
Use of languages other than English in practice
Years in medical practice
Whether board certified
Age
Race/ethnicity

B. JUSTIFICATION

Need and Legal Basis
The MCMP Demonstration is authorized by Section 649 of the Medicare Prescription Drug,

Improvement, and Modernization Act of 2003 (MMA). The legislation requires the Secretary of
the U.S. Department of Health and Human Services to establish a pay-for-performance
demonstration program with physicians to meet the needs of eligible beneficiaries through the
adoption and use of health information technology (HIT) and evidence-based outcome measures.
(See Appendix A for a copy of the legislation.) The MMA authorized up to four demonstration
sites to include urban and rural areas; CMS chose Arkansas, California, Massachusetts, and
Utah. An independent evaluation of the MCMP demonstration is required. The evaluation must
include an assessment of the impact of pay-for-performance on improving quality of care, care
coordination, and continuity of care, thereby reducing Medicare expenditures and improving
health outcomes. To measure these outcomes, the impact evaluation requires a survey of eligible
Medicare beneficiaries and a survey of physicians participating in the demonstration.
2.

Information Users
Information for the evaluation of the MCMP demonstration will be collected and analyzed

by MPR, under Contract Number 500-00-0033, Task Order 05, with CMS, titled “Evaluation of
Medicare Care Management Performance Demonstration”.
Findings from the impact analysis will be included in the Report to Congress (due within 12
months of the conclusion of the demonstration) and other internal reports to CMS.

Use of Information Technology
Data collection for the beneficiary survey will begin in January 2009, approximately 19

months from the start of the demonstration. Beneficiary survey data collection will rely on a
self-administered mail questionnaire and will be supplemented with computer-assisted telephone
interviewing (CATI). Data collection for the physician survey will also use both mail and CATI;
however, CATI will be the primary data collection method. Questionnaire content for each
survey will be the same across modes. Respondent signatures are not required for either of the
two surveys.
MPR will enter mail survey data using Viking data entry software on a SUN Ultra
Enterprise 2 workstation.

A data entry program specific to the survey instrument will be

developed and thoroughly tested before use. The program will contain study-specific logic and
range and consistency checks to produce high quality data.
Quality control and data entry of completed questionnaires will continue throughout the
field period (expected to run for 12 months for the beneficiary survey and 11 months for the
physician survey). The data entry program will contain edit specifications and will flag errors
electronically. Calls to collect critical missing information and resolve inconsistencies will be
made as needed. All errors will be reviewed and resolved during data cleaning, and all entries
will be 100 percent verified.
4.

Duplication of Effort
This information collection does not duplicate any other effort, and the information cannot

be obtained from any other source.

Small Businesses
Solo, small, and mid-size practices (that is, practices with 10 or fewer physicians, although

there may be exceptions) will be targeted for the physician survey. Participating in the survey
will impose minimal burden for physicians. The physician survey is designed to be completed in
10 or fewer minutes.
6.

Less-Frequent Collection
Both data collection efforts are one-time-only collections and are necessary for conducting a

credible evaluation. Not conducting the surveys would limit CMS’s understanding of the impact
of the MCMP demonstration and would impair CMS’s ability to provide a fully informed Report
to Congress, as required.
7.

Special Circumstances
There are no special circumstances related to the proposed data collection for the MCMP

evaluation.
8.

Federal Register/Outside Consultation
The notice required by 5 CFR 1320.8 (d), will be submitted by CMS for publication in the

Federal Register.
Outside consultation for the design of the study and surveys was received from the
following experts.
• Sheldon Retchin (M.D., M.P.H., University of North Carolina), Professor of Internal
Medicine and Chief Executive Officer of Virginia Commonwealth University (VCU)
Health System. Dr. Retchin provided advice regarding the development of the
physician survey instrument. He also assisted with the analysis of quality of care
measures. Dr. Retchin is a national expert in health policy and health care delivery
and has extensive experience with the implementation and study of the effectiveness
of electronic medical records in office practice settings. The VCU Health System,
where Dr. Retchin is CEO, recently installed a $57 million clinical information

system that includes computerized physician order entry (CPOE). The VCU Health
System has had mandatory CPOE at its hospitals for more than 20 years.
• Robert H. Miller (Ph.D., Economics, University of California, San Francisco
[UCSF]) is Professor of Health Economics in Residence, Institute for Health & Aging
at UCSF. Dr. Miller provided advice on the physician survey. His research focuses
on the economics of information technology (IT) and organizational change in
ambulatory care settings. He has conducted studies about the costs, benefits, and use
of electronic medical records; the economic feasibility of community-wide electronic
clinical data exchange; and the capabilities of e-health systems: their implementation,
use, and current/potential effects on quality and efficiency.
Several surveys that were used in other demonstrations sponsored by CMS were referenced
in the development of the beneficiary and physician survey instruments for MCMP to identify
questions that were previously used successfully with similar populations.

These included

(1) the Medicare Coordinated Care Physician Survey Questionnaire; (2) the Senior Dimensions
Second Generation Social Health Maintenance Organization Survey; and (3) the Medicare
Disease Management Program Evaluation Patient Questionnaire.

The two current survey

instruments were pretested with nine or fewer respondents.
9.

Payments/Gifts to Respondents
No payments or gifts are planned for respondents of either the beneficiary or physician

surveys.
10. Confidentiality
MPR will take several steps to assure respondents that the information they provide will be
treated as confidential and used for research purposes only. Survey respondents will be told that
they will not be identified individually (that is, by name) in any reports or in any
communications to CMS. The assurances and limits of confidentiality will be made clear in
advance material mailed to respondents and will be restated at the beginning of each telephone
interview. Respondents will also be told that their participation in the survey is voluntary,
though important, and that they have the option to refuse to answer questions in the survey. Staff
12

assigned to work on the project sign confidentiality pledges as a term of employment. The
confidentiality pledge requires staff to maintain the confidentiality of all information collected.
Questionnaires completed by mail will not contain names or other personally identifying
information. Instead, each questionnaire will contain a unique barcode that can be linked to the
respondent only for research purposes.
11. Sensitive Questions
The beneficiary survey includes questions about health status, medical diagnoses, and
medical visits that may be considered sensitive. Obtaining information about these potentially
sensitive topics is central to the evaluation.

Many of the questions were adapted without

modification from other surveys of similar populations, such as the Medicare Coordinated Care
Physician Survey Questionnaire and the Medicare Disease Management Program Evaluation
Patient Questionnaire. In these surveys, there was no indication that respondents were reluctant
to report on their health status, diagnoses, and health visits as well as other aspects of their health
and their experiences with health care providers. The questions in the physician survey are about
the use of electronic medical records, practices when caring for chronically ill Medicare
beneficiaries, experiences with the demonstration, and some general background questions.
These questions are not considered sensitive.
12. Burden Estimates (Hours and Wages)
Table B.1 presents estimates of respondent burden for the beneficiary and physician surveys.
It shows the expected number of respondents to each survey, hours per response, and the
annualized hour and cost burden.

Hour estimates for the beneficiary survey are based on pretests completed with eight
Medicare beneficiaries. In those pretests, completion times ranged from 10 to 14 minutes, and
averaged 11 minutes. This average was rounded up to the next quarter hour or 15 minutes.
Eight physicians also completed pretests.

Those pretests form the basis for the hour

estimates provided. For the physician survey, pretest completion times ranged from 4 to 18
minutes, and averaged 8 minutes overall. The cost per physician response was computed using
an estimated annual salary of $160,000 for primary care physicians and 2,080 annual work hours
as follows: $160,000/2,080 *0.17 hours = $13.08 per response. For the 272 total hours expected
to complete the survey (column 5 in Table B.1), the estimated total annual cost burden for the
physician survey is $3,558.
TABLE B.1
RESPONSE BURDEN FOR THE BENEFICIARY AND PHYSICIAN SURVEYS
Number of
Respondents
(1)

Frequency of
Response
(2)

Hours Per
Response
(3)

Beneficiary survey

4,800

0.25

1,200

Physician survey

1,600

0.17

272

Total

6,400

1,472

Survey

Annual Hour
Burden
(4)

Cost Per
Response
(5)

Annual Cost
Burden
(6)

NA
$13.08
NA

NA
$3,558
NA

13. Capital Costs
There are no direct costs to respondents other than their time to participate in the study.
14. Cost to Federal Government
The total current value for this contract is $2,299,876 over a period of seven years. The
estimated annualized cost to the government for conducting the surveys of beneficiaries and
physicians is $282,961 (over a period of three years). This estimate is based on the contractor’s
costs for conducting and tabulating mail survey results, including labor; conducting computerassisted telephone interviewing for both surveys; other direct costs for computer, telephone,
14

postage, reproduction, fax, printing, and survey facilities; and indirect costs for fringe benefits,
general and administrative costs, and fees.
15. Changes to Burden
This is a new data collection; therefore, there are no changes to burden.
16. Publication/Tabulation Dates
The demonstration evaluation will produce several reports including a cost neutrality
monitoring report, and interim and final evaluation reports that synthesize findings across states
and analytic components.

The evaluation reports will be adapted to develop a Report to

Congress. Table B.2 summarizes the delivery schedule for these reports. A summary of each
report follows.
a.

Cost Neutrality Monitoring Report
OMB has requested that MPR monitor cost neutrality over the first 18 months of the

demonstration.

This analysis will require comparing our regression estimates of the

demonstration’s effects on Medicare savings to the incentive payments made to demonstration
practices. Assuming the data for this analysis are available by month 21 (that is, 21 months after
the demonstration begins), MPR plans to deliver a draft of this report to CMS in month 24 (that
is, June 2009).

TABLE B.2
DELIVERY SCHEDULE FOR EVALUATION REPORTS
Due Date
Project Montha

Calendar Month

Design report

n.a.

May 2007

First interim evaluation report

October 2008

Report

Cost neutrality monitoring report
Second interim evaluation report

June 2009

24
28

October 2009

Report to Congress
(third interim evaluation report)

October 2010

Final evaluation report

September 2011

Refers to the number of months after the start of the demonstration (July 1, 2007).

n.a. = not applicable.

b. Interim and Final Evaluation Reports
One of the most important components of the evaluation will be the synthesis of the findings
from the implementation and impact analyses to determine whether the pay-for-performance
incentives improved quality of care for fee-for-service Medicare beneficiaries with chronic
illnesses and influenced the adoption and use of HIT and, therefore, whether pay-forperformance should be implemented on a larger scale.
MPR will prepare three interim evaluation reports (drafts due 16, 28, and 40 months after
the start of the demonstration, respectively) and a final evaluation report (draft due 51 months
after the start of the demonstration), all of which will synthesize those findings available at
different times during the demonstration.
The first interim evaluation report, due in October 2008 (16 months after the start of the
demonstration), will provide an overview of implementation and demonstration activities to date
in each state,

a comparison of baseline characteristics of demonstration and comparison

practices including their use of HIT, and summary statistics on the number of demonstration

practices that submitted baseline data. It will rely on data from the Office Systems Survey,
baseline claims data, and baseline quality measurement data from the demonstration practices.
The second interim evaluation report, due in October 2009 (28 months after the start of the
demonstration), will focus on impact estimates for the first year of program operations.
Although MPR will compare impacts on use of Medicare-covered services and costs across
practices and states, MPR will not attempt to draw inferences from them at this stage of the
evaluation. In addition, MPR will summarize findings from telephone discussions with highly
successful practices and with those that withdrew, if any, in year 2 of demonstration operations.
The third interim evaluation report, due in October 2010 (40 months after the start of the
demonstration), will focus on impact estimates for the second year of program operations. MPR
will also include findings on the impacts of pay-for-performance on physician-beneficiary
interactions (that is, access to care, care coordination, and satisfaction with care) from the
beneficiary survey. Finally, MPR will summarize findings from telephone discussions with
highly successful and unsuccessful practices (including those that withdrew, if any), in year 3 of
demonstration operations.
The final evaluation report, due in September 2011 (51 months after the start of the
demonstration), will provide final impact estimates from claims data using data from the third,
and final, year of demonstration operations. In addition, MPR will present impact estimates
from the physician survey on processes associated with the adoption of HIT to improve quality
of care. The report will also incorporate our synthesis analysis, including data from the last wave
of the Office Systems Survey.
c.

Report to Congress
MPR will produce one Report to Congress based on the independent evaluation. The draft

report is due in October 2010, approximately three months after the end of demonstration
17

operations. This report will analyze implementation experiences and findings of the MCMP
demonstration across the four states.
17. Expiration Date
The OMB expiration date will be displayed on all survey materials sent to sample members,
including the advance letter and questionnaire.
18. Certification Statement
Both data collection efforts will conform to all provisions of the Paperwork Reduction Act.

C. COLLECTION OF INFORMATION EMPLOYING
STATISTICAL METHODS

Respondent Universe and Sampling Methods

Respondent Universe
The MCMP demonstration targets practices serving at least 50 traditional fee-for-service

Medicare beneficiaries with selected chronic conditions for whom the practices are providing
primary care. The target populations consist of (1) the physicians (for the physician survey)
affiliated with the targeted practices and (2) the Medicare beneficiaries (for the beneficiary
survey) associated to these practices.
The Quality Improvement Organizations (QIOs) in the four demonstration states—
Arkansas, California, Massachusetts, and Utah—recruited practices on relationships built
through CMS’s Doctor’s Office Quality-Information Technology (DOQ-IT) project.

Only

practices participating in DOQ-IT were eligible to participate in the demonstration.

The

demonstration enrolled 106 practices in Arkansas, 236 practices in California, 236 practices in
Massachusetts, and 121 practices in Utah, with an estimated 2,800 physicians participating in
MCMP. Comparison practices will be chosen from DOQ-IT practices in non-demonstration
states. Each demonstration state was matched to a non-demonstration state based on specific
criteria that included demographic features, degree of health information technology and pay for
performance programs going on in the state, and other factors. Alternate comparison states were
chosen in the event that the selected state does not have a sufficient number of practices for
matching.

Comparison practices will be matched to the demonstration practices based on

practice size, experience with HIT, and use of ambulatory Medicare-covered services.
The demonstration states, and the practices within them, are not randomly selected from a
population of states and practices. Instead, CMS selected the four states following criteria
19

specified in the enabling legislation. Furthermore, physician practices volunteered to participate.
Thus, the sampled population cannot be generalized beyond those practices enrolled in the
demonstration and their matched counterparts.
b. Sampling Methods
The sample of physicians for the physician survey will be stratified by the number of
physicians in the participating practices (that is, practice size).

Table C.1 presents the

distribution of eligible practices, by size, in the four demonstration states.

To select the

physician sample, MPR will use a list of physicians in the demonstration practices collected from
the demonstration’s application form, to select one or more physicians from each of the
699 treatment practices. MPR will obtain the list of physicians for the comparison practices
from the Office Systems Survey. MPR will use this list to select one or more physicians from
the approximately 700 comparison group practices for this survey. For solo practices, the
physician will be selected with certainty. MPR will select a sample of 2,376 physicians—1,144
from practices in demonstration states and 1,232 from practices in comparison states—to get the
desired 1,600 completed interviews.

The goal is to have 200 completed interviews with

physicians in demonstration practices in each state and 200 completed interviews with physicians
in comparison practices per state for a total of 1600 interviews.
For the beneficiary survey, MPR will stratify sample members by medical condition. The
financial support contractor will provide MPR with lists of Medicare beneficiaries linked with
any of the demonstration or comparison-group practices during the first year of demonstration
operations (that is, July 2007 to June 2008). From these lists, MPR will select a sample of 6,400
beneficiaries to get the desired 4,800 completed interviews. The sample will be evenly split
across demonstration and comparison practices in each state (800 beneficiaries in demonstration
practices and 800 beneficiaries in comparison practices in each state).
20

TABLE C.1
DISTRIBUTION OF ELIGIBLE PRACTICES, BY SIZE,
IN DEMONSTRATION STATES
State

Practice Size

Number of Practices

Percentage

Arkansas

1
2
3
4
5
6
7
8
9
10

99
259
45
48
21
20
8
16
4
11

18.6
48.8
8.5
9.0
4.0
3.8
1.5
3.0
0.8
2.1

California

1
2
3
4
5
6
7
8
9
10

3,051
2,570
518
302
154
134
103
73
45
45

43.6
36.7
7.4
4.3
2.2
1.9
1.5
1.0
0.6
0.6

Massachusetts

1
2
3
4
5
6
7
8
9
10

468
324
90
63
52
34
26
26
22
14

41.8
29.0
8.0
5.6
4.7
3.0
2.3
2.3
2.0
1.3

Utah

1
2
3
4
5
6
7
8
9
10

39
112
23
23
15
9
3
7
6
3

16.3
46.7
9.6
9.6
6.3
3.8
1.3
2.9
2.5
1.3

Source: MCMP financial support contractor.

Table C.2 shows the distribution of Medicare beneficiaries by medical condition. In each
state, the total percentage exceeds 100 percent because there is overlap among conditions that
could not be accounted with the available data.5 Thus, MPR will stratify the sample into two
groups: (1) beneficiaries reported with at least one of the conditions of coronary artery disease
(CAD), congestive heart failure (CHF), and/or diabetes; and (2) beneficiaries reported with any
of the other conditions, but not CAD, CHF, or diabetes.6 The percentage of beneficiaries having
at least one of the target conditions (CAD, CHF, and/or diabetes) is estimated by summing the
percentages for specific conditions and dividing it by the total. For example, in Arkansas, the
sum of the percentages across conditions is 145 percent. Thus, the estimated percentage of
individuals with CAD, CHF, and/or diabetes is 39 percent [ = (22+13+22)/145].
2.

Procedures for the Collection of Information

Beneficiary Survey
A self-administered mail survey will be the primary data collection mode for the beneficiary

survey. The survey will start 19 months after the beginning of the demonstration’s operations (in
January 2009). Respondents will be sent a packet containing (1) a letter (printed on CMS
letterhead and signed by the CMS Information Officer) describing the survey, (2) a fact sheet of
commonly asked questions and their answers, (3) the questionnaire, and (4) prepaid return
mailing materials.

For example, someone who has both diabetes and a kidney condition is included in both percentages. It is not
known how many individuals have only diabetes and no other condition, and how many have diabetes in
combination with one or more of the other conditions.
6

The first stratum includes beneficiaries reported with CAD, CHF, or diabetes in combination with one or
more of the other conditions.

TABLE C.2
DISTRIBUTION OF MEDICARE BENEFICIARIES BY
CHRONIC CONDITION AND STATE
State

Condition

Number

Percentage

Arkansas

Coronary artery disease
Congestive heart failure
Diabetes
Age-related macular degeneration
Heart condition
Bone condition
Cancer
Kidney condition
Lung condition

36,293
20,316
36,195
22,874
33,340
33,076
19,527
8,950
24,442

22
13
22
14
21
20
12
6
15

California

Coronary artery disease
Congestive heart failure
Diabetes
Age-related macular degeneration
Heart condition
Bone condition
Cancer
Kidney condition
Lung condition

307,628
163,726
348,704
184,929
333,685
350,863
232,224
108,289
211,878

22
12
25
13
24
25
17
8
15

Massachusetts

Coronary artery disease
Congestive heart failure
Diabetes
Age-related macular degeneration
Heart condition
Bone condition
Cancer
Kidney condition
Lung condition

53,816
26,710
56,927
47,754
63,343
51,865
41,653
18,215
37,729

21
11
23
19
25
21
17
7
15

Utah

Coronary artery disease
Congestive heart failure
Diabetes
Age-related macular degeneration
Heart condition
Bone condition
Cancer
Kidney condition
Lung condition

7,585
5,512
11,323
7,782
9,978
11,631
7,605
2,815
5,396

14
10
21
14
18
21
14
5
10

Source: MCMP financial support contractor.

A copy of the letter that will be sent to respondents is included as Appendix C to this
submission; the fact sheet is in Appendix D. The beneficiary questionnaire (Appendix E) has
been designed with a high level of sensitivity to the age of the target population. A larger font
size than is typical for use with the general population will be used for the survey. MPR expects
that beneficiaries will be able to complete the survey in 15 minutes or less. The questionnaire
and all accompanying survey materials will be available in both English and Spanish.
The following topics will be covered by the beneficiary survey:
• Section A: Health Status. This section collects self-reported health status and
obtains information about medical diagnoses and knowledge of health conditions.
• Section B: Access to Care. This section asks about the usual sources of care,
primary care physician identification, and frequency of health care visits.
• Section C: Health Care Processes. This section collects information about the
procedures followed and advice obtained during physician visits.
• Section D: Care Coordination. This section collects information about physician’s
knowledge of beneficiary’s health information.
• Section E: Satisfaction with Care. This section collects information on the level of
satisfaction with various aspects of medical care received.
• Section F: Background Information. This section collects information on
beneficiary’s level of education, languages spoken, marital status, living
arrangements, employment status, and income.
MPR’s goal is to complete surveys with 4,800 eligible beneficiaries (600 from the
demonstration group and 600 from the comparison group in each state), for a 75 percent response
rate. The beneficiary survey will be administered over a 12-month period. The initial survey
mailing to beneficiaries will be supplemented with a reminder postcard, a second full mailing to
nonresponders, and a second reminder postcard. About halfway through the field period, MPR
will send a final appeal to get more respondents to return completed surveys by mail. To
complete the remaining interviews needed to achieve the targeted 75 percent response, MPR will

focus its remaining resources on completing the survey by telephone. A CATI system will be
used to facilitate data collection.
b. Physician Survey
For the physician survey, MPR’s goal is to complete surveys with 1,600 respondents (200
physicians from practices in each demonstration state and 200 physicians from practices in each
comparison state). These estimates assume response rates of 70 percent for demonstration
physicians and 65 percent for comparison physicians. MPR projects a lower response rate for
the comparison states because comparison group physicians will have no clear incentive to
participate in a survey. These response rate assumptions are consistent with MPR’s recent
experience interviewing physicians whose patients were participating in CMS’s care
coordination or disease management demonstrations.
The physician survey will be fielded approximately 25 months after the start of the
demonstration (in July 2009). MPR will also use a mail survey (with telephone follow-up) as the
data collection strategy for the physician survey. However, MPR will begin telephone data
collection immediately following the initial mailing. The initial mailing is being used primarily
as a way to alert the physicians that they will be receiving a call about the survey. Some
physicians will prefer to complete the survey by mail, and the mailing will facilitate completion
for them. MPR selected this approach because physicians’ busy schedules may make it difficult
for them to respond to an unscheduled telephone survey. The physician survey questionnaire for
demonstration physicians is included in Appendix F. Appendix G contains the version for
comparison group physicians. The surveys collect data on the following topics:
• Section A: Use of Electronic Medical Records. This section asks about the
physician’s experience with electronic medical records.

• Section B: Barriers to Adoption and Use of Electronic Medical Records. This
section asks about factors that may have been barriers in the adoption and use of
electronic medical records and the physician’s involvement in efforts to improve
quality and assess technology needs.
• Section C: Caring for Medicare Patients with Chronic Illnesses. This section
collects information about communication with Medicare patients.
• Section D:
Experiences with the MCMP Demonstration (Demonstration
Physicians Only). This section collects information from demonstration group
physicians. It asks for their opinions about the demonstration and its effect on their
service to Medicare patients.
•

Section E: Demographic and Socioeconomic Characteristics. This section asks for the
physician’s demographic and socioeconomic characteristics, including racial and ethnic
background and board certification status.

MPR will mail survey material to demonstration and comparison group physicians using
official CMS letterhead and envelopes. Included in the survey material will be a cover letter
signed by the CMS Privacy Officer, a mail questionnaire, and prepaid return mailing materials.
The advance letter will include a toll-free number giving physicians the option to call and
complete the survey by telephone. Demonstration and comparison group physicians will receive
slightly different versions of the advance letter (see Appendixes H and I).

In addition,

comparison group physicians will be sent a fact sheet about the demonstration (see Appendix J).
The initial mailing to physicians will occur in July 2009. Two weeks after the initial
mailing, MPR will begin telephone contact to schedule appointments and conduct interviews
with sampled physicians. This effort will continue throughout the 11-month survey period—
from July 2009 through June 2010. MPR will train staff experienced in interviewing physicians
to negotiate access with gatekeepers and to conduct the estimated 10-minute interview. About
midway through the survey period, MPR will send a second mailing appealing to physicians who
have not completed surveys or scheduled appointments. MPR expects that about 60 percent of

the completed surveys will come from CATI and that 40 percent will be completed by mail.
Table C.3 shows the data collection schedule for both surveys.
TABLE C.3
DATA COLLECTION SCHEDULE

Data Collection Activity
Beneficiary survey
Physician survey

Start Date

End Date

January 2009

December 2009

July 2009

June 2010

Methods to Maximize Response Rates

Beneficiary Survey
MPR will take a number of steps to maximize response to the survey of beneficiaries for the

MCMP evaluation. First, the cover letter that will accompany survey mailings will be printed on
CMS letterhead, personally addressed, and signed by the CMS Privacy Officer. The letter will
include a telephone number and Internet address for CMS, a toll-free number at which to
complete the survey or get additional information from MPR, and a fact sheet about the survey.
The letter will describe the evaluation and the purpose of the mail survey and will provide
prepaid return mailing materials for completed surveys. The letter will also indicate that the
survey is voluntary and will estimate the time needed to complete it (that is, 15 minutes).
A reminder postcard will follow the initial mailing to beneficiaries. Nonresponders to the
initial and reminder mailings will receive a second full mailing, a second reminder postcard, and
a priority mailing to encourage response. When these efforts are exhausted, trained interviewers
will begin to contact beneficiaries by telephone to complete the survey. All materials for the
beneficiary survey will be available in both English and Spanish. MPR projects a 75 percent
response rate for the beneficiary survey.

b. Physician Survey
MPR will utilize an initial mailing to alert both demonstration and comparison group
physicians about the MCMP physician survey. The cover letter for the initial mailing will be
printed on CMS letterhead, personally addressed, and signed by the CMS Privacy Officer. The
initial mailing will include a self-administered mail questionnaire and prepaid return mailing
materials.
Physicians participating in the demonstration will be aware that a survey will be conducted
as part of the evaluation and will, MPR hopes, be motivated to respond. Comparison group
physicians are less likely to be aware of the demonstration. The CMS Internet address and
telephone number that will be included in the letter should be helpful in providing information
about the demonstration to this group. Physicians will also be provided with the toll-free number
to call MPR to complete the survey by telephone. About two weeks following the initial mailing
to physicians, telephone interviewers trained at negotiating with gatekeepers for access to
physicians will begin to contact sampled physicians by telephone to complete the survey. These
telephone efforts will be supplemented by a second mailing to nonresponding physicians midway
through the data collection period. These efforts are projected to yield a response rate of
70 percent among demonstration physicians and 65 percent among comparison group physicians.
4.

Tests of Procedures or Methods
MPR conducted pretests to assess the clarity of questions, identify possible modifications to

question content and/or sequence, and estimate respondent burden for both survey instruments.
Convenience samples of Medicare beneficiaries and physicians were used for the pretests.7 The
pretests mirrored the data collection strategy planned for the main survey to the extent possible.
7

MPR staff identified pretest sample members for both surveys.

That is, mail surveys were sent to all sample members as the initial contact mechanism. These
surveys were followed up with a telephone call to debrief with the pretest sample members about
their experience completing the survey. During the debriefing calls, MPR asked questions to
assess respondents’ cognitive understanding of terms used and to identify problems they may
have had answering the questions. Respondents were asked to record their start and end times on
the survey.
a.

Beneficiary Pretest
Eight Medicare beneficiaries participated in the beneficiary survey pretest. Respondents

took an average of 11 minutes to complete the pretest survey, with completion times ranging
from 10 to 14 minutes. Overall, the response to the pretest was positive. Respondents provided
some suggestions for changes but found the questions easy to understand. All suggested changes
were considered and have been incorporated to the extent appropriate. In addition to the pretest
respondents, internal reviewers and reviewers at CMS provided comments on the survey drafts;
these have been incorporated as well.
b. Physician Pretest
MPR mailed pretest packets, including a cover letter, questionnaire, and prepaid return
mailing materials, to nine physicians. Of these, eight returned completed questionnaires. Seven
of the eight physicians currently serve Medicare patients. On average, physicians completed the
survey in 8 minutes, with completion times ranging from 4 to 18 minutes.

Debriefing

conversations with physician respondents were also conducted. Pretest physicians provided
valuable feedback about terminology and concepts covered in the questionnaire.

These

comments, along with those of MPR’s internal reviewers, external consultants, and CMS, have
been integrated into the revised version of the questionnaire that is included with this package.

Revisions reflecting the lessons learned from the pretests have been incorporated into the
current versions of both instruments included with this submission.
5.

Individuals Involved in Design
The following individuals have contributed to the study design and to the design of the

physician and beneficiary survey instruments:
• Dr. Lorenzo Moreno, an MPR senior health researcher and study project director,
(609) 936-2776
• Ms. Julita Milliner-Waddell, a survey researcher at MPR and study survey director,
(609) 275-2206
• Ms. Jillian Stein, an MPR survey associate, (609) 716-4395
• Dr. Eric Grau, an MPR sampling statistician, (609) 945-3330
• Dr. Sheldon Retchin, Professor of Internal Medicine and Chief Executive Officer of
Virginia Commonwealth University Health System, (804) 828-9770
• Dr. Robert H. Miller, Associate Professor of Health Economics in Residence,
Institute for Health & Aging at the UCSF, (415) 476-8568
• Dr. Lorraine Johnson, CMS Project Officer, Office of Research, Development, and
Information, (410) 786-9457
6.

Additional Information
Personally identifiable information and social security numbers are not being collected as

part of the beneficiary and physician surveys being conducted for MCMP.8 Mail questionnaires
will not contain names or other identifiers. Instead, a unique barcode will be affixed to each
questionnaire.

Identifiable data only will be used to draw the sample for the beneficiary survey from the Medicare
enrollment database, which includes beneficiary social security number and other personal identifiers. Access to
these data is governed by a Data Use Agreement between MPR and CMS for the MCMP demonstration. The
sample frame for the physician survey does not contain social security numbers, although it includes the tax
identification number of the practice to which the physician belongs. Access to these data also is governed by a
Data Use Agreement between MPR and MassPRO—the Massachusetts Quality Improvement Organization—for this
demonstration.

Safeguarding Personally Identifiable Identifiable (PII) Information
No personally identifiable information, including SSNs, is being collected for this project.

All information will be collected electronically using Computer-Assisted Telephone
Interviewing (CATI). The information will be stored electronically in a Non-CMS system.
DUA # 15692 is in place for collection and storage of claims data.
If you have questions about privacy impact assessments, contact Maribel Franey, Director,
Division of Privacy Compliance, Office of Information Services.
b. Social Security Numbers (SSN)
Social Security Numbers (SSNs) are not being collected.

REFERENCES

Bodenheimer, Thomas, Jessica H. May, Robert A. Berenson, and Jennifer Coughlan. “Can
Money Buy Quality? Physician Response to Pay for Performance.” Issue Brief no. 102.
Washington, DC: Center for Studying Health System Change, December 2005.
Iglehart, John K. “Linking Compensation to Quality—Medicare Payments to Physicians.” New
England Journal of Medicine, vol. 353, no. 9, September 1, 2005, pp. 870–872.
de Brantes, François. “Lessons Learned.” Presentation on the Bridges to Excellence Program at
the Institute of Medicine, Washington, DC, May 4, 2005.
Wilkin, John C., C. William Wrightson, David Knutson, Erika G. Yoshino, Anahita S. Taylor,
and Kerry E. Moroz. “Medicare Care Management Performance Demonstration. Design
Report.” Columbia, MD: Actuarial Research Corporation, January 5, 2007.

APPENDIX A
LEGISLATION

A.1

MEDICARE PRESCRIPTION DRUG, IMPROVEMENT, AND
MODERNIZATION ACT OF 2003
TITLE VI—PROVISIONS RELATING TO PART B
SUBTITLE D—ADDITIONAL DEMONSTRATIONS, STUDIES,
AND OTHER PROVISIONS
SEC. 649. MEDICARE CARE MANAGEMENT PERFORMANCE DEMONSTRATION
(a) ESTABLISHMENT.
(1) IN GENERAL.—The Secretary shall establish a pay-for-performance demonstration
program with physicians to meet the needs of eligible beneficiaries through the adoption and
use of health information technology and evidence-based outcomes measures for
(A) promoting continuity of care;
(B) helping stabilize medical conditions;
(C) preventing or minimizing acute exacerbations of chronic conditions; and
(D) reducing adverse health outcomes, such as adverse drug interactions related to
polypharmacy.
(2) SITES.—The Secretary shall designate no more than 4 sites at which to conduct the
demonstration program under this section, of which
(A) 2 shall be in an urban area;
(B) 1 shall be in a rural area; and
(C) 1 shall be in a State with a medical school with a Department of Geriatrics that
manages rural outreach sites and is capable of managing patients with multiple chronic
conditions, one of which is dementia.
(3) DURATION.—The Secretary shall conduct the demonstration program under this section
for a 3-year period.
(4) CONSULTATION.—In carrying out the demonstration program under this section, the
Secretary shall consult with private sector and non-profit groups that are under taking similar
efforts to improve quality and reduce avoidable hospitalizations for chronically ill patients.
(b) PARTICIPATION.
(1) IN GENERAL.—A physician who provides care for minimum number of eligible
beneficiaries (as specified by the Secretary) may participate in the demonstration program
under this section if such physician agrees, to phase in over the course of the 3-year
demonstration period and with the assistance provided under subsection (d)(2)

A.3

(A) the use of health information technology to manage the clinical care of eligible
beneficiaries consistent with paragraph (3); and
(B) the electronic reporting of clinical quality and outcomes measures in accordance with
requirements established by the Secretary under the demonstration program.
(2) SPECIAL RULE.—In the case of the sites referred to in subparagraphs (B) and (C) of
subsection (a)(2), a physician who provides care for a minimum number of beneficiaries with
two or more chronic conditions, including dementia (as specified by the Secretary), may
participate in the program under this section if such physician agrees to the requirements in
subparagraphs (A) and (B) of paragraph (1).
(3) PRACTICE STANDARDS.—Each physician participating in the demonstration program
under this section must demonstrate the ability
(A) to assess each eligible beneficiary for conditions other than chronic conditions, such
as impaired cognitive ability and co-morbidities, for the purposes of developing care
management requirements;
(B) to serve as the primary contact of eligible beneficiaries in accessing items and
services for which payment may be made under the Medicare program;
(C) to establish and maintain health care information system for such beneficiaries;
(D) to promote continuity of care across providers and settings;
(E) to use evidence-based guidelines and meet such clinical quality and outcome
measures as the Secretary shall require;
(F) to promote self-care through the provision of patient education and support for
patients or, where appropriate, family caregivers;
(G) when appropriate, to refer such beneficiaries to community service organizations;
and
(H) to meet such other complex care management requirements as the Secretary may
specify.
The guidelines and measures required under subparagraph (E) shall be designed to take
into account beneficiaries with multiple chronic conditions.
(c) PAYMENT METHODOLOGY.—Under the demonstration program under this section the
Secretary shall pay a per beneficiary amount to each participating physician who meets or
exceeds specific performance standards established by the Secretary with respect to the clinical
quality and outcome measures reported under subsection (b)(1)(B). Such amount may vary based
on different levels of performance or improvement.
(d) ADMINISTRATION
(1) USE OF QUALITY IMPROVEMENT ORGANIZATIONS.—The Secretary shall
contract with quality improvement organizations or such other entities as the Secretary deems
appropriate to enroll physicians and evaluate their performance under the demonstration
program under this section.
(2) TECHNICAL ASSISTANCE.—The Secretary shall require in such contracts that the
contractor be responsible for technical assistance and education as needed to physicians
A.4

enrolled in the demonstration program under this section for the purpose of aiding their
adoption of health information technology, meeting practice standards, and implementing
required clinical and outcomes measures.
(e) FUNDING.
(1) IN GENERAL.—The Secretary shall provide for the transfer from the Federal
Supplementary Medical Insurance Trust Fund established under section 1841 of the Social
Security Act (42 U.S.C. 1395t) of such funds as are necessary for the costs of carrying out the
demonstration program under this section.
(2) BUDGET NEUTRALITY.—In conducting the demonstration program under this section,
the Secretary shall ensure that the aggregate payments made by the Secretary do not exceed
the amount which the Secretary estimates would have been paid if the demonstration program
under this section was not implemented.
(f) WAIVER AUTHORITY.—The Secretary may waive such requirements of titles XI and
XVIII of the Social Security Act (42 U.S.C. 1301 et seq.; 1395 et seq.) as may be necessary for
the purpose of carrying out the demonstration program under this section.
(g) REPORT.—Not later than 12 months after the date of completion of the demonstration
program under this section, the Secretary shall submit to Congress a report on such program,
together with recommendations for such legislation and administrative action as the Secretary
determines to be appropriate.
(h) DEFINITIONS.—In this section:
(1) ELIGIBLE BENEFICIARY.—The term ‘‘eligible beneficiary’’ means any individual
who—
(A) is entitled to benefits under part A and enrolled for benefits under part B of title
XVIII of the Social Security Act and is not enrolled in a plan under part C of such title;
and
(B) has one or more chronic medical conditions specified by the Secretary (one of which
may be cognitive impairment).
(2) HEALTH INFORMATION TECHNOLOGY.—The term ‘‘health information
technology’’ means email communication, clinical alerts and reminders, and other
information technology that meets such functionality, interoperability, and other standards as
prescribed by the Secretary.

A.5

APPENDIX B
FEDERAL REGISTER NOTICE

B.1

The Federal Register Notice will be submitted by CMS.

B.3

APPENDIX C
MEDICARE CARE MANAGEMENT PERFORMANCE (MCMP) DEMONSTRATION
ADVANCE LETTER—MEDICARE BENEFICIARIES

C.1

CMS LETTERHEAD
ADVANCE LETTER—MEDICARE BENEFICIARIES

[DATE]
[NAME AND ADDRESS]
Dear Mr./Ms. [FILL LAST NAME]:
The Centers for Medicare & Medicaid Services (CMS) is sponsoring a study called the
Medicare Care Management Performance (MCMP) Demonstration. The purpose of the study is to
learn about the quality of care Medicare beneficiaries with chronic illnesses receive and their health
outcomes. Your name was selected for the study because Medicare records indicate that you have
been treated for one of the chronic conditions that we are studying.
Mathematica Policy Research, Inc. (MPR), an independent research company, is conducting the
study for CMS. As part of this important study, MPR will survey Medicare beneficiaries in different
parts of the United States. This letter is to invite you to take part in this study.
Please help us by completing the enclosed questionnaire and returning it in the postage-paid
envelope provided. Your participation is voluntary but we strongly encourage you to answer the
questions in the survey because your experiences will help Medicare design and improve health care
programs for persons who have health conditions similar to yours. The answers you provide will be
kept strictly confidential and will be used only as part of this evaluation. The questionnaire should
only take about 15 minutes to complete.
If you have any questions, or if you would prefer to complete the survey by phone, please call
MPR toll-free at 1-XXX-XXX-XXXX and ask for Melanie Costas. A fact sheet providing
additional information about the study is enclosed for your information. You can also visit the CMS
website at http://www.cms.hhs.gov/DemoProjectsEvalRpts/downloads/MMA649_Summary.pdf for
more information.
We look forward to including your valuable experience as a Medicare beneficiary in this study.
Sincerely,
CMS Privacy Officer
Enclosure
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless
it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-XXXX.
The time required to complete this information collection is estimated to average 15 minutes per response, including the time
to review instructions, search existing data resources, gather the data needed, and complete and review the information
collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form,
please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore,
Maryland 21244-1850.

C.3

APPENDIX D
MEDICARE CARE MANAGEMENT PERFORMANCE (MCMP) DEMONSTRATION
FACT SHEET FOR BENEFICIARIES

D.1

MEDICARE CARE MANAGEMENT PERFORMANCE (MCMP)
DEMONSTRATION FACT SHEET
WHAT IS THE MEDICARE CARE MANAGEMENT PERFORMANCE (MCMP)
DEMONSTRATION?
The Medicare Care Management Performance Demonstration is a special study being sponsored by the
Centers for Medicare & Medicaid Services (CMS). The study will look at the quality of care received by
Medicare beneficiaries and their experiences receiving treatment for their health problems such as chronic
artery disease (CAD), congestive heart failure (CHF), and diabetes.
WHAT IS CMS?
CMS is the Centers for Medicare & Medicaid Services. CMS is the federal agency in charge of the Medicare
and Medicaid programs.
WHO IS CONDUCTING THE STUDY?
Mathematica Policy Research, Inc. (MPR) is an independent research company that was hired by CMS to
conduct the MCMP study. MPR is a leader in the policy research and analysis field and has been conducting
surveys and evaluations for over 40 years. You can learn more about MPR by visiting its website at
www.mathematica-mpr.com.
HAS THIS RESEARCH STUDY BEEN APPROVED BY THE GOVERNMENT?
Yes, the MCMP Demonstration has been approved by the Office of Management and Budget (OMB). The
OMB approval number is xxxx-xxx. The approval expires on DATE.
WILL MY PARTICIPATION IN THE STUDY AFFECT MY MEDICARE BENEFITS?
No. Participating in the study will not affect your Medicare benefits now or at any time in the future.
WHAT HAPPENS IF I DO NOT PARTICIPATE IN THE SURVEY?
Your participation is voluntary, but it is also important. Learning about your experience as a Medicare
participant will help CMS improve the services provided by the Medicare program.
WILL MY INFORMATION BE KEPT CONFIDENTIAL?
Yes. All of the information we collect in the survey will be kept confidential as provided in the Privacy Act.
The information will be used for research purposes only. Your name will never be used in any reports.
HOW LONG WILL IT TAKE TO COMPLETE THE SURVEY?
In a pretest, most people took between 10 and 15 minutes to complete the survey.
HOW DID YOU GET MY NAME?
Your name was selected from among Medicare beneficiaries in your area.
WHO CAN I CONTACT FOR MORE INFORMATION?
For more information about the survey, please call MPR toll-free at 1-XXX-XXXX and ask for Melanie
Costas. You can also visit the CMS website at
http://www.cms.hhs.gov/DemoProjectsEvalRpts/downloads/MMA649_Summary.pdf for more
information.

D.3

APPENDIX E
MEDICARE CARE MANAGEMENT PERFORMANCE (MCMP) DEMONSTRATION
BENEFICIARY SURVEY

E.1

OMB Approval No.: xxxx-xxxx
Expiration Date: xx/xx/xxxx

Medicare Care
Management Performance (MCMP) Demonstration
Beneficiary Survey
Draft

ABOUT THIS SURVEY
The questions in this survey are about you, your health, and how you use health care
services.
Most of the questions can be answered by simply checking a box. A few ask you to
write in your answer.
All of your answers will be treated confidentially. Your responses will not change your
Medicare coverage, other health benefits, or any premiums you pay.
If you do not know an answer, please write “DK” next to the question.
If you have questions about this survey or your participation in it, please call Julita
Milliner-Waddell, the survey director, at 609-275-2206.
If you have difficulty answering the questions or would prefer to answer by telephone,
please call 1-xxx-xxx-xxxx toll free and ask for Melanie Costas.
When you are finished, please return the questionnaire in the enclosed postage-paid
envelope.
Thank you for your time and cooperation.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it
displays a valid OMB control number. The valid OMB control number for this information collection is 0938-XXXX. The
time required to complete this information collection is estimated to average 15 minutes per response, including the time to
review instructions, search existing data resources, gather the data needed, and complete and review the information
collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form,
please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore,
Maryland 21244-1850.
E-3

A. HEALTH STATUS
A1. In general, would you say your health is excellent, very good, good, fair, or poor?
MARK ONE ANSWER ONLY
1
2
3
4
5

Excellent
Very good
Good
Fair
Poor

A2. The next questions are about chronic health conditions you may have. Please mark
“Yes” if a doctor has ever told you that you had any of the conditions listed below.
MARK ONE ANSWER
PER ROW

Yes

a. Congestive heart failure (CHF) ......................................................................

b. Coronary artery disease (CAD) .....................................................................

c. Other heart problems such as arteriosclerosis, myocardial infarction,
heart attack, angina, or angina pectoris.......................................................

d. Diabetes or Diabetes mellitus........................................................................

e. A stroke ...........................................................................................................

f. Partial or complete paralysis.........................................................................

g. Alzheimer’s disease or dementia ..................................................................

h. A mental or psychiatric disorder other than Alzheimer’s disease or
dementia ..........................................................................................................

Any kind of cancer, malignancy, or non-benign tumor ..............................

Arthritis, including rheumatoid arthritis.......................................................

k. Osteoporosis...................................................................................................

Kidney disease................................................................................................

m. Lung conditions or breathing problems such as emphysema, asthma,
or chronic obstructive pulmonary disease (COPD) ....................................

n. Parkinson’s disease .......................................................................................

o. Other (Please list any other chronic conditions that a doctor has said
you have. (A chronic condition is any condition that lasts for 3 months
or more and has no known cure.) .................................................................

Prepared by Mathematica Policy Research, Inc.

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No
0
0

0
0
0
0
0

A3. How would you rate your knowledge about your chronic health conditions and the factors
that may affect these conditions in the future?
MARK ONE ANSWER ONLY
1
2
3
4
5

Excellent
Very good
Good
Fair
Poor

A4. How would you rate your knowledge about what to do if problems or symptoms
associated with your health conditions get worse?
MARK ONE ANSWER ONLY
1
2
3
4
5

Excellent
Very good
Good
Fair
Poor
B. ACCESS TO CARE

B1. Do you have a doctor whom you see or a place you go regularly to receive medical care?
1
0

Yes
No

B2. A primary care physician is a doctor who provides regular basic care. A primary care
physician can be a family or general practitioner, internist, or any specialist that provides
regular basic care.
Do you have a primary care physician? Please include specialists if you see them for
regular basic care.
1
0

Yes
No

GO TO QUESTION B6

B3. What is your primary care physician’s name?
___________________________________________________________

Prepared by Mathematica Policy Research, Inc.

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B4. What is the name of the office or practice where you usually see your primary care
physician?
___________________________________________________________

B5. How long have you been going to this primary care physician?
MARK ONE ANSWER ONLY
1
2
3
4

Less than 1 year
Between 1 and 3 years
Between 3 and 5 years
More than 5 years

GO TO QUESTION B11
B6. Is there one particular clinic, health center, doctor’s office, or other place that you usually
go to if you are sick or need advice about your health?
1
0

Yes
No

GO TO QUESTION B11

B7. Please indicate the kind of place you usually go to if you are sick or need advice about
your health.
MARK ONE ANSWER ONLY
1

Doctor’s office or HMO

Clinic or health center

Hospital outpatient department

Hospital emergency room

Urgent care center

Other type of place (Please describe)
_____________________________________________________

B8. Is there one particular doctor or health care professional, such as a nurse or physician’s
assistant, that you usually see at this place?
1
0

Yes
No

GO TO QUESTION B11

Prepared by Mathematica Policy Research, Inc.

E- 6

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B9. What is the name of the doctor or other health care professional that you usually see at
this place?
___________________________________________________________

B10. What is the name of the office or facility where you usually see this doctor or health care
professional?
___________________________________________________________

B11. The next questions are about health care you may have received during the past 12
months. During the past 12 months, how many times did you visit a physician or clinic?
MARK ONE ANSWER ONLY
0

Never

1 to 2 times

3 to 5 times

6 to 10 times

More than 10 times

B12. During the past 12 months, how many times did you go to an emergency room or urgent
care center for medical attention?
MARK ONE ANSWER ONLY
0

Never

1 to 2 times

3 to 5 times

6 to 10 times

More than 10 times

Prepared by Mathematica Policy Research, Inc.

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C. HEALTH CARE PROCESSES
For these next questions please think about the last time you saw your doctor or other health
care professional, such as a nurse or physician’s assistant.
C1. Please mark “Yes” if a doctor or other health care professional did any of the following
things during your last visit.
MARK ONE ANSWER
PER ROW

Yes

a. Measure your blood pressure....................................................................

b. Measure your height ...................................................................................

c. Measure your weight ..................................................................................

d. Ask if you have ever had a pneumonia vaccination ................................

e. Examine your heart and lungs with a stethoscope .................................

f. Examine your feet with a monofilament. This is a tool that looks like
a piece of nylon line that is pressed against the skin. ............................

g. Work with you to set goals for avoiding illness and staying healthy ....

h. Provide materials such as booklets, pamphlets, articles, or
videotapes to help you understand your health or chronic condition
or recommended treatments......................................................................

i.
j.

Explain what to expect with your health or illness in the future ............
Explain what to do if problems or symptoms continued, got worse, or
came back....................................................................................................

No
0
0
0
0
0

0
0

C2. During the past 12 months, has your doctor or other health care professional, such as a
nurse or physician’s assistant, advised you to do any of the following things?
If a question does not apply to you, please mark “No”.
MARK ONE ANSWER
PER ROW

Yes

a. Increase your physical activity or exercise...............................................
If “YES”, did you increase your physical activity or exercise? ..........
b. Quit smoking ................................................................................................
If “YES”, did you quit smoking? ............................................................
c. Cut down on or quit drinking ......................................................................
If “YES”, did you cut down on or quit drinking? ..................................
d. Cut down on salt in your diet......................................................................
If “YES”, did you cut down on salt in your diet?..................................
e. Eat fewer high fat or high cholesterol foods .............................................
If “YES”, did you eat fewer high fat or high cholesterol foods?.........

Prepared by Mathematica Policy Research, Inc.

E- 8

1
1
1
1
1
1
1
1
1
1

(2/14/08)

No
0
0
0
0
0
0
0
0
0
0

C3. During the past 5 years, have you had a test for colon cancer such as a stool blood test,
sigmoidoscopy, or colonoscopy?
A stool blood test is done to detect hidden blood in the stool. A sigmoidoscopy is an internal
exam of the lower portion of the colon using an instrument with a small camera attached to a
flexible tube. A colonoscopy is an internal exam of the entire colon using an instrument with a
small camera attached to a flexible tube. All three tests are used to view the colon for signs of
cancer and other health problems.
1
0

Yes
No

C4. During the past two years, did you receive a flu vaccination?
1
0

Yes
No

Please answer question C5 only if you have been diagnosed with diabetes.
C5. During the past 12 months, on average, how often have you examined your feet?
MARK ONE ANSWER ONLY
1
2
3
4
5
6

Daily
5 or 6 days a week
3 or 4 days a week
1 or 2 days a week
Less than once a week
Never

Please answer question C6 only if you have been diagnosed with congestive heart failure
(CHF).
C6. During the past 12 months, on average, how often have you weighed yourself?
MARK ONE ANSWER ONLY
1
2
3
4
5
6

Daily
5 or 6 days a week
3 or 4 days a week
1 or 2 days a week
Less than once a week
Never

Prepared by Mathematica Policy Research, Inc.

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D. CARE COORDINATION

D1. These next questions are about how your doctors share information about your care.
During the past 12 months, was there ever a time when you thought your doctors did not
talk to each other enough about your care?
MARK ONE ANSWER ONLY
1

Yes

One doctor only

D2. If you were referred to a specialist during the past 12 months, did the specialist have the
information he or she needed from your medical records?
MARK ONE ANSWER ONLY
1

Yes

Not referred to a specialist

D3. During the past 12 months, has your doctor ever been unaware of results of tests or
diagnostic procedures that another doctor had ordered?
MARK ONE ANSWER ONLY
1

Yes

No test results or procedures

Prepared by Mathematica Policy Research, Inc.

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E. SATISFACTION WITH CARE
E1. Thinking about the past 12 months, please indicate how satisfied you were with the
following aspects of the care you received from your doctor or other health care
professional, such as a nurse or physician’s assistant?
MARK ONE ANSWER PER ROW

Very
Satisfied

a. The amount of time your doctor or other
health care professional spends with you
during office visits?...................................
b. The attention that your doctor or other
health care professional gives you
during office visits (for example, not
getting easily distracted by telephone
calls or other patient needs)?...................
c. How well your doctor or other health
care professional explained what to
expect with your health or illness in the
future?.........................................................
d. The ability to talk to your doctor or other
health care professional as soon as you
need to, to get medical advice or help? ..
e. The ability to get an appointment as
soon as you want?.....................................
f. Your doctor’s or other health care
professional’s knowledge about your
health problems? .......................................
g. Reminders you may receive from your
doctor or other health care professional
to make or keep appointments for
medical care? .............................................
h. Advice you may receive from your doctor
or other health care professional about
ways to avoid illness or stay healthy? ....
i. Your doctor’s or other health care
professional’s involvement in your
overall care?...............................................
j. Your doctor’s or other health care
professional’s communication with other
doctors or health care professionals
about your medical care? .........................
k. Overall quality of health care and
services? ..................................................

Prepared by Mathematica Policy Research, Inc.

E- 11

Somewhat
Satisfied

Somewhat
Dissatisfied

Very
Dissatisfied

(2/14/08)

F. BACKGROUND INFORMATION

F1. What is the highest grade or year of school you have completed?
MARK ONE ANSWER ONLY
1

Did not complete high school or GED

High school: diploma

High school: GED

Some college or some vocational courses after high school

A vocational school diploma

2-year or 3-year college degree (Associate’s Degree)

4-year college degree (Bachelor’s Degree)

Some graduate work but no graduate degree

Graduate or professional degree (e.g., MA, MBA, Ph.D., JD, MD)

Other type of degree (Please specify)
_____________________________________________________

F2. Is English your primary spoken language?
1
0

Yes
No

GO TO QUESTION F4

F3. What is your primary spoken language?
___________________________________________________________

F4. What is your current marital status?
MARK ONE ANSWER ONLY
1

Married

Single and living with partner

Separated

Divorced

Widowed

Never married

Prepared by Mathematica Policy Research, Inc.

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F5. Please indicate which of the following best describes your household’s composition.
MARK ONE ANSWER ONLY
1

Live alone

Live with a spouse only

Live with a spouse and other relatives

Live with other relatives

Live with non-relatives

Live in some other living arrangement (Please describe)

GO TO QUESTION F7

_____________________________________________________

F6. How many people live in your household including yourself?
|

| PEOPLE IN HOUSEHOLD

F7. Please indicate whether you own your home, rent your home, or live in one of the other
housing arrangements listed below.
MARK ONE ANSWER ONLY
1

Own your home

Rent your home

Live with family or friends and pay part of the rent or mortgage

Live with family or friends and not pay rent or a mortgage

Live in a group shelter

Live in an assisted living facility

Live in some other housing arrangement (Please describe)
_____________________________________________________

Prepared by Mathematica Policy Research, Inc.

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F8. Which of the following best describes your current employment status?
MARK ONE ANSWER ONLY
1

Working full-time

Working part-time

Not working, but not retired

Retired

F9. Counting everyone in your household, what was your total household income in 2007?
Please include wages, benefits, earnings, and all other sources of income.
MARK ONE ANSWER ONLY
1

Less than $10,000

$10,000 or more, but less than $20,000

$20,000 or more but less than $30,000

$30,000 or more but less than $40,000

$40,000 or more but less than $50,000

$50,000 or more but less than $75,000

$75,000 or more but less than $100,000

More than $100,000

Thank you for taking the time to complete this questionnaire. Please mail your completed
survey in the pre-paid envelope provided. If you have misplaced your envelope, please mail it
to:
Julita Milliner-Waddell, Survey Director
Medicare Care Management Performance (MCMP) Demonstration
Mathematica Policy Research, Inc.
600 Alexander Park
Princeton, NJ 08543

Prepared by Mathematica Policy Research, Inc.

E- 14

(2/14/08)

APPENDIX F
MEDICARE CARE MANAGEMENT PERFORMANCE (MCMP) DEMONSTRATION
PHYSICIAN SURVEY—DEMONSTRATION PHYSICIANS

OMB Approval No.: xxxx-xxxx
Expiration Date: xx/xx/xxxx

Medicare Care
Management Performance (MCMP) Demonstration
Physician Survey
Demonstration Physicians
Draft

ABOUT THIS SURVEY
This survey is being conducted by Mathematica Policy Research, Inc. (MPR) on behalf of the Centers for
Medicare & Medicaid Services (CMS) as part of the Medicare Care Management Performance (MCMP)
Demonstration project.
These questions are about your use of electronic medical records (EMRs) and the primary care services you
provide to Medicare patients with chronic illnesses.
Most of the questions can be answered by simply marking a box. A few ask you to write in your answer. If you
do not know an answer, please write “DK” next to the question.
We estimate that it will take about 10 minutes to complete the questionnaire.
All of your answers will be treated confidentially. Your responses will not affect your Medicare compensation.
If you have questions about this survey or your participation in it, please call Julita Milliner-Waddell, MPR’s
survey director, at 1-609-275-2206.
If you would prefer to complete the survey by telephone, please call 1-xxx-xxx-xxx toll free and ask for Melanie
Costas.
When you have completed the questionnaire, please return it in the enclosed, postage-paid envelope.
Thank you for your time and participation.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information collection is 0938-XXXX. The time required to complete this information collection is
estimated to average 10 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete
and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please
write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Prepared by Mathematica Policy Research, Inc.

F-3

(2/18/08)

A. Use of Electronic Medical Records

The first questions are about your use of health information technology. If you work out of multiple locations,
please answer these questions for your primary ambulatory care location.
A1.

Electronic Medical Records (EMRs) are clinical information systems for tracking patient health information.
EMRs allow you to document office visits, transmit prescription and laboratory test orders electronically,
and perform other functions.
Does your practice currently have an EMR system? Please include both full and partial EMR systems.

A2.

Yes

How long ago did your practice acquire an EMR system?
YEARS |

A3.

A4.

GO TO B1

| MONTHS |

Do you use the EMR system to record and manage the care for any or all of your patients?
1

Yes

GO TO A5

When did you start using your practice’s EMR system?
| | | |
MONTH

| | |
YEAR

Prepared by Mathematica Policy Research, Inc.

F-4

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A5.

The following is a list of functions that may be available on your EMR system. Please indicate how often
you use each of the functions or whether you plan to use the function within the next 12 months. If the
function is not available on your system, please mark the last box in the row.
MARK ONE ANSWER PER ROW

How often do you use your EMR system to
perform the following functions?

Routinely

Occasionally

Not at All But
Plan To

Not at All and
NO Plans To

Function Not
Available

a. Document office visits and patient medical
history?.............................................................

b. Document patient medications? .......................

Document communication with other health
care providers, such as referrals to specialists
or responses from pharmacists? ......................

d. Enter orders for prescriptions? .........................

e. Enter orders for laboratory, radiology, or
diagnostic tests?...............................................

Review test results? .........................................

g. Issue alerts for possible drug interactions? ......

h. Issue reminders to schedule preventive
services? ..........................................................

Issue reminders to patients? ............................

Generate reports (for example, to identify
patients overdue for services)? ........................

A6.

How satisfied are you with the training you received on proper use of your EMR system?
MARK ONE ANSWER

A7.

Very satisfied

Somewhat satisfied

Somewhat dissatisfied

Very dissatisfied

No training received

How satisfied are you with your EMR system’s ability to meet your needs?
MARK ONE ANSWER
1

Very satisfied

Somewhat satisfied

Somewhat dissatisfied

Very dissatisfied

Not applicable, have not used the system

Prepared by Mathematica Policy Research, Inc.

F-5

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B. Barriers to Adoption and Use of EMRs

B1.

In the past 12 months, to what extent have the following factors
been a barrier to adopting or expanding the use of EMRs in your
practice?

MARK ONE ANSWER PER ROW

Not a
Barrier

Minor
Barrier

Major
Barrier

a. Start-up costs ............................................................................................

b. Maintenance costs ....................................................................................

Lack of time to acquire or set up the system .............................................

d. Lack of computer skills among clinical or other staff .................................

e. Skepticism about effectiveness or usefulness of EMRs ............................

Reluctance to change processes already working well .............................

g. Lack of training or technical support..........................................................

h. Patient privacy concerns ...........................................................................

The amount of time necessary to use the system .....................................

The time and ability to incorporate old records into the new system.........

Lack of a leader who has both clinical and technical knowledge to
spearhead the project of adopting an EMR system...................................

Gathering consensus among physicians...................................................

m. Poor return on investment .........................................................................

n. Opposition to this style of practicing medicine ..........................................

o. Limited or no interoperability—that is, other providers with whom you
communicate do not have EMR systems ..................................................

B2.

During the past 12 months, have you been involved in efforts to assess your practice’s technology needs?
1

Yes

Prepared by Mathematica Policy Research, Inc.

F-6

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C. Caring for Medicare Patients with Chronic Illnesses

To answer the questions in this section, please think about experiences you have had in the past 12 months
while caring for Medicare patients who have chronic illnesses including congestive heart failure, coronary
artery disease, diabetes, and other chronic conditions.
C1.

How do you currently issue reminders to Medicare patients about routine preventive care?
MARK ONE ANSWER

C2.

Reminders are issued using a computerized system

Reminders are issued using a manual system

Reminders are not currently issued; plan to implement in the next year

Reminders are not currently issued; no plan to implement in the next year

Compared to previous years, did you have more, fewer, or about the same number of office visits with each
Medicare patient on average during the past 12 months?
MARK ONE ANSWER

C3.

More visits

Fewer visits

About the same number of visits

Compared to previous years, has the average number of telephone conversations with your Medicare
patients changed during the past 12 months?
MARK ONE ANSWER

C4.

More telephone conversations now

Fewer telephone conversations now

No change; about the same number of telephone conversations

Compared to previous years, has the average number of email exchanges with your Medicare patients
changed during the past 12 months?
MARK ONE ANSWER
1

More email exchanges now

Fewer email exchanges now

No change, about the same number of email exchanges

Do not exchange email with patients

Prepared by Mathematica Policy Research, Inc.

F-7

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C5. In the past 12 months, how often have you encountered
the following situations involving your Medicare patients
with chronic illnesses who see other providers?

MARK ONE ANSWER PER ROW

More Than
10 Times

5 to 9
Times

1 to 4
Times

Never

a. Patients received the wrong drug, wrong dosage, or had a
drug-drug interaction ..................................................................

b. Patients underwent unnecessary or duplicate tests ...................

d. Other providers did not give you timely feedback after referrals

e. You did not receive timely information after a hospitalization.....

Other providers did not notify you of new or modified
prescriptions ...............................................................................

You did not have ready access to patient information during
office visits or other encounters..................................................

C6. Still thinking about your Medicare patients with chronic
illnesses, how satisfied are you with the following
aspects of their care?

MARK ONE ANSWER PER ROW
Very
Satisfied

Somewhat
Satisfied

Somewhat
Dissatisfied

Very
Dissatisfied

a. The overall quality of care they receive? .....................................

b. Their receipt of recommended preventive services? ...................

c. How well their care is coordinated across providers?..................

d. Your knowledge of their conditions and recommended
preventive care? ..........................................................................

e. Patients’ knowledge of their conditions and recommended
self-care?.....................................................................................

f. Patients’ adherence to recommended self-care? ........................

g. The amount of time you spend with patients in an average
office visit?...................................................................................

h. Your Medicare reimbursement? ..................................................

C7. Compared to a year ago, how often do you do each of the
following.

MARK ONE ANSWER PER ROW

More Often

Less Often

About the
Same

Don’t Do
At All

a. Produce data or reports on the number or percentage of your
Medicare patients who are receiving guideline-recommended
services? ....................................................................................

b. Identify your Medicare patients who have not received
guideline-recommended services and encourage them to get
the services? ..............................................................................

Have ready access to information about Medicare patients’
medical history, health conditions, and care plan during office
visits and other encounters? ......................................................

d. Review patient charts prior to office visits to flag any conditions
or topics needing attention? .......................................................

Prepared by Mathematica Policy Research, Inc.

F-8

(2/18/08)

D. Experiences with the MCMP Demonstration

D1.

Thinking about your participation in the MCMP demonstration during the past 12 months, please indicate
whether you agree or disagree with the following statements about the MCMP demonstration.
MARK ONE ANSWER PER ROW

Strongly
Agree

Agree

Disagree

Strongly
Disagree

a. The MCMP Demonstration targets important medical
conditions? .................................................................................

b. The MCMP Demonstration uses well-accepted, appropriate
measures of care quality? ..........................................................

The MCMP Demonstration encourages adoption and use of
EMRs? .......................................................................................

d. The MCMP Demonstration required a reasonable level of effort
to begin reporting quality data? ..................................................

e. The MCMP Demonstration requires a reasonable level of effort
to report annual quality data?.....................................................

The MCMP Demonstration has easy-to-understand rules for
rewarding quality care? ..............................................................

g. The MCMP Demonstration provides sufficient financial
rewards? ....................................................................................

D2.

During the past 12 months, how did MCMP affect the amount of time you spent educating Medicare
patients with chronic illnesses about taking care of themselves?
MARK ONE ANSWER

D3.

Increased the amount of time

Decreased the amount of time

No change

During the past 12 months, how did MCMP affect the amount of time you spent communicating with other
health care providers about your Medicare patients with chronic illnesses?
MARK ONE ANSWER
1

Increased the amount of time

Decreased the amount of time

No change

Prepared by Mathematica Policy Research, Inc.

F-9

(2/18/08)

D4. Please indicate how the following aspects of patient care have changed under MCMP.
MARK ONE ANSWER PER ROW
Made Better

Made Worse

No Change

a. The quality of your relationships with patients..............................

b. The overall health of your patients. ..............................................

Your patients’ satisfaction with their health care. .........................

d. Your adherence to recommended clinical practice guidelines or
evidence-based medicine.............................................................

e. Your clinical decision making. ......................................................

D5.

If your clinical decision making has been affected by your participation in the MCMP demonstration, please
explain below.

D6.

During the past six months, how has participation in the MCMP demonstration affected the number of
office visits made by your chronically ill Medicare patients?
MARK ONE ANSWER

D7.

Visits have increased

Visits have decreased

No change

GO TO D8

Was this increase or decrease in office visits medically appropriate?
1

Yes

Prepared by Mathematica Policy Research, Inc.

F - 10

(2/18/08)

D8.

Which of the following staff from your practice
attended the kick-off meetings for MCMP in May
or June 2007?

D11. Please list the names of other pay-forperformance programs with which you have
experience.

MARK ALL THAT APPLY

D9.

Physicians

Physician Assistants

Nurse Practitioners

Registered Nurses

Administrators

Business Managers

Office Managers

Other (Please specify)

No one attended

_________________________________________

Yes

No experience with other pay-for-performance
programs
GO TO E1

D12. How does MCMP compare to the other programs
with which you have experience?

Did you or anyone from your office participate in
training calls hosted by CMS or the QIO
(Lumetra, Health Insight, Masspro or Arkansas
Foundation for Medical Care)?
1

Better

Worse

Neither better nor worse

Please explain why:

D10. Would you recommend the MCMP demonstration
to your colleagues?
1

Yes

Prepared by Mathematica Policy Research, Inc.

F - 11

(2/18/08)

E. Demographic and Socioeconomic Characteristics

E1.

E5.

In an average week, about how many different
Medicare patients do you see who have chronic
illnesses?
|

| NUMBER OF MEDICARE PATIENTS

Are you Board Certified?
1

Yes

WITH CHRONIC ILLNESSES

E6.
E2.

Are you able to speak with patients in a language
other than English if the patient prefers?
1

Yes

E3.

E4.

Yes

Which of the following categories best describes
your race?
MARK ALL THAT APPLY

In what year did you begin medical practice?
|

(Please specify the languages
you speak)

E7.
0

Are you of Hispanic or Latino origin?

| YEAR

Are you male or female?
1

Male

Female

White

Black or African-American

Asian

American Indian or Alaskan Native

Other (Please specify)

Thank you for taking the time to complete this questionnaire. Please mail your completed questionnaire in the
pre-paid envelope provided. If you have misplaced your envelope, please mail it to:
Julita Milliner-Waddell, Survey Director
Medicare Care Management Performance
(MCMP) Demonstration
Mathematica Policy Research, Inc.
600 Alexander Park
Princeton, NJ 08543

Prepared by Mathematica Policy Research, Inc.

F - 12

(2/18/08)

APPENDIX G
MEDICARE CARE MANAGEMENT PERFORMANCE (MCMP) DEMONSTRATION
PHYSICIAN SURVEY—COMPARISON PHYSICIANS

OMB Approval No.: xxxx-xxxx
Expiration Date: xx/xx/xxxx

Medicare Care
Management Performance (MCMP) Demonstration
Physician Survey
Comparison Physicians
Draft

Prepared by Mathematica Policy Research, Inc.

G-3

(2/18/08)

A. Use of Electronic Medical Records

The first questions are about your use of health information technology. If you work out of multiple locations,
please answer these questions for your primary ambulatory care location.
A1.

A2.

Yes

How long ago did your practice acquire an EMR system?
YEARS |

A3.

A4.

GO TO B1

| MONTHS |

Do you use the EMR system to record and manage the care for any or all of your patients?
1

Yes

GO TO A5

When did you start using your practice’s EMR system?
| | | |
MONTH

| | |
YEAR

Prepared by Mathematica Policy Research, Inc.

G-4

(2/18/08)

A5.

How often do you use your EMR system to
perform the following functions?

Routinely

Occasionally

Not at All But
Plan To

Not at All and
NO Plans To

Function Not
Available

a. Document office visits and patient medical
history?.............................................................

b. Document patient medications? .......................

Document communication with other health
care providers, such as referrals to specialists
or responses from pharmacists? ......................

d. Enter orders for prescriptions? .........................

e. Enter orders for laboratory, radiology, or
diagnostic tests?...............................................

Review test results? .........................................

g. Issue alerts for possible drug interactions? ......

h. Issue reminders to schedule preventive
services? ..........................................................

Issue reminders to patients? ............................

Generate reports (for example, to identify
patients overdue for services)? ........................

A6.

How satisfied are you with the training you received on proper use of your EMR system?
MARK ONE ANSWER

A7.

Very satisfied

Somewhat satisfied

Somewhat dissatisfied

Very dissatisfied

No training received

How satisfied are you with your EMR system’s ability to meet your needs?
MARK ONE ANSWER
1

Very satisfied

Somewhat satisfied

Somewhat dissatisfied

Very dissatisfied

Not applicable, have not used the system

Prepared by Mathematica Policy Research, Inc.

G-5