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November 2010
Evaluation of the Physician Hospital Collaboration Demonstration
Physician Focus Groups
Office of Management and Budget (OMB) Clearance Package and Data Collection Instrument
Prepared for
William Buczko, PhD
Centers for Medicare & Medicaid Services
Office of Research, Development, and Information
Central Bldg. C3-20-14 / Mail Stop C3-19-26
7500 Security Boulevard
Baltimore, MD 21244-1850
Prepared by
Leslie M. Greenwald, PhD
RTI International
3040 Cornwallis Road
Research Triangle Park, NC 27709
Supporting Statement Evaluation of the Medicare Physician Hospital Collaboration Demonstration
by Leslie Greenwald, PhD, Project Director
Federal Project Officer: William Buczko, PhD
RTI International
November 2010
This project was funded by the Centers for Medicare & Medicaid Services under contract no. HHSM500-2005-00029I. The statements contained in this report are solely those of the authors and do not necessarily reflect the views or policies of the Centers for Medicare & Medicaid Services. RTI assumes responsibility for the accuracy and completeness of the information contained in this report.
A. BACKGROUND
The proposed physician focus groups are part of an overall evaluation of the Centers for Medicare and Medicaid Services (CMS)’s Medicare Physician Hospital Collaboration (PHC) Demonstration. The Congress, under Section 646 of the Medicare Modernization Act (MMA) of 2003 permitted CMS to conduct demonstrations to test methods for the provision of incentives for improving the quality and safety of care and achieving the efficient allocation of resources. Similar to the Medicare Gainsharing Demonstration (authorized under Section 5007 of the Deficit Reduction Act (DRA) in 2005), the primary goal of the PHC Demonstration is to evaluate gainsharing as means to align physician and hospital incentives to improve quality and efficiency. The methodology used by both demonstrations are essentially the same. The only difference between the two demonstrations is that the episode length for PHC is longer (90 days post discharge) than the DRA Gainsharing episode length. We are requesting OMB to extend their approval of the physician focus group protocols (OBN 0938-1138) to allow CMS to use these approved protocols for the physician focus groups planned for the evaluation of the MMA 646 Physician-Hospital Collaboration Demonstration.
At time of implementation in July 2009, the New Jersey Care Integration Consortium (NJCIC), represented by 12 participating hospitals, comprised the demonstration:
– Hunterdon Medical Center
– Holy Name Hospital
– Valley Hospital
– St Francis Medical Center
– Our Lady of Lourdes Medical Center
– Somerset Medical Center
– Overlook Hospital
– Atlanticare Regional Medical Center
– Jersey Shore University Medical Center
– Monmouth Medical Center
– JFK Medical Center
– Centrastate Medical Center
An evaluation of the PHC Demonstration is required by Congress under the demonstration’s enabling legislation. The evaluation will address a range of research questions. Those key research questions are the following:
What is the impact of the gainsharing model on hospital efficiency?
What is the impact of the gainsharing model on physician practice patterns?
What is the impact of the gainsharing model on Medicare expenditures?
What is the impact of the gainsharing model on quality of care?
What is the impact of the gainsharing model on beneficiary satisfaction?
The evaluation will analyze the impacts of gainsharing on Medicare expenditures using claims data, and will consider many elements of hospital efficiency, physician practice pattern, quality of care and beneficiary satisfaction using claims and other administrative data. However, since physicians are the primary drivers of care, we need to speak with demonstration participating and non-participating physicians to gather their assessment and feedback on how the demonstration impacts overall hospital efficiency, physician practice patterns, and quality of care. It is particularly critical to discuss the impacts of gainsharing on beneficiary satisfaction with the physicians who treat and interact with patients since there are few other available sources of information on this subject available to the evaluation team. OMB reviewed and approved the same basic methodology and approach for the Medicare Gainsharing Demonstration physician focus groups in August 2010 and issued an approval under OMB Control Number 0938-1103.
A.1 Need and Legal Basis
The Congress, under Section 646 of the Medicare Modernization Act (MMA) of 2003 permitted CMS to conduct demonstrations to test methods for the provision of incentives for improving the quality and safety of care and achieving the efficient allocation of resources. The focus group data collected will be used to supplement quantitative analyses for this evaluation. We are requesting OMB to extend their approval of the physician focus group protocols (OBN 0938-1138) to allow CMS to use these approved protocols for the physician focus groups planned for the evaluation of the MMA 646 Physician-Hospital Collaboration Demonstration.
The evaluation requires CMS to consider a number of issues including the impacts of the PHC Demonstration on Medicare program quality of care and costs. The primary analyses for the planned evaluation reports will be based on analyses using Medicare claims and other site-supplied quality and cost information. However, the demonstration evaluation also needs to supplement these analyses with contextual information that describes how actual providers viewed the operation of the demonstration and its impacts on costs and quality. Since Medicare demonstrations and other projects that deviate from the normal statutory Medicare regulations are undertaken on a voluntary basis by participating providers, and therefore can be operated only with this voluntary participation of physicians, understanding what worked and what could be improved operationally is critical to CMS and Congress in determining whether the PHC Demonstration model should be expanded under Medicare, and if so, with what modifications.
Particular areas of administrative and operational feasibility to be discussed during the physician focus groups include comments on the processes by which physician incentive payments were determined and made. A critical element of the gainsharing model assumes that these incentive payments will change physician behavior towards more efficient models of care. These behavioral changes can be examined to some extent by detecting shifts in utilization patterns in the demonstration versus control sites. That said, the interpretation of these quantitative analysis will be greatly enhanced by the contextual information offered by physicians during the focus groups discussion. The physician focus groups will therefore be used to interpret and gather contextual information on how the underlying systems of the gainsharing models operated and the results will be included in the administrative feasibility sections of the demonstration evaluation. Aside from conducting these focus groups, there is no other way to gather this operational and contextual information from physicians in the time frames necessary for the mandatory reporting.
The physician focus groups will also be used to supplement the quality and cost impact quantitative analysis by gathering physician’s perceptions of how the quality of care and costs were affected under the project. Physician feedback during the focus groups can provide information on whether cost savings were achieved using new internal procedural, patient care or other systems that placed an increased (or decreased) burden on direct care providers such as physicians. Physicians are also in a unique position to provide feedback on whether the gainsharing model as implemented in these demonstrations achieved a true collaboration between physicians and hospitals that resulted in positive impacts on cost and quality. Finally, physicians are in a unique position to observe whether the efficiency goals set under each gainsharing model has had small but important impacts on quality of care and patient satisfaction that may not be observable using the quantitative data available. Therefore, in addition to providing contextual information on administrative and operational feasibility, the physician focus groups will also provide critical feedback on the quality of care and cost impacts that will be used to supplement and interpret the claims and other data analyses.
To summarize, the physician focus groups to be conducted under the Medicare PHC Demonstration evaluation will add significant value to the evaluation by providing direct care provider feedback on the administrative and operational feasibility of the demonstration models, as well as adding similar feedback on how quality of care and cost goals were achieved. This physician feedback will allow for more complete interpretation of the quantitative claims and other data analysis by taking into account the perspectives of direct care providers.
A.2 Information Users
Results from these focus groups will be used by CMS and RTI for the evaluation of the Medicare PHC Demonstration. Together with the results obtained from the DRA Gainsharing Demonstration Evaluation, results from this demonstration will allow CMS and RTI to:
Gather selected qualitative feedback on why some physicians may or may not have elected to participate in gainsharing.
Gather selected qualitative feedback on the experiences and behavioral changes of some physicians under the gainsharing model.
Gather selected qualitative on some physician perspectives regarding quality of care impacts resulting from gainsharing.
Identify information on selected problems encountered by physicians under the gainsharing models.
Claims and other secondary data analysis may not provide a full picture of the impact of the Medicare PHC Demonstration on physicians because these sources cannot inform on the reasoning behind the decisions whether to participate in the program and physicians’ experiences under gainsharing if they participate. Conducting focus groups allows us to add limited qualitative information to our other analyses. Since physicians are the primary drivers of care, we need to speak with demonstration participating and non-participating physicians to gather their assessment and feedback on how the demonstration impacts overall hospital efficiency, physician practice patterns, and quality of care. It is particularly critical to discuss the impacts of gainsharing on beneficiary satisfaction with the physicians who treat and interact with patients since there are few other available sources of information on this subject available to the evaluation team.
Data from physician focus groups will enable the evaluation to include additional information on a segment of physicians’ perceptions on several important evaluation issues which could speak to the replicability of the demonstration. These evaluation issues include participating physician perceptions on: (1) how the gainsharing incentives may or may not have impacted their practice patterns; (2) how the specific operationalization–physician recruitment, development of clinical protocols, payments—of gainsharing worked at the physician level, and (3) whether beneficiary quality of care was impacted by the PHC Demonstration—and if so, in what way.
A convenience sample of physicians at each of the 12 demonstration hospital sites that have participated in gainsharing will gather meaningful information from direct care providers. The feedback will also help CMS determine whether there are demonstration lessons learned that should be included in future gainsharing initiatives. The focus groups will be run by Dr. Greenwald and additional RTI employees who will collect and analyze the information obtained.
Our approach for these physician focus groups under the Medicare PHC Demonstration differs from the OMB approved Medicare Gainsharing Demonstration in that we will not be recruiting and conducting non-participating physicians. We attempted to conduct non-participating physician focus groups under the Medicare Gainsharing Demonstration but found that either we had no non-participating physicians actually show up to the scheduled sessions or that we could not successfully recruit non-participating physicians to even theoretically attend. We therefore plan to reduce the burden estimate for the Medicare PHC Demonstration data collection to reflect that experience.
Preliminary results from both demonstrations indicate that participating hospitals were able to show savings from demonstration activities and, thus, could distribute gainsharing payments to participating physicians. Preliminary results also indicate that the participating hospitals were able to meet these demonstrations’ Medicare budget neutrality criteria. Thus, the operation of these demonstrations was not costing the Medicare program money. The information to be gained from these demonstrations will be used to inform and shape future CMS demonstrations, pilot programs and policy involving gainsharing applications, especially those that may be developed by the CMS Innovation center.
A.3 Use of Information Technology
The physician focus groups will make minimal use of information technology. A focus group facilitator from the RTI team will lead each discussion and a dedicated note taker will record participant responses.
A.4 Efforts to Identify Duplication
These focus groups will gather physician responses to an entirely new program, including unique site-specific information. No prior information exists that would specifically provide feedback about the operation of the Medicare PHC Demonstration. This information collection, thus, does not duplicate any other effort and the information cannot be obtained from any other source.
A.5 Involvement of Small Entities
For this evaluation, RTI will conduct focus groups with individual physician participants who have elected to participate in the PHC Demonstration. Except insofar as individual physicians may be in solo practice or work in small practices, there is no expected involvement for small entities including small businesses, local governments, or other small entities.
A.6 Less Frequent Collection
The focus groups will be conducted twice, at intervals allowing for the collection of physician feedback at the midpoint and end point of the demonstration. No other timing would allow for the collection of sufficient physician feedback at critical points in the demonstration that are necessary for the analyses included in the evaluation.
A.7 Special Circumstances
There will be no special circumstances.
A.8 Federal Register/Consultation Outside the Agency
The 60-day Federal Register notice published on March 1, 2011.
A.9 Payments/Gifts to Respondents
No remuneration will be offered to the physician focus group participants. We anticipate that physician participants have sufficient interest in the PHC Demonstration that they will be willing to participate without compensation. To facilitate participation, the focus groups will be held at either morning or end of the day at the demonstration participant hospitals. Beverages and some food will be offered at these focus groups. RTI’s past experience conducting focus groups for The CMS Specialty Hospital Evaluation indicated that physicians are more willing to attend a group discussion if a light meal is provided and the discussion is held at the hospital.
A.10 Confidentiality
A plan for assuring the confidentiality of the project includes signing ethics agreements from all personnel employed by the contractor who will have access to individual identifiers. Personnel training is also included in the plan regarding the significance and protection of confidentiality, particularly as it relates to controlled and protected access to focus group summary files. Further, materials will be sent to potential focus groups participants describing the purpose and the voluntary nature of the focus groups, as well as conveying the extent to which respondents and their responses will be kept confidential. We pledge to hold respondent information confidential to the extent provided by law.
A.11 Sensitive Questions
Information collected in the focus groups is not of a sensitive nature. Questions are confined to physician opinions and perspectives regarding the Medicare PHC Demonstration.
A.12 Burden Estimates (Hours and Wages)
One type of focus groups will be conducted: (1) Medicare PHC Demonstration physician participants. For each participating hospital, two rounds will be conducted. To minimize burden on individual physicians, no effort will be made to recruit the same panel of physician participants for each round. The length of each focus group will be no more than 60 minutes, including time to review the focus group processes and to obtain signed content. An estimate of $500 per hour has been used as the value of practicing physician time. This is the maximum rate the evaluation contractor (RTI International) has used for physician consultants. The respondent hourly burden for the focus groups is shown in Exhibit 1. Total burden is shown by demonstration site, by phase. The total (288 hours) reflects the total estimated burden for all focus groups, combined for both of the two phases.
Exhibit 1. Total respondent hourly burden, by focus group site and round Focus Group Name (Total Burden Hours) |
Medicare PHC Demonstration Participant Focus Groups Round 1: (144 Hours) – Hunterdon Medical Center (12 hours) – Holy Name Hospital (12 hours) – Valley Hospital (12 hours) – St Francis Medical Center (12 hours) – Our Lady of Lourdes Medical Center (12 hours) – Somerset Medical Center (12 hours) – Overlook Hospital (12 hours) – Atlanticare Regional Medical Center (12 hours) – Jersey Shore University Medical Center (12 hours) – Monmouth Medical Center (12 hours) – JFK Medical Center (12 hours) – Centrastate Medical Center (12 hours)
Medicare PHC Demonstration Participant Focus Groups Round 2: (144 hours) – Hunterdon Medical Center (12 hours) – Holy Name Hospital (12 hours) – Valley Hospital (12 hours) – St Francis Medical Center (12 hours) – Our Lady of Lourdes Medical Center (12 hours) – Somerset Medical Center (12 hours) – Overlook Hospital (12 hours) – Atlanticare Regional Medical Center (12 hours) – Jersey Shore University Medical Center (12 hours) – Monmouth Medical Center (12 hours) – JFK Medical Center (12 hours) – Centrastate Medical Center (12 hours)
|
TOTAL: 288 Hours |
Exhibit 2. Total respondent wage burden, by focus group site and round Focus Group Name (Total Wage Burden) |
Medicare PHC Demonstration Participant Focus Groups Round 1: ($72,000) – Hunterdon Medical Center ($6000) – Holy Name Hospital ($6000) – Valley Hospital ($6000) – St Francis Medical Center (1$6000) – Our Lady of Lourdes Medical Center ($6000) – Somerset Medical Center ($6000) – Overlook Hospital ($6000) – Atlanticare Regional Medical Center ($6000) – Jersey Shore University Medical Center ($6000) – Monmouth Medical Center ($6000) – JFK Medical Center ($6000) – Centrastate Medical Center ($6000)
Medicare PHC Demonstration Participant Focus Groups Round 2: ($72,000) – Hunterdon Medical Center ($6000) – Holy Name Hospital ($6000) – Valley Hospital ($6000) – St Francis Medical Center ($6000) – Our Lady of Lourdes Medical Center ($6000) – Somerset Medical Center ($6000) – Overlook Hospital ($6000) – Atlanticare Regional Medical Center ($6000) – Jersey Shore University Medical Center ($6000) – Monmouth Medical Center ($6000) – JFK Medical Center ($6000) – Centrastate Medical Center ($6000)
|
TOTAL: $144,000 |
A.13 Capital Costs
There are neither capital or startup costs nor are there any operation and maintenance costs to focus group participants.
A.14 Costs to Federal Government
Total costs associated with round one of Medicare PHC Demonstration focus groups (at 12 focus groups for each of two rounds, for a total of 24 focus groups) are estimated to be $120,000 for recruitment, focus group facilitation, meeting notes and analysis. The annualized costs are approximately $60,000 for each round of 12 focus groups; the two rounds occur in different years. These costs are funded by the CMS evaluation contract for this demonstration
A.15 Changes to Burden
This is a revision of the currently approved PRA information collection. The burden has increased by 211 hours.
A.16 Publication/Tabulation Dates
The primary purpose for this survey is to add to the analyses included in an interim evaluation report and a final report. No other publication is anticipated at this time. The final report will be completed in June 2013.
A.17 Expiration Date
The OMB expiration date will be displayed on all disseminated data collection materials.
A.18 Exceptions to Certification Statement
There are no exceptions to the certification statement.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | CMS |
| File Modified | 0000-00-00 |
| File Created | 2021-02-01 |