CMS-10399 Supporting Statement Part B v5 CLEAN_rev10-15-12

Supporting Statement – Part B
Collections of Information employing Statistical Methods
1. Respondent Universe and Sampling
The proposed exploratory study is descriptive in nature and the data obtained from the
12 case study sites will be providing preliminary data on an under researched area.
The results cannot be statistically generalized beyond the specific sites studied but are
expected to provide important insights regarding transportation barriers to utilization of
Medicare services by American Indian and Alaska Native (AI/AN) beneficiaries.
2. Describe the procedures for the collection of information.
The study we will use a convenience sample based on the 12 IHS Administrative Areas
and then by the type of health care center. Tribal health care centers (IHS currently
compacts with 328 tribes, who administer their own health programs) and IHS service
units will be identified; one site will be selected from either category for each
Administrative Area to create the sample of 12 sites. The sample will consist of a total of
six Tribal health centers and six IHS service unit sites. Sites will be chosen based on
remoteness of location, underdeveloped infrastructure, geographical diversity, and
whether there are a minimum of 500 AI/AN people using the facility. While the first three
criteria are important to ensure the study is reaching areas that can be most seriously
impacted by transportation barriers, the last measure will ensure that there is a sizeable
population to draw on for the study.
Estimation Procedure
Each case study site will be analyzed separately to ascertain the different kinds of
unique situations that could be impacting access to Medicare services because of
transportation barriers. First the data collected from the 12 sites will be analyzed
according to the themes presented. We will look at the influence of transportation
access to medical appointments and procedures and assess their impact on
Medicare services use (i.e., keeping appointments, provider treatment decision
making and medical outcome) and use demographic and situational
characteristics, e.g., age, gender, and Medicare eligibility, as moderators of the
relationship.
Data from each data source (health care provider interview, Medicare
beneficiaries’ interview, and Medicare beneficiaries and family member focus
group) will be analyzed separately to determine patterns and themes of response.
This process will enable us to isolate each group of participants (health care
providers, Medicare beneficiaries) while maintaining the uniqueness of each
individual site. The triangulation of the data will also help ensure accuracy of
findings. Next, the information will be analyzed based on how the information was
presented (context in which it was provided, the frequency in which it was
mentioned across and within interviews, and the weight it was given throughout
the narrative). This kind of information can be obtained through a systematic
content and discourse analysis of the narratives.

As part of the above data analysis we will focus on the context of
transportation barriers at each site, but also on how each of the different
populations experience the situation of transportation barriers, e.g., impact on
health care, access to services, influence on decision making, unmet needs,
and consequences. Comparisons will be made between the groups to
determine commonalities in views and issues as well as differences. In this
manner the case study will seek to answer questions on the use of different
transportation methods, the amount to which transportation is affecting access to
health care services, and the impact on unmet medical needs. Themes that
address operational connections will be compared across sites.
Lastly, we will look for the evidence of a generalizable theory or theories (not
statistical generalizations) that address key issues as specified in the research
questions (see, e.g., Yin, 1994). Was there a generalizable theory that developed that
could be tested in a future, more comprehensive study?

Degree of Accuracy
Data will be triangulated such that themes will be compared across the three sources
of data collection at each individual site and then across all 12 sites in the study.
Unusual Problems Requiring Specialized Sampling Procedures
No unusual problems are anticipated.
Use of Periodic (Less Frequent than Annual) Data Collection
As mentioned early in this document, only one data collection is required for this study.
3. Describe methods to maximize response rate.
Medicare Beneficiaries and Family Members
A local advisory committee will be set up at each of the 12 sites. The committee will be
comprised of key health care providers and tribal policy makers. These individuals will
provide the project guidance and direction for their individual sites, informing the
contractor on the best ways, places, and times to recruit participants to the project. For
Medicare beneficiaries these locations and events could include but are not limited to
senior centers, programs, groups, and health care centers.
Contact will be made through group presentations and one on one contact with
beneficiaries or through response to a posted flyer or advertisement in the local tribal
newspaper. To ensure a good response rate, all individuals who are interested in
participating will be asked to provide contact information in the form of their name and
means for contacting them. This initial contact will be followed up by a call or visit by
project staff who will answer any questions the person might have about the project
and the beneficiary’s or family member’s participation. If the person agrees to
participate, the project staff will set up a meeting time for the interview or focus group.
The day before the interview or focus group is to take place, participants will be called
to remind them of the event.

Health Care Providers
Initial contact with health care providers will be by email or postal mail. A letter of
recruitment explaining the project will be sent to all health care providers at each site.
All providers at the 12 sites will be sent a letter introducing and explaining the purpose
of the project.
The letter outlines what participation in this phase of the study entails (See Appendix
H2: Health Care Provider Interview Recruitment Letter.) and the purpose of the
study and interview. It also provides the names, telephone numbers, and email
addresses for contractor staff who can be contacted should the participant have any
questions or concerns about the data collection or its purpose. Within a week’s time all
those who responded to this second request will be contacted to ensure their
participation and to set up a time and date for the interview. If there are more
respondents than will be needed to complete the sample, a notification of nonselection will be sent to the provider.
4.

Tests of procedures or methods

The data collection forms have been reviewed by experts in the field of AI/AN Medicare
services to ensure the methods are appropriate and will be properly administered. The
overall methodology has been reviewed with contacts in the field at three IHS and tribal
health center sites. Three sites (1 IHS service unit and 2 tribal health centers) were
selected, based on location, type of facility, and level of geographical isolation, for
pretesting the instruments. Three respondents for each instrument at each of the three
sites were interviewed, with seven participants attending the Medicare Beneficiaries
and Family Members Focus Group at one site.
5. Name and telephone number of individuals consulted; name of agency unit;
and contractor.
Consulted on Statistical Analysis
Not applicable for a qualitative study.
AGENCY UNIT
Rodger Goodacre, Tribal Affairs Group/OEA, Centers for Medicare and Medicaid
Services, 410.786.3209
CONTRACTOR
Kauffman & Associates, Inc. will be responsible for data collection and analysis under
the direction of Dr. Jeanette Hassin, 301.588.6800 or
[email protected].

REFERENCE
Crouch, J. and Kao, C. (2009). American Indian and Alaska Native Medicare Program
and Policy Statistics. A Report for the Center for Medicare and Medicaid Services from
the Technical Tribal Advisory Group.
Yin, R.K. (1994). Case Study Research Design and Methods. Thousand Oaks, CA:
Sage Publications.