2Supporting_Statement_-_Part_A_PGPTD

Supporting Statement For Paperwork Reduction Act Submissions
Specific Instructions

A. Background
The Centers for Medicare & Medicaid Services (CMS) is requesting an extension of a currently
approved tool for the collection of ambulatory care clinical performance measure data for the
Office of Management and Budget (OMB) approved Medicare Demonstration. The data will be
used to continue implementation of the congressionally-mandated Physician Group Practice
Transition Demonstration (PGP-TD) (PGP) project. The demonstration will test new payment
methods for improving the quality and efficiency of health care services delivered to Medicare
fee-for-service (FFS) beneficiaries, especially those with chronic conditions that account for a
disproportionate share of Medicare expenditures.
The PGP-TD Demonstration, an extension of the original Physician Group Practice (PGP)
demonstration involving 10 large multi-specialty group practices, is a pay-for-performance
(P4P) initiative for physicians under the Medicare program. The Demonstration rewards
physicians for improving the quality and cost efficiency of health care services delivered to the
Medicare FFS population. Mandated by section 412 of the Medicare, Medicaid, and SCHIP
Benefits Improvement, and Protection Act of 2000, the goals of the Demonstration are to
encourage coordination of Part A and Part B services; promote cost efficiency and effectiveness
through investment in care management programs, process redesign, and tools for physicians
and their clinical care teams; and reward physicians for improving health outcomes. Payments
under this Demonstration are contingent upon achieving savings as well as targeted quality
performance levels. PAT is used to collect the clinical quality data which is used to determine
payment. For the two performance periods of the PGP TD, data will be collected in the
summers of 2012 and 2013.
The proposed ambulatory care measures being used were developed by CMS in conjunction
with the American Medical Association’s Physician Consortium for Performance Improvement
and the National Committee for Quality Assurance. CMS worked directly with the industry and
participants in the PGP-TD Demonstration to minimize administrative burden and to align the
measures with those used by commercial payers.
The justifications provided below show that proposed collections for information pose minimal
risk to the Agency, Administration, and/or the Public.
B. Justification
1. Need and Legal Basis
The Demonstration for which this extension is being sought is considered a high priority for the
Administration and Congress. The PGP Demonstration was mandated by section 412 of the
Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 and is the

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precursor to the Medicare Shared Savings Program. Section 1899(k) of the Social Security Act,
as added by section 10307(k) of the Affordable Care Act (as amended by section 10307 of the
Health Care and Education Reconciliation Act of 2010), states “the Secretary may enter into an
agreement with an ACO under the Demonstration under section 1866A, subject to rebasing and
other modifications deemed appropriate by the Secretary.” The Demonstration extension is
entitled the PGP Transition Demonstration.
2. Information Users
The proposed collection of information is strictly voluntary in nature and was developed in
conjunction with the industry and Demonstration participants. Only organizations that
voluntarily respond and elect to participate in the Demonstration will be reporting the
measures. Moreover, CMS will not be using this information to regulate and/or sanction but
rather to provide financial incentives for improving the quality of care.
The collection of information to be used under this extension is being used to test quality data
collection systems and determine incentive payment levels to participating physician group
practices participating in the PGP-TD.
In addition, this data will be used to evaluate the effectiveness of these payment models and
provide insight into the most appropriate way for the agency to collect clinical information.
3. Use of Information Technology (IT)
The collection of information will be done using an automated, electronic tool developed and
refined with industry input. Referred to as “PAT,” it was developed explicitly for Medicare
Demonstrations and has been used successfully over the past 5 years. It should be
emphasized that CMS is not creating an electronic health record (her). Rather, PAT is used
to facilitate collection and scoring of the clinical quality measure data which can be provided
by a physician group practice from either a paper chart of an EHR system. Initially, PAT
will be pre-populated by our contractor based on claims data. Demonstration participants
will only have to provide information that is available only from a medical record. The tool
will reduce the administrative burden in collecting and reporting information.
Groups participating in the Demonstration may input the data directly into the tool using their
computer or, alternatively, the tool is able to import data electronically from an EHR, patient
registry, or other electronic file. Once completed, the PAT file is then returned to CMS for
scoring using “Quality Net Exchange,” a secure method for transmitting data that is approved
for use by the Quality Improvement Organizations.
4. Duplication of Efforts
The collected information will be used by CMS to demonstrate alternative physician payment
models that might move CMS further in the direction of being a value-based payer and

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achieving its vision of capturing clinical information from providers for use in payment
policy. In 2007, after CMS had already implemented the PGP Demonstration, CMS began a
Physician Quality Reporting Initiative (PQRI) in which all Medicare physicians could
participate. This program collects data via the submission of special codes on Medicare
claims. In 2010, CMS began offering physician groups the opportunity to submit via a
similar data collection tool as included in this request part of the Physician Quality Reporting
System (PQRS) Group Practice Reporting Option (GPRO). A distinction is that the
Demonstration rewards not just the reporting of data but actual performance by physicians on
quality-related process and outcome measures. Nonetheless, CMS recognizes the importance
of minimizing reporting burden on physicians. Towards this end, in 2007 CMS’ Office of
Research, Development, and Information sought, and were granted from OMB, a waiver for
group practices participating in Demonstrations that would allow these practices to earn
PQRS incentives as well as Demonstration payments through their participation in the
Demonstration. By doing so, we are rewarding those practices that have voluntarily agreed
to participate in the Demonstration and reduced the reporting burden they would otherwise
have had if they had to submit duplicate clinical quality data using two different systems.
5.Small Businesses
The only small businesses affected by this effort will be those medium-sized PGPs that
voluntarily elect to participate in the Demonstration, though the minimum requirement for
participation is 200 physicians. To assist practices participating in the Demonstration, we
have contractors who are available to provide technical assistance in using PAT. Our
experience, to date, is that PAT is user-friendly for group practices. Again, participation in
this Demonstration is voluntary.
6. Less Frequent Collection
The information is to be collected on an annual basis. If the information were collected less
frequently, CMS would not be able to obtain the information necessary to process payments
and otherwise implement this congressionally-mandated and high priority Demonstration.
7. Special Circumstances
The PGP TDis a congressionally-mandated Demonstration that, has been approved by OMB
and is expected to produce savings to the Medicare program as well as reward high quality
providers. Only those group practices volunteering to participate will be required to submit
the requested information. Group practices generally have 8-10 weeks to submit this data.
We reiterate that CMS is not creating an EHR. Rather, PAT is used to facilitate collection
and scoring of the clinical quality measure data.
8. Federal Register/Outside Consultation
The Federal Register notice soliciting public comment for this collection was originally

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published on August 19, 2005. A subsequent notice was published on September 12, 2008.
CMS consulted with key stakeholders in designing and implementing the standardized
quality measures to be used in this Demonstration and reported as part of this data collection
effort. For example, the standardized ambulatory care measures were developed by CMS in
conjunction with the American Medical Association’s Physician Consortium for
Performance Improvement and the National Committee for Quality Assurance. In addition,
over the past 5 years, in response to comments and suggestions by group practices
participating in the Demonstration, we have provided additional pre-populated data in the
tool, reports to facilitate their data collection efforts, and refinements to PAT to minimize
administrative burden. We have also worked with IT staff and the practices and EHR
vendors to make the measures specifications available so that practices could more readily
create files from their EHRs that the data collection tool could import electronically, thereby
reducing the amount of manual effort involved.
9. Payments/Gifts to Respondents
There will be no payments or gifts to respondents for the collection of information.
However, based on how well physician practices electing to participate in the Demonstration
perform on the clinical measures, they will be eligible to earn incentive payments under the
terms of the Demonstration.
10. Confidentiality
As a matter of policy, CMS will prevent the disclosure of personally identifiable information
contained in the data submitted. It should be emphasized that we are not creating a
comprehensive EHR or an individual personalized health record for beneficiaries as part of
these demonstrations. Rather, PAT is being used solely to facilitate the collection and
scoring of clinical quality measure data. Any reports pertaining to the collected information
by an independent evaluator will be in aggregate form.
11. Sensitive Questions
Other than the information noted above in section 10, there are no sensitive questions
included in the information request.
12. Burden Estimates (Hours & Wages)
The estimate is based on the number of participating physician practices in each
demonstration, the estimated number of hours to load PAT, the estimated hourly cost
including fringe benefits, and when reporting will begin. Group practices will only have to
report once each year and we assume an average hourly personnel cost of $65.
The PGP-TD Demonstration involves 10 large multi-specialty group practices. Because of

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the size of these practices and the number of patients they serve, it is expected that it will take
79 hours, on average, per respondent.

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Based on the above assumptions, we estimate the total burden for 2009 through 2011 to be as
follows:
Demonstration

# Respondants per Year

2009
PGP
Demonstration
MCMP
Demonstration
EHR
Demonstration
Total

2010

Total Cost Per Year
Hours/
Response

2011

Cost/
Hour

2009

2010

2011

10

10

10

79 $

55

$

43,450

$

43,450

$

43,450

650

650

650

24 $

55

$

858,000

$

858,000

$

858,000

0

0

400

24 $

55

$

$

528,000

660

660

1060

$

1,429,450.00

-

$ 901,450.00

$

-

$ 901,450.00

13. Capital Costs
There is no capital costs required for the collection of this information. The data abstraction
tool will be provided to Demonstration participants at no cost. Demonstration participants will
not be required to purchase or maintain any systems or capital equipment solely for the
collection of this data.
14. Cost to Federal Government
The costs to the Federal Government to implement this data collection effort include CMS staff
resources to manage the project (.35 full-time equivalent per year) and contractor costs (paid
for under CMS’ administrative budget) to collect the data, program reports, and provide
technical assistance to practices participating in the Demonstration.
MCMP
Demonstration

PGP Demonstration

CMS Staff*

Contractor Costs

Total

Grand Total
Average/ Year

*

EHR Demonstration

TOTAL

2009

$

52,500

$

52,500

$

2010

$

54,075

$

54,075

$

108,150

2011

$

55,697

$

55,697

$

167,092

2009

$

240,000

$

450,000

$

690,000

2010

$

240,000

$

450,000

$

690,000

2011

$

240,000

$

450,000

$

$

958,366

2009

$

292,500

$

502,500

$

-

$

795,000

2010

$

294,075

$

504,075

$

-

$

798,150

2011

$

295,697

$

505,697

$

324,063

$

1,125,457

$

882,272

$

1,512,272

$

324,063

$

2,718,607

$

906,202

$

55,697

268,366

Estimated as .35 FTE per year, GS 14 ($150,000 / year including all salary and fringes); 3% annual inflation

105,000

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15. Changes to Burden
The changes in the estimated burden in this PRA application, since the original submission, are
due to the following changes
•

•

Removing the Medicare Care Management Performance (MCMP) Demonstration from
the application. The Combining the PRA application for the PGP and MCMP
Demonstrations into a single application. Data collection under the MCMP
Demonstration has ended so the extension request is only for the additional two years of
the PGP Transition Demonstration.
An increase in the estimated cost per hour (salary + fringe) for collecting the data from
$55 to $60 due to the general increase in labor costs over the past 3 years.

16. Publication/Tabulation Dates
The terms of the PGP TD include that CMS may publicly report the site-specific results of the
quality measures. This is an option, but CMS may also elect to only publish the data at the
aggregate level.
17. Expiration Date
CMS would like approval to use this data collection tool for a period of 2 years from the
expiration of the current approval (12/31/2011). There are no paper forms involved in this data
collection activity. Any expiration date would be printed on the data collection log on screen
(See current sample with 12/31/2011 date).
18. Certification Statement
There are no exceptions to the certification statement.