2900-0609 justification

SUPPORTING STATEMENT FOR SURVEY OF VETERAN ENROLLEES’ HEALTH AND RELIANCE UPON VA

VA FORM 10-21034g, OMB CONTROL NUMBER 2900-0609

A. JUSTIFICATION

1. Explain the circumstances that make the collection of information necessary. Identify legal or administrative requirements that necessitate the collection of information.

1. Legal or administrative requirements

The Department of Veterans Affairs (VA) Survey of Veteran Enrollees’ Health and Reliance upon VA (Survey of Enrollees) surveys a sample of Veterans enrolled in the Veterans Health Administration (VHA) in order to inform both Veterans Health Administration (VHA) medical care budget estimates and critical VA policy decisions. Ideally, it is conducted annually (it has been conducted every year since 1999 with the exception of 2000, 2001, 2004, and 2009) and fielded in the first quarter of the calendar year to assure optimal recall about the previous year on the part of respondents.

A key VA policy decision is the VA Secretary’s annual enrollment level decision, which is necessitated by Public Law 104-262, the Veterans’ Health Care Eligibility Reform Act of 1996. This act mandates that VHA implement eligibility reforms and enroll Veterans by specified priorities to the extent available resources permit. To reach this enrollment decision, VA relies on annual projections of enrollment, utilization, and expenditures from the Enrollee Health Care Projection Model (EHCPM) and the EHCPM is based on information obtained from the Survey of Enrollees.

In addition to the enrollment decision, EHCPM projections derived from the Survey of Enrollees, support approximately 95 percent of VHA’s medical care budget estimates every budget cycle.

A critical component of VHA utilization includes the use of Long Term Care and, as an enhancement to the EHCPM, VHA has begun development of a Long Term Care Projection Model. Currently, this model is based on a subset of the VA-enrolled population. The survey in this application adds three Long Term Care questions which we believe will enhance the full demand projection in two ways. First, by combining the survey data with enrollment and workload data, we believe the results can be used to validate the assumptions regarding the Medicare/Medicaid sub-populations and their relevance to the entire VA population. Secondly, it will allow us to understand the prevalence of non-governmental payment sources for long term care services, such as self-pay and private long term care insurance policies. Currently, we have no data regarding the prevalence of these non-governmental payment sources.

Information obtained from the survey also helps VHA to understand Veteran family composition and caregiver characteristics. This enables VA to meet the requirements of the Caregivers and Veterans Omnibus Health Services Act of 2010. In implementing this legislation, VA has initiated many new programs and policies aimed at eligible post-9/11 Veterans and their families who elect to receive their care in a home setting from a primary family caregiver.

Looking forward, information collected by the Survey of Enrollees will support VHA’s preparation for the impact of the Patient Protection and Affordable Care Act (ACA) of 2010. While the 8.5 million individuals who are currently enrolled in VA will be considered to meet the ACA individual coverage mandate, they will not be eligible for the tax credit associated with purchasing health care on state exchanges if they continue to be enrolled in VA. In addition, a Veteran’s family’s new health care options may further impact their health care utilization choices. Therefore, the ACA may lead to changes in terms of Veteran enrollment in and utilization of VA. As a result, the survey questions have been updated to assist VA in its preparation for those shifts.

Additional emerging considerations for which the survey has been updated include accessibility and economic factors that may shift utilization.

These are the prime examples of the survey uses in policy and budget decision making. However, the information gathered from the Survey of Enrollees increasingly is used as a foundation for VA policy and planning. Making sure VHA is able to provide the “right care at the right time” is dependent on a reliable understanding of the Veterans that we serve.

2. Need for essential information that is not available from other sources

The information that is available in VA administrative databases does not reflect all enrollees’ health status, income, or their reliance upon the VA system; all elements which are critical to making valid projections of demand, supporting the Secretary’s enrollment level decision, and making Veteran-centric policy. Basic demographic and socioeconomic data in VA administrative files are generally not complete or valid for all segments of the VHA enrollee population to be of sufficient utility for enrollment based policy and budget development.

3. Need for frequent collection of data

The Veteran population is becoming increasingly diverse with wide ranging needs in and expectations for a health care provider. Rapid changes going on in the world around them, such as troop draw downs from recent conflicts, changes to the national health care landscape, adjustments to Medicare/Medicaid, the enactment of the ACA, and shifts in the state of our nation’s economy, will affect Veterans’ opinions about whether or not VA is best able to meet those needs and expectations. The need for real time information on key health care utilization drivers necessitates the annual Survey of Enrollees to capture this critical information for input into data-driven policy and budgetary analyses.

4. Need for periodic changes in the questions for Survey of Enrollees

Over the years that the Survey of Enrollees has been conducted, the questionnaire has evolved to meet VA’s increasingly complex data needs. The overall survey concept and instrument was last approved by OMB in 2010 under OMB Control Number 2900-0609. The survey instrument submitted with this application reflects a basic “core” set of questions that has changed little over time; probing for basic socioeconomic, demographic, and health-related data that are necessary to collect and monitor each year. To both reduce burden on the Veteran and to optimize VA’s opportunity to gain better understandings of Veteran need, additional “supplemental” or “modular” question sets that can be asked periodically have been identified and included in this application. This includes long term care (L1-L3), certain reliance questions (B1-B10, B12-22), travel time and access (C2-C9), Activities of Daily Living/Incidental Activities of Daily Living (C40-45), certain “Key Driver” questions (D10-D18), Economic Recovery impact on utilization (PREA1b) and Health Care Reform questions (F1-2). The survey submitted with this supporting statement includes both active questions and questions that have been previously approved, but are not currently asked. As the later questions may be re-activated in future surveys if a need is identified, we have submitted them in a separate section.

2. Indicate how, by whom, and for what purposes the information is to be used; indicate actual use the agency has made of the information received from current collection.

Since 1999, the Survey of Enrollees (VA Form 10-21034g), has provided VHA with “quantitative” data that is not available from any VHA administrative files. This data informs Veteran population estimates, which, in turn, provide the Secretary with current information for sound decisions that affect the entire VA health care delivery system and the Veterans it serves. The Survey of Enrollees has proved to be a critical input into the VA EHCPM, the Secretary’s Annual Enrollment Level Decision processes, and the VISN Strategic Planning process (including capital planning). Overall, the survey has served as the basis for VA’s emphasis on population-based budget formulation, policy scenario testing, and strategic planning.

In addition, future uses for the Survey of Enrollees include data driven decisions as VA continues to build a patient-centric model for health care in an ever changing environment and improved understandings of geographic differences in patient utilization patterns.

VHA also produces a report on the VHA Survey of Enrolled Veterans’ Health and Reliance Upon VA that is made available to the public. The report presents aggregated findings for the current and prior years in both graphical and narrative form. The report is regularly used to communicate important information about enrolled Veteran characteristics, attitudes, and preferences.

3. Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g. permitting electronic submission of responses, and the basis for the decision for adopting this means of collection. Also describe any consideration of using information technology to reduce burden.

Historically, VHA has utilized the services of contractors to conduct telephone surveys. VHA provides a stratified random sample and phone numbers to the contractor. The telephone survey is administered using Computer Assisted Telephone Information (CATI) with responses entered directly into an electronic database, making the collection of data very efficient and reliable. This reduction of respondent burden through reliance on CATI meets the spirit of the Government Paperwork Elimination Act (GPEA).

Advances in technology and changes in how people communicate have challenged telephone and uni-mode response bias. In 2008 and 2010, VHA experimented with reverse telephone look-up directories using Veteran address information for those enrollees without valid telephone information. Responses from enrollees reached in this manner showed different patterns of health utilization than enrollees with valid telephone contact information. However, given the security restrictions for the study, reverse telephone look-ups were not a viable option during the 2011 Survey. While the 2011 Survey of Enrollees sample included Veterans without telephone numbers, it relied on these Veterans to respond to a tailored letter and call the contractor to complete the survey. Survey response from these Veterans was low. To capture information from these Veterans and, therefore, to reduce survey response bias, VHA introduced a methodological experiment into the 2012 fielding that offered a small number of enrolled Veterans the opportunity to participate via mail survey or web-based survey. VA applied all relevant regulations and statutes regarding privacy and security to these modalities. This experiment allows VA to compare survey response rates and completion rates across modality. Based on the results of this methodological experiment (e.g., should response rates markedly increase), VA will re-visit survey administration techniques. Successful implementation of a multi-mode survey will also respond to the desire expressed by many Veterans that they receive the survey either through mail or to have the opportunity to complete it on line.

4. Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purposes described in Item 2 above.

No information on the total health care utilization of services of all VA enrollees, both within VA and in the private community, is available. The term “reliance” means the percentage of a Veteran’s total care that is obtained within VA. Other surveys have not covered the entire enrollee population and have not focused on the necessary network-specific information needed to project enrollment and utilization of VA services. In addition, the Survey of Enrollees gathers information about enrollee perceptions, understandings, and attitudes about their health care that have been statistically proven to predict future behavior. This information is not available in any other data base.

5. If the collection of information impacts small businesses or other small entities, describe any methods used to minimize burden.

No small businesses or other small entities are impacted by this information collection.

6. Describe the consequences to Federal program or policy activities if the collection is not conducted or is conducted less frequently as well as any technical or legal obstacles to reducing burden.

VA could not be responsive to the needs of Veterans, enrollees in VHA, or to legislation impacting Veteran health care (e.g., the Health Care Eligibility Reform Act), if this information was collected less frequently. Without this information, the analysis upon which enrollment level decisions is made may be imprecise. Moreover, VA would lack a source of reliable data about shifts in Veteran characteristics and experiences that inform sound policy and program decisions. If VHA could not develop an accurate estimate of Veteran enrollment, utilization, costs, preferences, and concerns, it would not be able to prepare accurate budget requests or adequately prepare for new service members entering the system.

7. Explain any special circumstances that would cause an information collection to be conducted more often than quarterly or require respondents to prepare written responses to a collection of information in fewer than 30 days after receipt of it; submit more than an original and two copies of any document; retain records, other than health, medical, government contract, grant-in-aid, or tax records for more than three years; in connection with a statistical survey that is not designed to produce valid and reliable results that can be generalized to the universe of study and require the use of a statistical data classification that has not been reviewed and approved by OMB.

There are no such special circumstances.

8. a. If applicable, provide a copy and identify the date and page number of publication in the Federal Register of the sponsor’s notice, required by 5 CFR 1320.8(d), soliciting comments on the information collection prior to submission to OMB. Summarize public comments received in response to that notice and describe actions taken by the sponsor in responses to these comments. Specifically address comments received on cost and hour burden.

The notice of Proposed Information Collection Activity was published in the Federal Register: Vol. 76, No. 211 /Tuesday, November 1, 2011 /Notice 67557. VA received no comments in response to this notice.

b. Describe efforts to consult with persons outside the agency to obtain their views on the availability of data, frequency of collection, clarity of instructions and recordkeeping, disclosure or reporting format, and on the data elements to be recorded, disclosed or reported. Explain any circumstances which preclude consultation every three years with representatives of those from whom information is to be obtained.

In order to develop the initial Survey of Enrollees in 1999, a VHA representative attended the consultant panel meeting of internal and external agency participants conducting VA’s SF-36V survey, including scientists with the VA Health Services Research and Development Service (HSR&D Service); the Health Care Finance Administration (HCFA), the Foundation for Accountability (FACCT), the Health Institute at the New England Medical Center, the Rand Corporation, the National Center for Health Promotion at Duke University, and the National Committee for Quality Assurance (NCQA) Washington, D.C. Various individuals are consulted over time in the planning and development of the enrollee surveys regarding the availability of data, frequency of collection, clarity of instructions, internal VA record keeping, disclosure, or reporting format, and on the data elements. This includes individuals both inside and outside of the agency. Additionally, outside consultation is conducted with the public through the 60- and 30-day Federal Register notices.

9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.

No payment or gift is provided to survey respondents.

10. Describe any assurance of privacy, to the extent permitted by law, provided to respondents and the basis for the assurance in statue, regulation, or agency policy.

An assurance is made in writing that answers provided are strictly private and that VA will protect the enrollee’s identity to the extent allowed under the law. Furthermore, respondents are assured that their answers will in no way affect their benefits and that no information provided will be released to the general public in a way that can be traced back to the respondent. The information collected will become part of the system of records identified as 97VA105, “Consolidated Data Information System-VA” as set forth in the Compilation of Privacy Act Issuances via online GPO access at http://www.gpoaccess.gov/privacyact/index.html

11. Provide additional justification for any questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private; include specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.

There are no questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private on the Survey on Enrollees.

12. Estimate of the hour burden of the collection of information:

a. Estimated burden hour.

1). Number of Respondents estimated at 42,080 per year

2) Frequency of Response is one time for most enrollees

3) Annual burden is 14,728 hours

4) Estimated completion time of 21 minutes is based on review by staff personnel and previous usage of this form

b. If this request for approval covers more than one form, provide separate hour burden estimates for each form and aggregate the hour burdens in Item 13 of OMB 83-I.

Only one form number is used for this collection.

c. Provide estimates of annual cost to respondents for the hour burdens for collections of information. The cost of contracting out or paying outside parties for information collection activities should not be included here. Instead, this cost should be included in Item 14.

The estimated cost to the respondents for taking the time to respond to the survey is $338,714 (14,728 hours x $23 per hour (Bureau of Labor Statistics January 2012 average hourly earnings/all employees)). We do not require any additional record keeping.

13. Provide an estimate of the total annual cost burden to respondents or recordkeepers resulting from the collection of information. (Do not include the cost of any hour burden shown in Items 12 and 14).

a. There is no capital, start-up, operation or maintenance costs.

b. Cost estimates are not expected to vary widely.

c. There is no anticipated recordkeeping burden.

14. Provide estimates of annual cost to the Federal Government. Also, provide a description of the method used to estimate cost, which should include quantification of hours, operation expenses (such as equipment, overhead, printing, and support staff), and any other expense that would not have been incurred without this collection of information. Agencies also may aggregate cost estimates from Items 12, 13, and 14 in a single table.

1. The total cost to the Federal Government is estimated at $1.5 million.

2. It is estimated that the amount paid to the contractor for the VHA Survey of Veteran Enrollees’

Health and Reliance Upon VA Survey will be approximately $1.5 million. Costs include travel, survey improvements, programming of the questionnaire for telephone, print, and web administration, questionnaire pretest, interviewing, validation, mailing activities, data processing, providing a clean data file, project management, staff education, and supervision. Estimated costs were obtained via market research with companies that do surveys. The total estimated cost is an average of estimated costs obtained from several companies.

15. Explain the reason for any changes reported in Items 13 or 14 above.

The increase in burden was caused by a change in the completion time.

16. For collections of information whose results will be published, outline plans for tabulation and publication. Address any complex analytical techniques that will be used. Provide the time schedule for the entire project, including beginning and ending dates of the collection of information, completion of report, publication dates, and other actions.

The primary purpose of this data collection is not for publication. Data is aggregated and provided to the actuary who prepares projections for the enrollment level decision by the Under Secretary for Health and the Secretary of VA. Data will also be used for general descriptive information and analyses on enrollees. The aggregated information will be disseminated nationally primarily in VA reports, but the aggregate results may be published. Data will also be used for VA internal policy and budget scenario development and related analyses.

17. If seeking approval to omit the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.

We request approval to omit the expiration date for the OMB approval from this telephone survey. The more information presented at the beginning of the survey, the greater the possibility for a respondent to either refuse or become confused.

18. Explain each exception to the certification statement identified in Item 19, “Certification for Paperwork Reduction Act Submissions,” of OMB 83-I.

There are no exceptions.

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