18774 ID_0990-SurveyPhysiciantime useSupporting Statement A_SSS_6-26-13_VersionA

Supporting Statement – Part A
Survey of Physician Time Use Patterns under the Medicare Fee Schedule
A.

Justification

1.

Circumstances Making the Collection of Information Necessary

The Office of the Assistant Secretary for Planning and Evaluation is currently
conducting a number of research studies exploring different aspects of the Medicare
Fee Schedule. The objectives of this study are to conduct an initial exploration of
the time inputs to the Medicare Fee Schedule. The information, to be collected
through primary data collection and analysis of administrative data, will help ASPE
to better understand—for a limited number of services and specialties--one aspect of
how clinical services are delivered and the relationships between the clinical time
spent by physicians and the time that is currently part of the fee schedule. This
collection of data is authorized by Section 301 of the U.S. Public Health Service Act
(42 U.S.C.241).
2.

Purpose and Use of Information Collection

The intended data collection effort is a survey of physician providers in five
specialties (family medicine, radiology, cardiology, ophthalmology, and orthopedics)
to gather information on the clinical time spent by the physician and associated nonphysician providers in providing selected services as well as related information on
the physician’s practice. The information collected focuses on the time data that is
used as an input in the fee schedule. As part of the project the time data collected in
the survey of physicians will be analyzed along with time input data from the fee
schedule to examine (i) the strength of the correlation between physician-reported
clinical time and fee-schedule time values for surveyed services; (ii) how consistent
the relationships are across services and across specialties; and (iii) whether the
relationships vary across physicians in different types of practice settings.
3.

Use of Improved Information Technology and Burden Reduction

The research team is proposing a multi-mode data collection. Physician respondents
will be encouraged to submit responses online through a web survey component.
We anticipate that approximately half of respondents will respond online. In order
to provide as much as flexibility as possible to respondents, we will also provide the
option of submitting a completed survey via regular mail, fax, or over the phone
with a trained interviewer.

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4. Efforts to Identify Duplication and Use of Similar Information
The research team has conducted an extensive literature review to assess whether
this type of data is available. The only source identified is the American Medical
Association/Specialty Society Relative Value Scale Update Committee (RUC), which
acts as an expert panel in developing relative value recommendations to the Centers
for Medicare and Medicaid Services. The process used by the RUC relies heavily on
medical specialty societies. The proposed effort would offer an alternative approach
for data collection. One purpose of this data collection effort is to better assess how
the current time estimates that have been developed through the RUC process
compare with times reported through an independent data collection effort.
5.

Impact on Small Businesses or Other Small Entities

We assume that the majority of physicians are deemed as small entities for the
purposes of this data collection.
6.

Consequences of Collecting the Information Less Frequent Collection

This is a one-time data collection. Foregoing this data collection would preclude
ASPE from being able to assess how the current time estimates used as one input in
the Medicare Fee Schedule compare to actual clinical times reported by physicians
and how those times may vary by specialty and practice type. It would also
preclude comparing times that have been developed through the RUC process with
times reported through an independent data collection effort.
7.

Special Circumstances Relating to the Guidelines of 5 CFR 1320.5

This information collection will not involve any of the special circumstances.
8.

Comments in Response to the Federal Register Notice/Outside Consultation

A technical expert panel (TEP) consisting of physicians with in-depth knowledge of
the Medicare Fee Schedule and the Relative Value Scale was consulted in
development of the survey instrument. In particular, the TEP members advised on
the selection of physician specialties to be surveyed and the specific services to be
included in the data collection.
A 60-day Federal Register Notice was published in the Federal Register on February
13, 2013, vol. 78, No. 30; pp. 10174-75 (see Appendix A). Comments were
received from 12 specialty societies (see Appendix B). These comments included
recommendations to increase the survey burden, include an estimate of service
intensity, and approach the project with strict neutrality. Additionally, suggestions

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were made on the selection of CPT codes. All of these comments have been carefully
considered by ASPE.
Based on comments that the estimate of time to complete the survey was low as
well as results from the project’s pre-test (limited to 9 physician respondents), we
have adjusted the estimate of survey burden in the revised Paperwork Reduction Act
(PRA) package submitted to the Office of Management and Budget.
Regarding suggestions to include a measure of service intensity, we note that the
objectives of this study are narrowly defined—the goal of this study is to conduct
research focusing on an initial exploration of the time inputs to the Medicare Fee
Schedule. The information, to be collected through primary data collection and
analysis of administrative data, will help us to better understand—for a limited
number of services and specialties--one aspect of how clinical services are delivered
and the relationships between the clinical time spent by physicians and the time that
is currently part of the fee schedule. There is general agreement among
policymakers that relative work values should reflect intensity. ASPE and CMS, as
well as MedPAC, recognize this and substantial work on intensity has and will
continue to be implemented. The current study focuses on clinical time spent by
physician and the study will not serve as the sole source of information for any
recommendations about payment.
Specialty societies requested that investigators be neutral in the conduct of the
study. We are aware that different groups have different perceptions on the history
of relative payments received by different specialties. The extent to which previous
adjustments have decreased or increased payments to specific specialties is not a
factor in the current investigation which only looks at estimates of physician time.
This contract was awarded to Social & Scientific Systems (SSS) as a result of a
competitive procurement. SSS and its subcontractor, the Urban Institute, were
awarded the contract based on their operational capabilities to conduct a provider
survey, their ability to procure and analyze data and their overall proposed technical
approach. The study will be conducted with scientific rigor and will not be based on
any preconceptions about whether services are or are not undervalued. None of the
investigators have any financial interest in the results of the project and they have
no incentive to base their findings on anything other than the empirical results.
Finally, we have noted recommendations with respect to the replacement of specific
CPT codes for the survey. CPT code 71010 has been replaced with 71020 for
Radiologists. The project team will continue to review these comments and consult
the project Technical Expert Panel as necessary.

9.

Explanation of any Payment/Gift to Respondents

We propose to include a prepaid incentive of $100 in the initial mail packets to
physicians. Incentives have been shown to increase response rates in surveys and
prepaid incentives tend to yield higher response rates than incentives that are

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promised. Based on our experience conducting provider surveys, we expect that the
$100 incentive will be cost-effective by saving resources that would have been
needed for additional fieldwork. The purpose of the payment is to signal respect for
the physician’s time and to establish trust. In addition, because we are interested in
obtaining data on the clinical time spent performing services, it is not possible to
have proxy respondents complete the questionnaire for the physician.
10.

Assurance of Confidentiality Provided to Respondents

Respondents will be assured that their participation is voluntary and that only
aggregated data will be disseminated.
11.

Justification for Sensitive Questions

The data collection does not include any sensitive questions.
12.

Estimates of Annualized Hour and Cost Burden

The table below provides an estimate of time burden for the data collection activities
for which approval is being sought. The total average burden hours for which we are
seeking approval in this package is 200 hours. The survey will be multi-mode, with
50% of responses anticipated via the web survey, 45% through the mail, and 5%
over the phone. The latter will be obtained by interviewers who conduct a follow up
with non-respondents by telephone to prompt completion of the survey; they will
provide an opportunity to complete the paper survey over the phone. The surveys
are estimated to take an average of 20 minutes to complete. A total of 600
physicians are expected to complete the survey. According to the Employment and
Wages May 2010 national estimates from the Occupational Employment Statistics
(OES) survey, the mean hourly wage of general internists and family and general
practitioners is $85.26 and the mean hourly wage for other physicians is $88.78.

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TABLE A. AVERAGE BURDEN TO RESPONDENTS IN HOURS

Data Collection
Activities

Number of
Respondents

Average
Burden
Hours/
Respondent

Total
Average
Burden
Hours

Average
Hourly
Rate

Estimated
Monetary
Cost Burden
To
Respondents

Physician
Survey:
Primary Care

120

.33

40

$85.26

$3,410.40

Physician
Survey:
Specialists

480

.33

160

$88.78

$14,204.80

Estimated
Total

600

.33

200

$88.08

$17,615.20

Sources:
“Family and General Practitioners”: http://www.bls.gov/oes/current/oes291062.htm
“Physicians and Surgeons, All Other”:
http://www.bls.gov/oes/current/oes291069.htm

13.
Estimates of other Total Annual Cost Burden to Respondents or
Recordkeepers/Capital Costs
No capital costs will accrue to respondents.
14.

Annualized Cost to Federal Government

The total cost to the Federal Government, including design, data collection, and
analysis, is estimated to be $493,626.
15.

Explanation for Program Changes or Adjustments

This is a new data collection.
16.

Plans for Tabulation and Publication and Project Time Schedule

The project will develop data analyses designed to address several distinct
questions:


Are survey responses highly correlated with fee-schedule time values for
surveyed services?

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Are service-level time estimates fairly consistent among physicians of the
same specialty?

For services surveyed in more than one specialty, are service-level time
estimates consistent across specialties?

We will produce both measures of central tendency (mean, median, mode) and of
dispersion for survey time responses. These will be shown for each service vignette,
overall and by physician specialty, if the vignette was included for more than one
specialty. The shell on the following page is suggestive of the type of table we would
produce. We will report the correlation between the fee-schedule time and survey
time across services. In the case of services surveyed across more than one
specialty, such as Service A in the table, we will also report the key test statistics
related to testing the hypothesis that the time estimates are equal across specialty—
the particular test to be used will depend on sample sizes and the distribution of
responses.
Service/
specialt
y

Service
A

Feeschedule
time

Survey Responses
Central Tendency
N

Mean

Media
n

Mode

Dispersion
StD
ev

25%

X mins

ALL
Spec 1
Spec 2
Spec 3
Service
B

Y mins

Service
C

Z mins

17.

Reason(s) Display of OMB Expiration Date is Inappropriate

The expiration date will be displayed.

18.

Exceptions to Certification for Paperwork Reduction Act Submissions

No exemptions are being requested.

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