CMS-10477 Physician interview verbal consent script

Attachment 2.c. Consent Form and Verbal Informed Consent from Physicians
Thank you for making time to speak with us today. We are researchers from Research
Triangle Institute (RTI), International and the National Academy for State Health Policy
(NASHP), evaluating the Medicaid Incentives for Prevention of Chronic Diseases demonstration.
In this discussion, we are interested in gathering your perspective on implementation
progress and challenges, program details such as the types of special populations involved or
targeted by your State initiative, your data collection processes, and the project’s evaluation
progress. We are also particularly interested in your perspective on the effectiveness and
sustainability of this initiative on reducing Medicaid and health care costs.
Our evaluation is being funded by the Centers for Medicare and Medicaid Services
(CMS). As a condition of participation, CMS expects state staff and program partners to
cooperate with the evaluation team, but ultimately your decision to participate in this aspect of
the study is voluntary. If you do not wish to participate in this interview or answer specific
questions, please let us know immediately.
We believe there are minimal risks to you from participation, and every effort will be
made to protect your confidentiality. We want to assure you that we will not quote you by name.
We will use some quotes in reports, but quotes will not be attributed to an individual or his/her
organization.
There are no direct benefits to you from participating in this study. But your insights will
be used by federal and state policymakers as well as other Medicaid programs to improve the
impact incentives have on chronic disease prevention and management among Medicaid
beneficiaries as well as address the challenges involved in implementing an incentivized health
prevention program. CMS along with RTI’s Institutional Review Board (IRB) have reviewed
and approved this research protocol.
Finally, we would like to record our conversation, to ensure our notes from today are
complete.
Do I have your permission to audio record our conversation today? Are the remaining
interview conditions OK with you? Do you have any questions before we begin?

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