CMS-10493 - Supporting A [rev 10-31-2013 by OSORA PRA]

Supporting Statement – Part A

Nationwide Consumer Assessment of Healthcare Providers and Systems (DCAHPS) Survey for Adults in Medicaid

CMS-10493, OCN 0938-New

Background

The CMS Center for Medicaid and CHIP Services (CMCS) requests approval for conducting a nationwide Consumer Assessment of Healthcare Providers and Systems (CAHPS®) survey in 2014 of adults covered by Medicaid. The office of the Assistant Secretary of Planning and Evaluation (ASPE) is providing technical expertise to CMCS on this activity. The goal of the survey is to attain national and state-by-state estimates of adult Medicaid beneficiaries’ access and experiences and satisfaction with care across different financing and delivery models (e.g., managed care and fee-for-service) and population groups (e.g., beneficiaries with physical and/or mental disabilities, dually eligible beneficiaries, all other beneficiaries).

The survey will serve as baseline information on the experiences of low-income adults during the early stages of implementation of the Affordable Care Act (ACA) provision that permits states to expand Medicaid eligibility to adults with income below 138 percent of the federal poverty level (FPL) who were not previously eligible. CMCS and states can use the survey information as one indicator of the quality of care within and across states. Currently, there is no standardized way of collecting these data for adult beneficiaries from state-to-state. It also will be used to assist CMCS and states in efforts to provide better care and more affordable care to Medicaid beneficiaries.

CMCS will use a data collection model similar to that used by Medicare for the health plan CAHPS, the Hospital CAHPS, and the Home Health Care CAHPS. CMCS has identified a contractor, NORC at the University of Chicago, which will collect and submit the survey data to CMCS. NORC has a subcontract with Thoroughbred Research Group, a vendor certified to conduct Medicaid CAHPS. CMCS will provide oversight of the contractor to ensure that they follow the data collection protocols and provide information on the sample population directly to the survey vendor. The survey instrument that will be used is a modified version of the adult CAHPS Medicaid 5.0H survey. CMCS has added 20 additional proposed questions to the CAHPS survey, including the new U.S. Department of Health and Human Services’ (HHS) health disparities data collection standards per section 4302 of the ACA.

A. Justification

1. Need and Legal Basis

Provisions of the Affordable Care Act (ACA) will expand health coverage to millions of Americans, many of whom are adults and will enroll in Medicaid. Section 2701 of ACA required the Secretary of Health and Human Services to identify an initial core set of health care quality measures for adults enrolled in Medicaid for voluntary reporting by states. One of the measures identified by a multi-stakeholder process,¹ the adult CAHPS survey, will be useful for obtaining information on the experiences of care of adults covered by Medicaid. This request will support our state partners in reporting CAHPS data in the first year that CMCS is collecting data on the adult core measures. Consistent with paragraph 4 below, CMCS will make every effort not to duplicate current state CAHPS reporting.

2. Information Users

There are two primary purposes for conducting the CAHPS survey. First, the information will be used by CMCS and states for program management purposes, i.e. monitoring the health care experiences of beneficiaries with the goal of identifying areas in which to improve the quality of care provided to enrollees. Second, the information will be made available to support states that have an interest in using some of the CAHPS data for creating a state consumer guide on beneficiaries’ experiences with care in health plans and/or with fee-for service providers.

3. Use of Information Technology

There are no barriers or obstacles that prohibit use of improved technology for this information collection activity. Respondents will be asked to return the completed mail surveys to the certified CAHPS vendor and the data will be aggregated electronically. Telephone follow-up of non-respondents to the mail survey will be conducted using Computer Assisted Telephone Interviewing (CATI) technology and also entered into an electronic database.

4. Duplication of Efforts

CMCS recognizes that some State Medicaid agencies and Medicaid health plans survey Medicaid beneficiaries using the CAHPS instrument. In some cases the survey is conducted as part of a health plan’s accreditation process. Based on CMCS’ preliminary review, 12 states submitted adult CAHPS survey data from their health plans to the Agency for Healthcare Research and Quality’s (AHRQ) CAHPS Database in 2011, and 15 states submitted results in 2010. Working with the contractor, CMCS will systematically assess each state’s current plans for collecting and reporting CAHPS data at the state/health plan level and develop a plan for coordinating efforts so as not to duplicate state efforts or burden Medicaid enrollees with multiple surveys. CMCS also is working with staff from the CMS Medicare-Medicaid Coordination Office and the Center for Medicare to coordinate with efforts in conducting Medicare CAHPS surveys of beneficiaries dually eligible for Medicare and Medicaid.

5. Small Businesses

CAHPS survey respondents will be Medicaid beneficiaries. The survey instruments and procedures for completing the instruments are designed to minimize burden on respondents and should not affect small businesses or other small entities.

6. Less Frequent Collection

N/A. This PRA package requests approval for conducting a single nationwide adult Medicaid CAHPS survey in 2014.

7. Special Circumstances

Medicaid CAHPS does not require any special circumstances noted in the instructions.

8. Federal Register/Outside Consultation

Comments in Response to Federal Register Notice

As required by 5 CFR 1320.8(d), on July 22, 2013, the Centers for Medicare & Medicaid Services (CMS) published a Federal Register notice (78 FR 43887) announcing an opportunity for the public to comment within 60 days on its intention to request an OMB review of data collection activities related to a nationwide Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey for adults in Medicaid.

In response, CMS received five sets of comments on its proposal to conduct a nationwide CAHPS survey of adult Medicaid beneficiaries, plus one set of comments intended for another Federal Register notice. Commenters included the California Department of Health Care Services, the Kaiser Commission on Medicaid and the Uninsured (KCMU), the Indian Health Service Tribal Self-Governance Advisory Committee, the National Indian Health Board, and the Tribal Technical Advisory Group. KCMU expressed support for CMS’ overall plans to conduct a nationwide survey, and the proposed structure of the sample and sub-samples to include adults in both fee-for-service and managed care, adults with physical and mental disabilities, and dual eligible beneficiaries. KCMU indicated this approach will greatly enhance efforts to analyze and compare access under the Medicaid program’s two major delivery and financing systems and help to better understand how Medicaid subgroups fare in absolute terms and, relative to each other. The California Department of Health Care Services and the organizations representing American Indians and Alaska Natives (AI/ANs) were generally supportive of the survey, but asked clarifying questions and expressed concerns, as described in our summary of comments and response (attached to this package).

Updates to Survey Instrument Following Submission of 60-day Federal Register Notice

Following internal review between CMS and the NORC/Thoroughbred team, a series of updates were made to the draft questionnaire included in the 60-day Federal Register notice. The 60-day notice’s crosswalk (attached to this package) summarizes the changes that have been made as a result of this comprehensive review of the survey instrument. We do not anticipate that any of these changes will result in a substantive change to the burden estimates for completion of the survey.

9. Payments/Gifts to Respondents

There will be no payment/gifts to respondents.

10. Confidentiality

Individuals and organizations will be assured of the confidentiality of their replies under Section 934(c) of the Public Health Service Act, 42 USC 299c-3(c). They will be told the purposes for which the information is collected and that, in accordance with this statute, any identifiable information about them will not be used or disclosed for any other purpose.

Individuals and organizations contacted will be further assured of the confidentiality of their replies under 42 U.S.C. 1306, 20 CFR 401 and 422, 5 U.S.C.552 (Freedom of Information Act), 5 U.S.C.552a (Privacy Act of 1974), and OMB Circular No.A-130. In instances where respondent identity is needed, the information collection fully complies with all respects of the Privacy Act.

11. Sensitive Questions

No questions of a sensitive nature are included in the survey.

12. Burden Estimates (Hours & Wages)

The Medicaid CAHPS survey takes, on average, 20 minutes to complete the self-administered mail survey and the phone survey.

We assume a response rate of 45 percent for a sample of 1.5 million adult enrollees, with 60 percent of respondents completing the mail survey and 40 percent completing the phone survey. After adjusting for the removal of ineligible sample members due to disenrollment or invalid contact information, the number of completed interviews is estimated at 510,000.

With these assumptions, the time burden for about 510,000 respondents is approximately 170,000 hours. Using an average hourly wage of $16.64,² the total wage burden across all respondents is $2,828,800.

Exhibit1. Estimated Respondent Burden

	Sample/Units	Sample by Type	Burden	Total Hours
Disabled	51	127,500	20 / 60	42,500
Nondisabled, MCO	51	127,500	20 / 60	42,500
Nondisabled, FFS	51	127,500	20 / 60	42,500
Dual Eligibles	51	127,500	20 / 60	42,500
TOTAL		510,000	20 / 60	170,000

Costs to respondents are the time required by respondents to complete the survey. These costs are estimated as follows.

Exhibit2. Estimated Cost to Respondents

	Number of Respondents	Total Burden Hours	Average Hourly Wage	Estimated Data Collection Cost to Respondents
Disabled	127,500	42,500	$16.64	$707,200
Nondisabled, MCO	127,500	42,500	$16.64	$707,200
Nondisabled, FFS	127,500	42,500	$16.64	$707,200
Dual Eligibles	127,500	42,500	$16.64	$707,200
TOTAL	510,000	170,000	$16.64	$2,828,800

Estimated Burden on States

Each state will be asked to extract Medicaid beneficiary data from the state’s MMIS database. CMCS and NORC will work with each state to determine the best approach for extracting the information. In some cases, the states may wish to provide a download of all MMIS records for the period of time requested. For other states, the best approach may be for state staff to perform the data processing, including selecting the sample based on specifications furnish by CMCS and NORC. The amount of time it will take a state’s staff to perform the necessary tasks will vary between 10 hours and 80 hours of an FTE, averaging 40 hours per state. With this assumption, the time burden for all 50 states and DC is 2,040 hours. Using the Bureau of Labor Statistics’ (BLS) average hourly wage for Data Processing, Hosting, and Related Services of $25.69,³ the total wage burden across all states is $52,408.

13. Capital Costs

There are no capital or maintenance costs involved in collecting the information.

14. Cost to Federal Government

The total cost to the federal government for conducting a nationwide CAHPS survey in 2014 should not exceed $7.7M in contracting costs for 18 months, with an average annual cost of $3.85M. The contractor costs include sample design, sampling, conducting the survey, oversight of survey vendor, and cleaning of the data prior to submission to CMCS.

15. Changes to Burden

Not applicable. This is a new collection of information.

16. Publication/Tabulation Dates

Within eight months of fielding the CAHPS survey, the survey data files are to be transmitted by NORC to CMCS. In early 2014, CMCS will identify a contractor that will take the lead in the analysis of CAHPS state specific and national findings. Findings will be publically reported in the 2015 Secretary’s Report on the Quality of Care for Adults Covered by Medicaid, which is required by ACA to be released annually by September 30^th of each year. CMCS will identify a contractor to conduct analysis of the data and support states efforts in making these findings useful as a tool in improving care.

17. Expiration Date

No exemption is being requested.

18. Certification Statement

There are no exceptions taken to item 19 of OMB Form 83-I.

1 A full listing of the Initial Core Set of Health Care Quality Measures for Adults in Medicaid can be found: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Quality-of-Care/Downloads/AdultCoreMeasures.pdf

2 To calculate the annualized cost to respondents for the hour burden, we assume an average household income of $34,748, or 200 percent of the poverty threshold of $17,374 for a family of three (http://www.census.gov/hhes/www/poverty/data/incpovhlth/2010/tables.html). Assuming 2088 work hours per year, this translates to an hourly rate of $16.64.

3 http://www.bls.gov/oes/2011/may/oes434061.htm

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