Supporting_Stmt_A_PRA

Part A. Supporting Statement
Physician Quality Reporting System and the Electronic Prescribing Incentive Program
A.

Background

This request is for clearance to conduct three surveys, one of Medicare beneficiaries, one of
eligible professionals, and one of administrators, in support of an evaluation of the Physician
Quality Reporting System (PQRS) and the Electronic Prescribing (eRx) Incentive Program. In
addition, we will interview a small number of eligible professionals and administrators. This
evaluation is designed to determine how well the PQRS and the eRx are contributing to better
and affordable health care for Medicare beneficiaries. The PQRS is a voluntary reporting
program that provides an incentive payment to eligible professionals who satisfactorily report
data on quality measures. The Centers for Medicare & Medicaid Services (CMS) uses quality
measures to promote improvements in care delivery and payment and to increase transparency.
The PQRS program rewards eligible professionals based on a percentage of the estimated
Medicare Physician Fee Schedule of their allowed Part B charges if they meet the defined
reporting requirements. The PQRS was initially referred to as the Physician Quality Reporting
Initiative, or PQRI.
The PQRS was first implemented in 2007 as an incentive for voluntary reporting of quality
measures in accordance with a section of the Tax Relief and Health Care Act of 2006. The PQRS
was further extended and enhanced by legislation such as the Medicare, Medicaid, and State
Children’s Health Insurance Program (SCHIP) Extension Act of 2007 (MMSEA) and the
Medicare Improvements for Patients and Providers Act of 2008 (MIPPA). A number of changes
have been made to the PQRS, including group measures, the group reporting option, and
additional measures. The PQRS was extended further with the enactment of MMSEA. MMSEA
provided professionals greater flexibility for participating in the PQRS for 2008 and 2009 by
authorizing CMS to establish alternative reporting criteria and alternative reporting periods for
the reporting measures groups and for the submission of data on the PQRS quality measures
through clinical data registries. MIPPA, enacted in July 2008, made the PQRS program
permanent, further enhanced the PQRS, and established a new stand-alone incentive program for
successful electronic prescribers.
The eRx Incentive Program, the other program being evaluated in this project, was first
implemented in 2009. The eRx is another incentive reporting program that uses a combination of
incentive payments and payment adjustments to encourage eRx by eligible professionals. The
program provides an incentive payment to practices with eligible professionals who successfully
e-prescribe for covered Physician Fee Schedule services furnished to Medicare Part B Fee-ForService (FFS) beneficiaries. Eligible professionals do not need to participate in PQRS to
participate in the eRx Incentive Program.
The PQRS and eRx incentive programs have grown over the years to promote participation and
reporting success.

1

Surveys of eligible professionals and administrators can help us understand possible motivations
for participating in PQRS/eRx. For example, providers who view quality measures as meaningful
and reliable indicators of the care that they provide may be more likely to participate in a quality
improvement program. Similarly, providers’ comfort and experience with HIT (Health
Information Technology) may influence the decision of whether to participate in programs like
PQRS/eRx and, once the decision has been made to participate, will clearly affect the choice of
data submission method. As such, it will be important to the implementation and impact
evaluation to collect this type of survey data from participating and non-participating eligible
professionals to help determine whether differences in attitudes and experiences toward HIT and
quality measurement might be associated with program participation. In addition, the
participation in these initiatives requires administrators (e.g., practice managers, billing
managers, and office managers) to address the technical aspects of the project regarding
experience with data submission. Therefore we will survey two groups: (1) eligible professionals
and (2) administrators who work at eligible professionals’ facilities.
Documents to be used in this study are in Attachments A through D as follows:
A. List of Eligible Professionals.
B. Eligible Professional and Administrator Surveys and Correspondence.
B1.

Eligible Professional Survey—Electronic.

B2.

Eligible Professional Survey—Hardcopy.

B3.

Administrator Survey—Electronic.

B4.

Administrator Survey—Hardcopy.

B5.

Eligible Professional and Administrator Surveys Correspondence.

B6.

Fact Sheet.

B7.

Screen Shots.

C. Interview Topic Guides and Correspondence.
C1.

Eligible Professional and Administrator Interview Topic Guide: Participation
Module.

C2.

Eligible Professional and Administrator Interview Topic Guide: Non-Participation
Module.

C3.

Eligible Professional and Administrator Interview Topic Guide: Correspondence.

D. Survey of Medicare Beneficiaries and Correspondence.
D1.

Survey of Medicare Beneficiaries.
2

D2.

Survey of Medicare Beneficiaries: Correspondence.

Other attachments are:
E. Response to Public Comments.
F. Revisions to Eligible Professional Survey.
B.

Justification

1. Need and Legal Basis
Pursuant to SECTION 3002 of Health Care Reform H.R. 3590, TITLE III—IMPROVING THE
QUALITY AND EFFICIENCY OF HEALTH CARE, Subtitle A—Transforming the Health
Care Delivery System, Part I, the work under this contract is being performed. The collection of
information for this study is voluntary and applies to eligible professionals or group practices
who participate in the PQRS and/or eRx. In addition, this study includes eligible professionals
who do not participate in the PQRS/eRx (for comparison purposes) and Medicare beneficiaries
served by the eligible professionals selected for the study. The evaluation of PQRS and eRx is
being carried out by Econometrica, Inc., a private research organization under contract with
CMS.
2. Information Users
Data collected in this study will be used by CMS to assess the impact of PQRS and eRx on the
quality of care provided to Medicare beneficiaries. In addition, the findings will enable CMS to
make informed decisions regarding how to improve and/or modify the programs in future years.
3. Use of Information Technology
The information will be collected by telephone, electronically, and by mail. Eligible
professionals and administrators will be given the option of reporting through a mail survey or
electronically through a commercial Web survey system. Information from beneficiaries will be
collected by mail. Beneficiaries will also be given the opportunity to complete the survey by
telephone.
4. Duplication of Similar Information
This collection does not duplicate similar information collection.
5. Impact of Small Business
While small businesses will be impacted, this collection does not impose significant impact on
small businesses and other entities (e.g., individual eligible professionals). In addition, questions
have been held to the absolute minimum that is required for the intended use of the data.

3

6. Less Frequent Collection
If these data are not collected, CMS will not be able to measure the impact of the PQRS and the
eRx programs on the quality of care being provided to Medicare beneficiaries. It will hinder
CMS’ ability to make informed decisions regarding how to improve and/or modify these
programs in the future. This survey has not been conducted in the past and is a onetime data
collection activity. The information being collected is not available from any other source.
7. Special Circumstances
There are no special circumstances associated with this data collection.
8. Federal Register/Consultation
The 60-day notice was published in the Federal Register, Volume 78, page number 35937 on
June 14, 2013. The comment period ended August 13, 2013. One organization submitted
comments, which are as follows:
1.

The survey should make clear which professionals are eligible for the eRx Incentive
Program as well as make clear the applicable hardship exemptions.

2.

In the Eligible Professionals/Administrators Survey, add “anesthesiology” to the list of
professionals and delete “nurse anesthesiology” from the list.

3.

Question 1 of the Medicare beneficiary survey collects information about care to the
beneficiary in the last 12 months; therefore, many of the questions are not applicable to
physician anesthesiologists.

A response to these comments is in the document “CMS Responses to Public Comments
Received for CMS-10482.” (Attachment E.)
Discussions were not held outside of CMS in the development of this evaluation study.
9. Payments/Gifts to Respondents
To encourage Web response on surveys of eligible professionals and administrators, they will be
offered a $100 postpay gift card for Web completion or a $50 postpay gift card for mail survey
completion. The gift card is a show of appreciation for the eligible professional’s and
administrator’s time and is being used to maximize response rate.
Physicians, other clinicians, and administrators are a challenging group from which to receive a
sufficient response rate; therefore, we are including an incentive. Incentives have been shown to
encourage participation and increase response rates, which in turn improves the validity and
reliability of the data (Shettle and Mooney 1999; Abreu and Winters 1999).1 “In a recent survey
1

Shettle, Carolyn and Geraldine Mooney. 1999. “Monetary Incentives in Government Surveys.”
Journal of Official Statistics 15:231–50; Abreu, Denise A., Elizabeth Martin, and Franklin Winters. 1999. “Money
and Motive: Results of an Incentive Experiment in the Survey of Income and Program Participation.” Paper

4

of HIV practitioners, a postpay differential incentive ($40 Web/$20 mail) resulted in two-thirds
of responses gathered via the Web, despite the lack of email addresses” (Mathematica 2012).2
Similarly, in a survey of recent college graduates, a differential incentive was also shown to
encourage Web response over other modes when the incentive favored that method collection
(NSRCG 2008, 2010).3 To facilitate Web completion in a similar situation where email
addresses are lacking, we will initially offer the Web mode (the approach mode that is least
burdensome and most cost-efficient) with a $100 postpay incentive in the initial contact and first
reminder letter. Then, at the point of the second and third reminder mailings, we will offer both
the Web and the mail mode with a differential incentive favoring Web response. That is, Web
respondents will receive a $100 postpay incentive, whereas those who respond by mail will
receive a $50 postpay incentive. (Attachment B5.)
Medicare beneficiaries selected to participate in the survey will receive a $2 prepay incentive to
encourage their participation.
10. Confidentiality
All respondents will be assured of confidentiality and told the purposes for which the
information is collected; any identifiable information about them will not be used or disclosed
for any purpose. In instances where respondent identity is needed, the information collection will
fully comply with all aspects of the Privacy Act of 1974. The only personally identifiable
information that will be used are names and mailing addresses that will be acquired from CMS
data files for the purpose of mailing letters and surveys instruments to survey participants. It has
been determined that a Privacy Impact Assessment does not need to be done. The contractor and
its staff will adhere to all CMS statutes, regulations, and policies regarding confidentiality of all
data collected in the surveys.
11. Sensitive Questions
Sensitive questions are not being asked of any of the respondents selected for this study.

presented at the International Conference on Survey Nonresponse, Portland, Oregon.
2
HIV Workforce Study, Mathematica Policy Research, 2012.
3
Heaviside, Sheila, Donsig Jang, Kirsten Barrett, Geraldine Mooney, and Kelly Kang. “Impact of Monetary
Incentives and Web Survey Options in the 2008 National Survey of Recent College Graduates (NSRCG) on
Increasing Response Rates in Historically Low Responding Groups.” Paper presented at the American Association
of Public Opinion Research Annual Meeting, Chicago, May 14, 2010.

5

12. Burden Estimates
Surveys of Eligible Professionals and Administrators
Assumptions:
Total responses
Administrators (paper) share (%)
Professionals (electronic) share (%)
Administrators share (#)
Professionals share (#)
Hourly cost burden for Administrators
Hourly cost burden for Professionals

8,400
40
60
3,360
5,040
$46.17
$87.18

Hours and Cost per Response for Reporting for Surveys of Eligible Professionals and
Administrators
Time per
Response
(minutes)

Hours per
Response

Hourly Cost
Burden

Annual
Hour
Burden

Cost per
Response

Annual Cost
Burden

Administrators

15

0.25

$46.17

840

$11.54

$ 38,782.80

Professionals

10

0.17

$87.18

840

$14.53

$ 73,231.20

Total

$112,014.00

The Time per Response is 15 minutes (0.25 hours) for administrators and 10 minutes (0.17
hours) for professionals. The Annual Hour Burden for all administrators is 840 hours, and the
Annual Hour Burden for all professionals is 840 hours. At an Hourly Cost Burden of $46.17 and
a Cost per Response of $11.54 for administrators and an Hourly Cost Burden of $87.18 and a
Cost per Response of $14.53 for professionals, the Total Annual Cost Burden is $112,014.00.
Survey of Medicare Beneficiaries
Assumptions:
Total responses
Hourly burden cost for beneficiaries

4,200
$7.11

Hours and Cost Per Response for Reporting for Survey of Medicare Beneficiaries

Beneficiaries

Time per
Response
(minutes)

Hours per
Response

Hourly Cost
Burden

Annual
Hour
Burden

Cost per
Response

Annual Cost
Burden

30

0.50

$7.11

2,100

$3.56

$14,931.00

The Time per Response is 30 minutes (0.5 hours). The Annual Hour Burden for all beneficiaries
is 2,100 hours. At an Hourly Cost Burden of $7.11 and a Cost per Response of $3.56, the Annual
Cost Burden is $14,931.00.
6

Interviews of Eligible Professionals and Administrators
Assumptions:
Total responses
Administrators (paper) share (%)
Professionals (electronic) share (%)
Administrators share (#)
Professionals share (#)
Hourly burden cost for Administrators
Hourly burden cost for Professionals

50
50
50
25
25
$46.17
$87.18

Hours and Cost Per Response for Reporting for Surveys of Eligible Professionals and
Administrators
Time per
Response
(minutes)

Hours per
Response

Hourly Cost
Burden

Annual
Hourly
Burden

Cost per
Response

Annual Cost
Burden

Administrators

30

0.50

$46.17

12.5

$23.09

$577.13

Professionals

30

0.50

$87.18

12.5

$43.59

$1,089.75

Total

$1,666.88

The Time per Response is 30 minutes (0.5 hours). The Annual Hour Burden for administrators is
12.5 hours and the Annual Hour Burden for professionals is 12.5 hours. At an Hourly Cost
Burden of $46.17 and a Cost per Response of $23.09 for administrators and an Hourly Cost
Burden of $87.18 and a Cost per Response of $43.59 for professionals, the Annual Cost Burden
is $1,666.88.
13. Capital Costs
There are no capital costs associated with this study.
14. Annualized Costs to the Federal Government
Since these are onetime information collection activities, the total estimated cost is also the
annualized cost.
Surveys of Eligible Professionals and Administrators
We will contact 8,400 eligible professionals and administrators at solo and group practices
selected from the survey sampling frame provided from the analysis of program and claims data
to participate in the survey. We will offer a differential incentive to complete the survey via the
Web method—$100 gift card for Web completion versus $50 for mail completion. We anticipate
a 50-percent response rate yielding 4,200 respondents, with 60 percent of respondents using
electronic means and 40 percent using paper/mail.

7

Hours: 500 hours including design, methodology, formulating questions, writing and testing
survey, implementation, data collection, data analyses, and report.
Operational expenses:
Incentives:
Equipment/supplies:
Overhead:
Printing and mailing:
Support staff:

$336,000
$1,000
$50,000
$30,000
Support staff will be used to answer questions and
phone calls about the surveys and are included in the
500 hours.

Total: $ 492,000.
Survey of Medicare Beneficiaries
We will contact approximately 4,200 beneficiaries with an anticipated ineligibility rate of 10
percent, yielding an eligible sample of 3,750. The estimated response rate is between 30 and 35
percent, yielding approximately 1,275 completed surveys.
Hours: 670 hours including design, methodology, formulating questions, writing and testing
survey, implementation, data collection, data analyses, and report.
Operational expenses:
Incentives:
Equipment/supplies:
Overhead:
Printing and mailing:
Support staff:

$8,400
$2,000
$112,320
$15,000
Support staff will be used to answer questions and
phone calls about the surveys and are included in the
670 hours.

Total: $ 238,220.
Interviews of Eligible Professionals and Administrators
A small percentage of surveyed eligible professionals and administrators will be the subject of
more in-depth interviews to elicit information not amenable to a survey. We will interview 25
eligible professionals and 25 administrators, offering an incentive of $100 in the form of a gift
card.

8

Hours: 150 hours including design, methodology, formulating topic guides, writing and testing
topic guides, implementation, data collection, data analyses, and report.
Operational expenses:
Incentives:
Equipment/supplies:
Overhead:
Printing:
Support staff:

$5,000
$100
$1,000
$100
Support staff will be used to answer questions and phone
calls about the surveys and are included in the 150 hours.

Total: $28,700.
Federal FTE on Project
GS 13-2 salary at 20 percent FTE

$27,000

Total: $27,000.
Total Cost to the Government:
Surveys of Eligible Professionals and Administrators
Survey of Medicare Beneficiaries
Interviews of Eligible Professionals and Administrators
Federal FTE on Project
Total

$492,000
$238,220
$28,700
$27,000
$785,920

15. Changes to Burden
The sample size for eligible professionals and administrators increased from 2,100 to 8,400. The
main reason for the increase is to ensure acceptable precision in the estimates for the various cell
strata after determination of what those strata would be. The figure of 8,400 was arrived at using
conventional power calculation formulas.
There is also a change in reporting burden from $28,003.50 to $112,014.00, a four-fold increase.
The change is solely due to the quadrupling the sample size from 2,100 to 8,400. Total annual
hours burden increased by the same multiple, from 210 to 840. Time per response, hourly cost
burden, and cost per response are unchanged.
Following is a summary of changes to the instruments: The list of specialties in the electronic
version of the Eligible Professional Survey was revised based upon comments received to the 60day notice in the Federal Register. Other changes were made to dates in the electronic and
hardcopy version of the Eligible Professional Survey, the electronic version of the Administrator
Survey, and the hardcopy version of the Administrator Survey to adjust for the surveys being
initiated in 2014 instead of 2013 (Attachment F).

9

16. Publication/Dates
Data collected for this evaluation study will be published. The schedule of major activities for
the study is as follows:
Activity

Start Date

End Date

December 2012

February 2013

December 2012

February 2013

December 2012

February 2013

Request OMB Clearance
Conduct Survey of Eligible Professionals and
Administrators
Conduct Interviews of Eligible Professionals and
Administrators
Conduct Survey of Medicare Beneficiaries

April 2013

December 2013

January 2014

February 2014

January 2014

February 2014

January 2014

March 2014

Analyze Data

February 2014

April 2014

Develop Reports

May 2014

July 2014

Develop Surveys of Eligible Professionals and
Administrators Instruments
Develop Interviews of Eligible Professionals and
Administrators Modules
Develop Survey of Medicare Beneficiaries Instrument

17. Display of Expiration Date
The expiration date will be displayed on the cover page of the Surveys of Eligible Professionals
and Administrators and the Survey of Medicare Beneficiaries and on the invitation letter for the
Interviews of Eligible Professionals and Administrators.

10