Physician Quality Reporting System and the Electronic Prescribing Incentive Program Data Assessment, Accuracy and Incorrect Payments Identification Support
Background
The Physician Quality Reporting System (PQRS) and Electronic Prescribing Incentive (eRx) Program Data Assessment, Accuracy and Incorrect Payments Identification Support contract was created to identify and address problems with data handling, data accuracy, and incorrect payments for the PQRS and eRx Programs.
Because the data submitted by, or on behalf of, eligible professionals (EPs) to the PQRS and eRx Programs is used to calculate incentive payments and payment adjustments, it is critical that this data is accurate. Additionally, the data is used to generate Feedback Reports for EPs and, in some cases, is posted publicly on the CMS website, further supporting the need for accurate and complete data.
The ultimate use of the clinical quality reporting data is to improve the quality of care for Medicare beneficiaries. This aligns with the CMS mission and helps to make healthcare more cost-effective and efficient.
This request is for clearance to conduct surveys of Group Practices, Registries, EPs submitting data via the Electronic Health Record (EHR) Direct reporting option, and EHR Data Submission Vendors (DSVs) in support of evaluating the data submitted for the PQRS and eRx Incentive Programs. The survey uses a series of questions, arranged by category, to gather information about data handling practices, training, and quality assurance, as well as the challenges that stakeholders faced in participating in the PQRS and eRx Incentive Programs.
The survey is completely automated and was designed with simplicity as a core requirement – it does not require a login and can be accessed via a link provided in a survey invitation email. There is no Protected Health Information (PHI) or Personally Identifiable Information (PII) submitted in the survey. In order to minimize the burden on the participant community, the number of questions in a survey will not exceed thirty-three. The majority of the questions in the survey are “point and click”, allowing the participant to complete the survey quickly. There is a Feedback section included in the survey, which allows for free-form text entry and document upload; however, document uploads are not required.
In very isolated instances, additional follow-up may be required. The preferred method of contact for the follow-up interview is a second electronic survey, which will contain the necessary questions. In the event there are issues making contact electronically or there are other technical challenges that cannot be overcome, the team may reach out and ask the questions telephonically.
B. Justification
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 Group Practices using the Group Practice Reporting Option (GPRO), Registries, EPs submitting data via the EHR Direct reporting option, and EHR DSVs who participate in the PQRS and/or eRx Programs. The evaluation of the PQRS and eRx data is being carried out by Arch Systems, LLC, a private organization under contract with CMS.
The survey uses a series of questions, arranged by category, to gather information about data handling practices, training, and quality assurance, as well as the challenges that stakeholders faced in participating in the PQRS and eRx Incentive Programs. Information gleaned from the surveys will be analyzed and used to make recommendations to CMS regarding improving data quality.
The survey is a fully automated, web-based application. In rare cases, if there are issues making contact electronically or there are other technical challenges that cannot be overcome, there may be a need to ask clarifying questions, via telephone, about the information submitted in the survey.
This collection does not duplicate similar information collection.
Although small businesses will be affected, this collection does not impose a significant impact on those small businesses or other entities (e.g., individual eligible professionals). In addition, survey questions have been held to the absolute minimum required for the intended use of the data.
If these data are not collected, CMS will not be able to uncover the data integrity issues in PQRS and the eRx programs or make informed decisions regarding how to improve and modify these programs in the future. This survey has not been conducted in the past and will happen once in the Base Year and will occur again in each of the three Option Years. The information being collected is not available from any other source.
There are no special circumstances associated with this data collection.
The 60-day notice was published on March 17, 2014. Comments were received and addressed.
Discussions were not held outside of CMS in the development of this evaluation study.
There is no incentive paid to Group Practices, Registries, EPs, and DSVs for responding to the survey.
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. If a respondent’s identity is needed, the information collection will comply completely with all aspects of the Privacy Act of 1974. It has been determined that a Privacy Impact Assessment does not need to be done is not required. The contractor and its staff will adhere to all CMS statutes, regulations, and policies regarding confidentiality of all data collected in the surveys.
Sensitive questions are not being asked of any of the respondents selected for this study.
12. Burden Estimates
We estimate that it will take 1 hour and 30 minutes to complete the survey:
* 45 minutes to complete the online survey
* 15 minutes to collect supporting information
* 15 minutes to upload supporting information
* 15 minutes for a phone follow-up (only if needed)
Table 1 shows the Total Survey Burden in Hours by contract year based on the projected yearly samples.
Contract Year |
Number of Entities Selected to Receive a Survey |
Time Burden per Survey |
Total Survey Burden Hours |
Base Year |
9 |
1.50 Hours |
13.5 |
Option Year 1 |
115 |
1.50 Hours |
172.5 |
Option Year 2 |
115 |
1.50 Hours |
172.5 |
Option Year 3 |
115 |
1.50 Hours |
172.5 |
Totals |
354 |
|
531 |
Table 1: Total Survey Burden in Hours by Contract Year
Table 2 shows the Annual Cost Burden by Entity.
Entity |
Applicable Contract Year |
Time Required to Complete the Survey (in hours) |
Hourly Cost Burden1 |
Annual Cost Burden |
GPRO |
Option Years (OY) 1, 2, and 3 |
1.5 |
$17.68 |
$26.52 |
Registry |
Base Year (BY) and OY 1, 2, and 3 |
1.5 |
$17.68 |
$26.52 |
EPs via EHR Direct |
OY 1, 2, and 3 |
1.5 |
$17.68 |
$26.52 |
EHR DSV |
OY 1, 2, and 3 |
1.5 |
$17.68 |
$26.52 |
1 - Hourly Cost Burden based upon the mean hourly wages, “National Compensation Survey: Occupational Wages in the United States, May 2012,” U.S. Department of Labor, Bureau of Labor Statistics. |
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As stated in the footnote above, we calculated the Hourly Cost Burden based upon the mean hourly wages, “National Compensation Survey: Occupational Wages in the United States, May 2012,” U.S. Department of Labor, Bureau of Labor Statistics.
http://www.bls.gov/oes/current/oes_nat.htm#b29-0000
Role: Medical Records and Health Information Technicians
Table 3 shows the Total Cost Burden by Contract Year based on the projected yearly samples.
Contract Year |
Annual Cost Burden per Survey |
Sample Size |
Total Cost Burden |
Base Year |
$26.52 |
9 |
$238.68 |
Option Year 1 |
$26.52 |
115 |
$3,049.80 |
Option Year 2 |
$26.52 |
115 |
$3,049.80 |
Option Year 3 |
$26.52 |
115 |
$3,049.80 |
|
Total |
354 |
$9,388.08 |
In the Base Year, the Total Burden Hours for 9 entities is 13.5. At an hourly cost of $17.68 the Total Annual Cost Burden in the Base Year is $238.68.
In Option Years 1, 2, and 3, the Total Burden Hours for 115 entities is 172.5. At an hourly cost of $17.68, the Total Annual Cost Burden for Option Years 1, 2, and 3 is $3,049.80.
13. Capital Costs
There are no capital costs associated with this study.
14. Annualized Costs to the Federal Government
Because these are onetime information collection activities, the total estimated cost is also the annualized cost.
Surveys of Registries, Group Practices, EPs submitting via EHR Direct, and DSVs
In Option Years 1, 2, and 3, we will contact 115 entities selected from the survey sampling frame provided from the analysis of program.
Hours: 400 hours including design, methodology, formulating questions, writing and testing survey, implementation, data collection, data analyses, and report.
Operational expenses:
Equipment/supplies: $12,000.00
Support staff: $24,120.00
Total cost to Government: $36,120.00
The Equipment cost per year is $3000.00 and the Total Equipment cost for base + option years is $12,000.00. The support staff cost is for base year is $17,370 includes Design, Development and Administrator & Maintenance. For Option years the there is only Administrative & Maintenance and the cost is $2,250.00 for each Option year.
See Table 4 for Equipment and Support Staff Cost
Years |
Equipment/supplies: |
Support staff |
Base Year Cost |
$ 3,000.00 |
$17,370.00 |
Option 1 Year Cost |
$3,000.00 |
$2,250.00 |
Option 2 Year Cost |
$3,000.00 |
$2,250.00 |
Option 3 Year Cost |
$,3000.00 |
$2,250.00 |
Total Cost |
$12,000.00 |
$24,120.00 |
Table 4: Equipment and Support Staff Cost
Total Cost to Government =$36,120.00
15. Changes to Burden
This is a new information collection.
Data collected for this evaluation study will be published. The schedule of major activities for the study is as follows: See below in Table 5.
Activity |
Start Date |
End Date |
Develop Surveys of Group Practices, Registries, and Data Submission Vendors (DSVs) |
December 2013 |
January 2014 |
Request OMB Clearance |
January 2014 |
September 2014 |
Conduct Survey of Group Practices, Registries, and Data Submission Vendors (DSVs) |
September 2014 |
September 2014 |
Analyze Data |
November 2014 |
November 2014 |
Develop Reports |
November 2014 |
November 2014 |
Table 5: Schedule for Major Activities for the Surveys
17. Display of Expiration Date
CMS will display the expiration date.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | vidya |
| File Modified | 0000-00-00 |
| File Created | 2021-01-26 |