CMS-10519 PQRS Data Validation Electronic Survey - Supporting Statement A - final

Part A. Supporting Statement

Physician Quality Reporting System and the Electronic Prescribing Incentive Program Data Assessment, Accuracy and Incorrect Payments Identification Support

1. 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. The survey is primarily used to ensure the program’s burdens for reporting are low, logical and achievable by the majority of providers.

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, Qualified Clinical Data Registries (QCDRs), EPs submitting data via the Electronic Health Record (EHR) Direct and Claims reporting options, 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 30. 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. Lastly, as part of the survey process, the vendors who submit data on behalf of EPs will be asked to provide data samples and/or the aggregation logic that they use to compile the data files submitted to CMS.

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.

2. 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 required and applies to Group Practices using the Group Practice Reporting Option (GPRO), Registries, Qualified Clinical Data Registries (QCDRs), EPs submitting data via the EHR Direct and Claims reporting options, and EHR Data Submission Vendors (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.

2. Information Users

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. CMS uses this information for analysis and planning. Data collected and results are not released to the public. The statistical sampling size for this survey does not provide insight for any program determinations or public release.

3. Use of Information Technology

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.

4. Duplication of Similar Information

This collection does not duplicate similar information collection.

5. Impact of Small Business

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.

6. Less Frequent Collection

If these data are not collected, CMS will not be able to uncover the data integrity issues in the 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.

7. Special Circumstances

There are no special circumstances associated with this data collection.

8. Federal Register/Consultation

The 60-day notice was published on September 25, 2015. There was one comment and it was addressed.

Discussions were not held outside of CMS in the development of this evaluation study.

9. Payments and Gifts to Respondents

There is no incentive paid to Group Practices, Registries, EPs, and DSVs for responding to the survey.

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. 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 is not required because no PII or PHI is collected. 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

There are no sensitive questions in the survey.

12. Burden Estimates

We estimate that it will take 1 hour or less to include answering the questions and uploading the survey. An additional 30 minutes may be needed if follow-up is necessary.

Table 1: Total Survey Burden in Hours by Contract Year, below, shows the total survey burden in hours by contract year based on the projected yearly samples.

Table 1: Total Survey Burden in Hours by Contract Year

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 2: Annual Cost Burden by Entity, below, shows the Annual Cost Burden by Entity.

Table 2: 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
EPs via Claims	OY 2 and 3	1.5	$17.68	$26.52
QCDRs	OY 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.
http://www.bls.gov/oes/current/oes_nat.htm#b29-0000; Role = Medical Records and Health Information Technicians

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: Total Cost Burden by Contract Year, below, shows the Total Cost Burden by Contract Year based on the projected yearly samples.

Table 3: Total Cost Burden by Contract Year

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
x	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, QCDRs, EPs submitting via EHR Direct and Claims, and EHR DSVs

In Option Years 1, 2, and 3, we will contact 115 entities selected from the survey sampling frame provided from analysis of the Program.

Hours: 400 hours including design, methodology, formulating questions, writing and testing survey, implementation, data collection, data analyses, and reporting.

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 $3,000.00 and the Total Equipment cost for base + option years is $12,000.00. The support staff cost for base year is $17,370, and includes Design, Development, Administration, and Maintenance. For Option years, there is only Administration and Maintenance, and the cost is $2,250.00 for each Option year.

Table 4: Equipment and Support Staff Cost shows the costs for equipment and support staff.

Table 4: 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	$3,000.00	$2,250.00
Total Cost	$12,000.00	$24,120.00

Total Cost to Government =$36,120.00

15. Changes to Burden

This is an amendment to an existing collection. PQRS program operations and policies are transitioning from an incentivized quality reporting program to a voluntary quality reporting program that allows eligible providers to avoid payment adjustments. The burden for the survey does not change, though the environment and incentives under which collection occurs has changed.

16. Publication/Dates

Data collected for this evaluation study will not be published. The schedule of major activities for the study is shown in Table 5: Schedule of Major Study Activities, below.

Table 5: Schedule of Major Study Activities

Activity	Start Date	End Date
Develop updated PRA Package, to include QCDRs and EPs submitting via Claims	December 2014	January 2015
Request OMB Clearance	January 2015	September 2015
Develop and administer surveys of Group Practices, Registries, QCDRs, EPs submitting via Claims and EHR Direct, and EHR DSV	September 2015	May 2016
Analyze Data	May 2016	July 2016
Develop Reports	August 2016	November 2016

17. Display of Expiration Date

CMS will display the expiration date.