Justification 2900-0823_form 10_10143e

SUPPORTING STATEMENT

EXPANDED ACCESS TO NON-VA CARE THROUGH THE VETERANS CHOICE PROGRAM

OMB 2900-0823

A. JUSTIFICATION

1. Explain the circumstances that make the collection of information necessary. Identify legal or administrative requirements that necessitate the collection of information.

The Veterans Access, Choice, and Accountability Act of 2014 (the Act) requires implementing measures to allow the Secretary of Veterans Affairs to improve health care for veterans who have not been seen within established wait-time goals or who experience challenges based on their place of residence. The Act directs VA to provide hospital care and medical services to eligible veterans through agreements with eligible non-VA health care entities or providers. VA already collects information through the following OMB approved forms: VA Form 10-10143, Election to Receive Authorized Non-VA Care and Selection of Provider for the Veterans Choice Program; VA Form 10-10143a, Health-Care Plan Information for the Veterans Choice Program; VA Form 10-10143b, Submission of Medical Record Information under the Veterans Choice Program; VA Form 10-10143c, Submission of Information on Credentials and Licenses by Eligible Entities and Providers.

VA seeks approval to add VA Form 10-10143e, Secondary Authorization Request for VA Community Care, required under this authority to authorize additional services clinically recommended by the non-VA health care entities and providers.

2. Indicate how, by whom, and for what purposes the information is to be used; indicate actual use the agency has made of the information received from current collection.

Approval of this additional form and collection of information are required to properly adjudicate and implement the requirements of the Choice Act.

1. VA Form 10-10143e would require non-VA health care providers to submit requests for additional services supporting the original authorized plan of care to the agency. A copy of all medical and dental records (including but not limited to images, test results, and notes or other records of what care was provided and why) related to a Veteran's care provided under this Program must be submitted to VA for entry into the veteran’s electronic medical record. Providers will be required to submit records produced as a result of care authorized after the beginning of the Program.

3. Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g., permitting electronic submission of responses, and the basis for the decision for adopting this means of collection. Also describe any consideration of using information technology to reduce burden.

In accordance with the Government Paperwork Reduction Act (GPEA), this collection meets the established goals as respondents are permitted to submit information electronically via the internet or by phone. Electronic versions of these forms will reduce the amount of outgoing paper from the agency. Similarly, such an adjustment will reduce the costs acquired from printing and storage of hard copy forms, postage, and hours required in delivering these forms to the public.

4. Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purposes described in Item 2 above.

The information gathered from respondents will be unique and not readily available from other VA sources. As a result, there would be no duplication of information collected.

5. If the collection of information impacts small businesses or other small entities, describe any methods used to minimize burden.

VA Form 10-10143e (Submission of Secondary Authorization Request for VA Community Care) will not impose a significant impact on these businesses as they only request essential information from each provider.

6. Describe the consequences to Federal program or policy activities if the collection is not conducted or is conducted less frequently as well as any technical or legal obstacles to reducing burden.

Failure to collect this information would prohibit VA from properly implementing the requirements of the Veterans Choice Act. Specifically, failure to collect this information would make it impossible for the agency to establish eligibility or to allow veterans to elect participation in the Choice Program. VA would also be unable to make payments on claims related to care or services furnished under the Program if it does not have information about the veteran’s other health insurance or the medical records from the non-VA provider.

7. Explain any special circumstances that would cause an information collection to be conducted more often than quarterly or require respondents to prepare written responses to a collection of information in fewer than 30 days after receipt of it; submit more than an original and two copies of any document; retain records, other than health, medical, government contract, grant-in-aid, or tax records for more than three years; in connection with a statistical survey that is not designed to produce valid and reliable results that can be generalized to the universe of study and require the use of a statistical data classification that has not been reviewed and approved by OMB.

PL 113-146 requires that information be collected prior to each use of the program. Information will be collected telephonically by contract staff.

8. a. If applicable, provide a copy and identify the date and page number of publication in the Federal Register of the sponsor’s notice, required by 5 CFR 1320.8(d), soliciting comments on the information collection prior to submission to OMB. Summarize public comments received in response to that notice and describe actions taken by the sponsor in responses to these comments. Specifically address comments received on cost and hour burden.

The notice of Proposed Information Collection Activity was published in the Federal Register on May 27, 2016 (Vol. 81, Number 33738, Pages 33738-33739). There were no comments received in response to this notice.

b. Describe efforts to consult with persons outside the agency to obtain their views on the availability of data, frequency of collection, clarity of instructions and recordkeeping, disclosure or reporting format, and on the data elements to be recorded, disclosed or reported. Explain any circumstances which preclude consultation every three years with representatives of those from whom information is to be obtained.

Outside consultation will be conducted with the public through the Federal Register comment notice period.

9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.

No payment or gifts will be provided to respondents.

10. Describe any assurance of privacy, to the extent provided by law, to respondents and the basis for the assurance in statute, regulation, or agency policy.

Information collected on these forms is protected by the Privacy Act of 1974, VA confidentiality statutes 38 USC § 5701 and 38 USC § 7332 and 45 CFR Parts 160 and 164, Health Insurance Portability and Accountability Act. Respondents are informed that the information collected will be included as a part of the system of records identified as 54VA16, Health Administration Center Civilian Health and Medical Program Records-VA as set forth in the 2005 Compilation of Privacy Act Issuances via online GPO access at http://www.gpoaccess.gov/privacyact/index.html and disclosures made in accordance with the statute.

11. Provide additional justification for any questions of a sensitive nature (Information that, with a reasonable degree of medical certainty, is likely to have a serious adverse effect on an individual's mental or physical health if revealed to him or her), such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private; include specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.

VA Form 10-10143e (Submission of Secondary Authorization Request for VA Community Care), requires a provider to furnish claim-specific medical information, including information that is considered sensitive, but would be known to the Veteran based on the consultation with the non-VA health care provider. Examples of documentation are identified within the document.

12. Estimate of the hour burden of the collection of information:

1. The number of respondents, frequency of responses, annual hour burden, and explanation for each form is reported as follows:

Form #	Respondents	Response	X Minutes ÷ 60	Annual Hours
10-10143	440,794	12.64	10	928,606
10-10143a	440,794	1.2	10	88,159
10-10143b	187,000	29.80	5	464,383
10-10143c	187,000	1	5	15,583
10-10143-e	190,675	4.56	20	289,826
TOTALS	1,446,263	49.2	50	1,786,557

The number of respondents for VA Form 10-10143 and 10-10143a are based on the estimated number of Veterans who are most likely to utilize the Veterans Choice Program. The estimated number of responses is based on their expected need to submit the required information

The number of respondents for VA Form 10-10143b and 10-10143c are based on the estimated number of eligible providers furnishing hospital care and medical services to eligible veterans through the Veterans Choice Program. The estimate is based off the number of providers furnishing non-VA care under the Patient Centered Community Care (PC3) initiative; the number of participating providers in that program for one of the two vendors (85,000) was doubled and subsequently increased by an additional 10 percent to reflect the anticipated number of providers who would furnish care under the Veterans Choice Program.

The number of respondents for VA Form 10-10143e is the expected number of forms submitted to VA by community providers requesting additional medical care for Veterans. The estimate is based off the number of providers currently estimated to be furnishing non-VA care under the Veterans Choice Program (VCP) was 187,000; the number of participating providers in that program was subsequently increased by an additional 3,675. This calculation was arrived at by knowing that 147 VA sites potentially could add an estimated 15-50 providers under the Provider Agreement initiative, so estimated 147 VA sites x 25 = 3675, for a total of 190,675 to reflect the to reflect the anticipated number of newly added providers who would furnish care under the Provider Agreement Program. The form will also be completed by community providers and submitted to VA staff directly as scheduling processes return to VA staff, beginning with Alaska tentatively scheduled to begin April 2016.

Based on the average monthly number of secondary authorization requests received by both contractors over the past 6 month period (3484/month), x 12 for an annual estimate of 41,804 secondary authorization requests, the estimated number of responses is based on the expected need for each respondent to submit the form, and is estimated at 4.56.

b. If this request for approval covers more than one form, provide separate hour burden estimates for each form and aggregate the hour burdens in Item 13 of OMB 83-I.

In accordance with the Bureau of Labor Statistics May 2015 Occupational Wage Code Median Hourly, the annualized cost to respondents is estimated at $23,225,241 (1,786,557 hours x $13 per hour).

The Occupational Code is defined as 31-0000 Healthcare Support Occupations percentile (50%Median):

(https://www.bls.gov/soc/2010/soc310000.htm)

c. Provide estimates of annual cost to respondents for the hour burdens for collections of information. The cost of contracting out or paying outside parties for information collection activities should not be included here. Instead, this cost should be included in Item 14.

There are no costs to respondents for completing the forms.

13. Provide an estimate of the total annual cost burden to respondents or record-keepers resulting from the collection of information. (Do not include the cost of any hour burden shown in Items 12 and 14).

1. This collection does not have capital, start-up, operation or maintenance costs.

2. Cost estimates are not expected to vary widely. The only estimated cost is that for the time of respondents.

2. There is no anticipated recordkeeping burden beyond that which is considered usual and customary.

14. Provide estimates of annual cost to the Federal Government. Also, provide a description of the method used to estimate cost, which should include quantification of hours, operation expenses (such as equipment, overhead, printing, and support staff), and any other expense that would not have been incurred without this collection of information. Agencies also may aggregate cost estimates from Items 12, 13, and 14 in a single table.

All work for the first four forms will be performed by two contractors hired specifically for this program. First year cost will be $300 million for the entire administrative fee for the program, including the call centers, card production, appointing and billing.

Administrative costs associated with processing of VA Form 10-10143e by VA personnel are estimated at additional 73.5 FTE (.5 nurse at each VA facility; 147 facilities, 73.5 FTE total) to perform the clinical review determinations previously performed by the contractor clinical staff. The total annual cost for the 73.5 FTE is $10,773,924 (73.5 * $146,584).

  

Grade/Step & Locality	Yearly Salary (2016)	Benefits at 100%	FTE Unit Cost
Nurse 2/5 (Rest of U.S.)	$73,292	$73,292	$146,584

15. Explain the reason for any burden hour changes since the last submission.

VA Form 10-10434e is now required to provide a communication tool for secondary authorization requests from VA Community providers directly to VA staff. This need presented with the implementation of VA Provider Agreement and Alaska Scheduling implementation, both of which now necessitate communication directly between community provider and VA staff. This form was not included in the original information collection as there was not a need for it at that time. Because of this additional form, there has been a burden increase.

16. For collections of information whose results will be published, outline plans for tabulation and publication. Address any complex analytical techniques that will be used. Provide the time schedule for the entire project, including beginning and ending dates of the collection of information, completion of report, publication dates, and other actions.

There are no plans to publish the results of these collections.

17. If seeking approval to omit the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.

VA also seeks to minimize cost of collecting, processing and using the information by not displaying the expiration date. VA seeks an exemption to waive the displaying of the expiration date to increase efficiency for the agency and respondents. Moreover, the expiration date of the Veterans Choice Program is not known at this time. It will be no later than August 31, 2017 (absent further legislative action), but it could be sooner if the Veterans Choice Fund is exhausted before then.

18. Explain each exception to the certification statement identified in Item 19, “Certification for Paperwork Reduction Act Submissions,” of OMB 83-I.

There are no exceptions.

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