CMS-R-246 - Supporting Statement A - Passback2 - 032218 CLEAN

SUPPORTING STATEMENT – Part A

Medicare Advantage, Medicare Part D, and Medicare Fee-For-Service Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey

CMS-R-246, OMB 0938-0732

Note: This information collection request’s currently approved title is, “Medicare Advantage and Medicare Fee-For-Service Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey.” In this iteration we propose to revise the title to read, “Medicare Advantage, Medicare Part D, and Medicare Fee-For-Service Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey.” This title more accurately reflects the data collection.

BACKGROUND

Based on requirements in the 2003 Medicare Prescription Drug Improvement and Modernization Act (MMA), the Centers for Medicare & Medicaid Services (CMS) has collected information about the experiences of Medicare Advantage and Medicare Prescription Drug Plan enrollees with their plans through the annual implementation of the CAHPS Survey since 2006. Earlier, requirements in the Balanced Budget Act of 1997 also required CMS to collect and report satisfaction and quality information about the Medicare health plans available under the Medicare + Choice plans and the Medicare Fee-For-Service (FFS) program and to provide this information to Medicare enrollees to assist them in their selection of a Medicare plan. The CAHPS survey for health plans has been collected since 1997, and the Medicare FFS survey has been collected since 2000.

The MMA under Sec. 1860D-4 (Information to Facilitate Enrollment) requires CMS to conduct consumer satisfaction surveys of plan enrollees in Medicare Advantage (MA) and Medicare prescription drug plans (PDPs) and report the results to Medicare beneficiaries prior to the annual enrollment period. This request for approval is for CMS to continue conducting the Medicare CAHPS surveys annually to meet the requirement to conduct consumer satisfaction surveys regarding the experiences of beneficiaries with their health and prescription drug plans.

This information collection request includes the CAHPS data collection requirements set forth in the Part C and D final rule published on January 22, 2009. We issued regulations to require that MA organizations, Part D sponsors, and section 1876 cost contracts pay for the data collection costs of the annual CAHPS survey beginning in 2011. Previously, CMS had paid for the fielding of these surveys. As we noted in the preamble to the final rule, in the 2010 Call Letter to Part C and D sponsoring organizations, we informed all MA and Part D contracts with at least 600 enrollees as of July 1 of the prior calendar year that they would be expected to pay for the data collection costs of the CAHPS survey starting with the administration of the 2011 annual CAHPS survey. The final rule set forth this requirement under §422.152(b)(5) for Part C, §417.472(j) for section 1876 cost contracts, and §423.156 for Part D. CMS will continue to pay for the data collection costs for the Medicare FFS CAHPS survey.

CMS is using a data collection model similar to the one used for the Health Outcomes Survey (OMB 0938-0701, CMS-10203), commercial health plan CAHPS (this is not a government survey, consequently an OMB control number is not applicable), Hospital CAHPS (OMB 0938-0981, CMS-10102), and Home Health Care CAHPS (OMB 0938-1066, CMS-10275). CMS approves and trains survey vendors to collect and submit data on behalf of the MA, section 1876 cost, and Part D contracts. All contracts that are required to conduct CAHPS need to contract directly with an approved vendor. CMS is responsible for approving and training vendors, providing technical assistance to vendors, overseeing vendors to ensure that they are following the data collection protocols, providing the samples directly to the survey vendors, collecting and analyzing the data for public reporting, and producing reports that the plans can use for quality improvement.

In addition to revising this information collection request’s title, this iteration reduces the time for Medicare beneficiaries to complete a CAHPS survey. We have also updated the pneumonia question on the FFS, MA-only, and MA-PD surveys. The requirements and burden for MA and PDP contracts is unchanged.

A. JUSTIFICATION

1. Need and Legal Basis

CMS is required to collect and report information on the quality of health care services and prescription drug coverage available to persons enrolled in a Medicare health or prescription drug plan under provisions in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA). Specifically, the MMA under Sec. 1860D-4 (Information to Facilitate Enrollment) requires CMS to conduct consumer satisfaction surveys regarding Medicare prescription drug plans and Medicare Advantage plans and report this information to Medicare beneficiaries prior to the Medicare annual enrollment period. The Medicare CAHPS survey meets the requirement of collecting and publicly reporting consumer satisfaction information. The CAHPS survey measures are incorporated into the Star Ratings that are published on www.medicare.gov each fall for consumers. A subset of the CAHPS measures are also included in the Medicare & You Handbook.

2. Information Users

The primary purpose of the Medicare CAHPS surveys is to provide information to Medicare beneficiaries to help them make more informed choices among health and prescription drug plans available to them. Survey results are reported by CMS in the Medicare & You handbook published each fall and on the Medicare Plan Finder website. Beneficiaries can compare CAHPS scores for each health and drug plan as well as compare MA and FFS scores when making enrollment decisions. The Medicare CAHPS also provides data to help CMS and others monitor the quality and performance of Medicare health and prescription drug plans and identify areas to improve the quality of care and services provided to enrollees of these plans. CAHPS data are included in the Medicare Part C & D Star Ratings and used to calculate MA Quality Bonus Payments. The Star Ratings program has led to health and drug plan quality improvement. For example, the average enrollment-weighted overall Star Rating for MA-PD contracts has increased from 3.92 in 2015 to 4.06 in 2018. In 2015 approximately 60% of MA-PD enrollees were in contracts with 4 or more stars; this has increased to 73% of enrollees in 2018.

3. Use of Improved Information Technology

There are no barriers or obstacles that prohibit the use of improved technology for this information collection activity. CMS will provide approved CAHPS vendors with the samples of enrollees for their client plans. The data collection protocol is mixed mode (mail with telephone follow-up of non-respondents).

4. Duplication of Efforts

The health plan section of the survey that CMS is conducting is the same survey that is required by the National Committee for Quality Assurance (NCQA) for accreditation of Medicare health plans; thus, there is no duplication of effort.

5. Small Business

Survey respondents are Medicare Advantage (MA with or without a Prescription Drug Plan), Medicare Fee-For-Service (FFS), or Medicare Stand Alone Prescription Drug Plan (PDP) enrollees. Both MA and PDP contracts pay for the data collection using vendors approved by CMS. The cost of conducting the CAHPS survey for each contract is estimated to be approximately $5,000. The survey instruments and procedures for completing the instruments are designed to minimize burden on all respondents and will not have a significant impact on small businesses or other small entities.

6. Less Frequent Collection

The Medicare CAHPS survey is conducted annually. CMS is required to provide up-to-date information to Medicare beneficiaries each year prior to the annual enrollment period to help them make more informed plan choices. Additionally, the information is used by CMS for monitoring of plan quality and by plans to improve the health care and services they provide to their enrollees. Given the uses of the data, it is important that persons with Medicare, CMS, and others have current information about the experiences of persons enrolled in Medicare health and prescription drug plans. Provision of this information on an annual basis allows for the design of quality improvement initiatives on a timely basis and helps inform beneficiaries about the quality and performance of health and prescription drug plans at the time they make a health or drug plan selection each year.

7. Special Circumstances

There are no special circumstances that would require an information collection to be conducted in a manner that requires respondents to:

-Report information to the agency more often than quarterly;

-Prepare a written response 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;

-Collect data 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;

-Use a statistical data classification that has not been reviewed and approved by OMB;

-Include a pledge of confidentiality that is not supported by authority established in statue or regulation that is not supported by disclosure and data security policies that are consistent with the pledge, or which unnecessarily impedes sharing of data with other agencies for compatible confidential use; or

-Submit proprietary trade secret, or other confidential information unless the agency can demonstrate that it has instituted procedures to protect the information's confidentiality to the extent permitted by law.

8. Federal Register/Outside Consultation

The 60-day notice published in the Federal Register on June 13, 2016 (81 FR 38187). Comments were received and are attached to this package along with our response.

Subsequent to publication of the 60-day notice, CMS identified via internal review that the pneumonia question on the FFS, MA-only, and MA-PD surveys was not properly updated. The question has been updated in the 30-day information collection request’s surveys and crosswalks.

9. Payment/Gifts to Respondents

Respondents do not receive any payments or gifts.

10. Confidentiality

Individuals and organizations contacted are assured of the confidentiality of their replies under 42 U.S.C. 1306, 20 CFR parts 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. The System of Records is HPMS No. 09-70-4004 (January 14, 2008; 73 FR 2257).

11. Sensitive Questions

There are no sensitive questions associated with this collection. Specifically, the collection does not solicit questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private.

12. Burden Estimate (Hours & Wages)

Wage Estimates

To derive average costs for individuals we used data from the U.S. Bureau of Labor Statistics’ May 2016 National Occupational Employment and Wage Estimates for our salary estimate (www.bls.gov/oes/current/oes_nat.htm). We believe that the burden will be addressed under All Occupations (occupation code 00-0000) at $23.86/hr since the group of individual respondents varies widely from working and nonworking individuals and by respondent age, location, years of employment, and educational attainment, etc.

We are not adjusting this figure for fringe benefits and overhead since the individuals’ activities would occur outside the scope of their employment.

Burden Estimates

The Medicare CAHPS survey is conducted annually. The CAHPS survey takes on average 13 minutes to complete. This burden varies by survey type as shown below. For the total sample of 799,650 members, the total burden to complete the survey is approximately the sum of MA¹ (0.25 hours x 427,200), PDP (0.17 hours x 97,500), and FFS Medicare (0.25 x 274,950) or 192,113 hours.

The reason for the variation in burden hours by survey type is that the CAHPS survey has specific questions relevant to the Medicare plan in which a sample member is enrolled, i.e., MA-only, MA-PD, PDP, or FFS. Sample size for PDP survey is 1,500 to improve reliability, and the sample size for FFS is needed for refined comparisons with MA.

Time

-	Units	Sample/Unit	Sample by Type	Burden/Survey	Total Hours
MA	534	800	427,200	0.25	106,800
PDP	65	1,500	97,500	0.17	16,575
FFS	78	3,525	274,950	0.25	68,738
TOTAL HOURS	-	-	799,650	-	192,113

Cost

-	Number of Respondents	Total Burden Hours	Average Hourly Wage	Estimated Data Collection Cost to Respondents
MA	427,200	106,800	$23.86/hr	$2,548,248
PDP	97,500	16,575	$23.86/hr	$395,479.5
FFS	274,950	68,738	$23.86/hr	$1,640,088.68
Total	799,650	192,113	$23.86/hr	$4,583,816.18

Information Collection Instruments and Instruction/Guidance Documents

• MA-only Survey

• MA-PD Survey

• PDP Survey

• FFS Survey

13. Capital Costs

The cost to Medicare MA and PDP contracts is the cost of their contracting with Medicare CAHPS vendors approved by CMS to pay for the data collection for the sample of Medicare enrollees in their respective contracts that CMS provides to the vendors. CMS estimates this cost is about $5,000 per contract at the contract level, although the final cost is dependent on the negotiated contracts that the MA/PDP contracts execute with CAHPS approved vendors for their data collection. CMS is estimating that there are 599 MA/PDP contracts that are impacted by this small cost. We estimate a total cost of $2,995,000.

14. Cost to Federal Government

The total cost to the Federal government for the 2017 CAHPS Survey is estimated to be $6 million. This total includes CMS management and implementation of the Medicare FFS data collection; approval process for survey vendors; training, oversight, and technical assistance of the approved survey vendors for the MA and PDP contracts; preparation and cleaning of data submitted by the survey vendors for the MA and PDP contracts; data analysis; preparation of CAHPS measures for public reporting; and production of plan reports to be used by all participating MA and PDP plans for quality improvement.

15. Changes to Burden

This information collection request’s currently approved title is, “Medicare Advantage and Medicare Fee-For-Service Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey.” In this iteration we propose to revise the title to read, “Medicare Advantage, Medicare Part D, and Medicare Fee-For-Service Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey.” This title more accurately reflects the data collection.

CMS shortened the Medicare CAHPS surveys by removing some questions that are not used in current Part C & D Star Ratings measures. The MA-PD survey is 27 items shorter, the MA-only survey is 15 items shorter, the PDP survey is 18 items shorter, and the FFS survey is 19 items shorter. The questions removed dealt with phoning a doctor’s office or clinic after regular hours; personal doctors using a computer or handheld device; visit notes; reminders about appointments, immunizations, and tests; items about Medicare rights; and items about prescription drug plan customer service. None of the items removed are used in the Part C & D Star Ratings. Please see survey crosswalks for details. Due to this reduction in survey content, the burden to Medicare beneficiaries to complete a CAHPS survey has gone down: MA burden is 0.25 hour and the stand-alone PDP and FFS survey burdens are 0.17 and 0.25 hours, respectively. Compared to prior survey burden of 0.4 for MA, 0.25 for stand-alone PDP, and 0.3 for FFS. The overall burden has been reduced by 85,627 hours. Changes to the survey content are demonstrated in the respective Crosswalks which are attached to this package.

The burden to MA and PDP contracts has been moved from Supporting Statement section 12 (Burden Estimates) to its proper place in section 13 (Capital Costs). The cost per contract has not changed from the currently approved estimate. However, because Capital Costs are not added to the ROCIS burden table, this change adjusts our burden estimate by minus 32,346 hr and $2,995,000.

Subsequent to publication of the 60-day Federal Register notice, CMS identified via internal review that the pneumonia question on the FFS, MA-only, and MA-PD surveys was not properly updated, so we have updated the question on those surveys and crosswalks. This item is a HEDIS quality measure based on NCQA specifications, and NCQA recommended the wording change due to updated pneumococcal vaccination guidelines. This change has no impact on our burden estimates.

16. Publication/Tabulation Dates

The CAHPS survey results are disseminated through tools on www.medicare.gov – Medicare Plan Finder – that contain comparative information on prescription drug and health plans. The information is made available to the public through “print on demand” (i.e., beneficiaries can request a hardcopy of this information from 1-800-MEDICARE). The Medicare & You Handbook also contains some CAHPS information and instructions about how to obtain information on additional measures. The information is made available in the fall following each annual data collection, prior to the annual enrollment period.

Medicare health and prescription drug plans also receive plan-specific reports that contain detailed information on the CAHPS results for their plan for use in quality improvement initiatives. These reports include background information on the methodology and definitions used in CAHPS to assist them in understanding the information in their report.

The Medicare CAHPS survey meets the requirement of collecting and publicly reporting consumer satisfaction information. MA & PDP CAHPS survey measures are incorporated into the Part C & D Star Ratings that are published on www.medicare.gov each fall for consumers. A subset of the CAHPS measures are also included in the Medicare & You Handbook.

17. Expiration Date

No exemption is being requested.

18. Certification Statement

There are no exceptions taken to item 19 of OMB Form 83-1.

1 We have combined estimates for MA-only and MA-PD survey versions here for simplicity.

1