CMS-10695 MIPS Survey Supporting Statement B_032720

Supporting Statement – Part B

Quality Payment Program/Merit-Based Incentive Payment System (MIPS) Surveys and Feedback Collections

CMS-10695, OMB Control Number: 0938-NEW

Introduction

Data collection methods and procedures will vary; however, the primary purpose of these collections will be for internal process and procedure development and improvement purposes; there are no plans to publish or otherwise release this information as official agency documents.

1. Describe (including a numerical estimate) the potential respondent universe and any sampling or other respondent selection method to be used. Data on the number of entities (e.g., establishments, State and local government units, households, or persons) in the universe covered by the collection and in the corresponding sample are to be provided in tabular form for the universe as a whole and for each of the strata in the proposed sample. Indicate expected response rates for the collection as a whole. If the collection had been conducted previously, include the actual response rate achieved during the last collection.

The potential respondent universe for the surveys and feedback collections approved under this generic clearance may include any MIPS eligible clinician, voluntary reporter, or third-party intermediary, payers, Alternative Payment Model (APM) entities or participants within APM entities, Medicare beneficiaries and caregivers, and any other audiences who we anticipate will submit data to the Quality Payment Program.

In section VI of the CY 2020 PFS final rule (84 FR 63105), we explain that we estimate approximately 780,000 MIPS eligible clinicians will submit quality data as individual clinicians, or as part of groups or Shared Savings Program ACOs and others may voluntarily submit. We also will receive data submitted by third-party intermediaries; for the 2021 MIPS performance period, we estimate 76 Qualified Clinical Data Registries (QCDRs), 153 Qualified Registries, and 15 CAHPS survey vendors will submit MIPS data. Finally, we will receive data from commercial and other private payers as well as APM entities and eligible clinicians seeking APM determinations; as a result, for the 2021 MIPS performance period, we estimate a total of 260 additional respondents submitting information who may be requested to complete a survey or provide feedback.

For the HCD user testing volunteer sign-up, background information will be collected and used to target participants for the user satisfaction, product usage, and benchmarking surveys based on need. For example, when testing the cost performance category feedback, we may desire to target small to mid-size practices. Respondents for both surveys may be clinicians, practice staff, third-party intermediaries, and APM entities or participants within APM entities who have submitted data to the Quality Payment Program. For the Physician Compare user testing, respondents will include Medicare beneficiaries, caregivers, and members of the general public.

For the HCD user testing volunteer sign-up, we will invite participants to complete the survey and use the background information collected to select potential survey participants for the HCD user satisfaction, product usage, and benchmarking surveys. For the Physician Compare user testing, CMS intends to utilize a respondent pool of Medicare beneficiaries, caregivers, and general public which reflects the broad population of Physician Compare users.

Results will not be used to make statements representative of the universe of study, to produce formal statistical descriptions, or to generalize the data beyond the scope of the sample. When applicable, the method for soliciting participation will be described fully in each collection request. Participation for all surveys and feedback collections will be voluntary.

2. Describe the procedures for the collection of information including:

- Statistical methodology for stratification and sample selection,

- Estimation procedure,

- Degree of accuracy needed for the purpose described in the justification,

- Unusual problems requiring specialized sampling procedures, and

- Any use of periodic (less frequent than annual) data collection cycles to reduce burden.

Online survey methods will be used for the HCD user testing volunteer sign-up survey and HCD user satisfaction, product usage, and benchmarking survey. For the Physician Compare user testing, we anticipate using a combination of one-on-one in-depth interviews using an online platform and as feasible, in-person sessions at a designated testing facility in order to employ the use of eye tracking technology to identify gaze trails and locations where users look the most.

For each data collection under the Quality Payment Program, respondents are required to submit data no more than once annually. Because the surveys and feedback collections under this generic clearance are primarily intended to collect data on user experience, it is necessary to collect this data with at least the same identical frequency. In most cases, more frequent collection would provide no additional benefit. However, some respondents may provide data on a more frequent than annual basis; in this case, it is possible these respondents would respond to certain surveys of feedback collections more than once per year. We do not anticipate using sampling or statistical estimation for any survey or feedback collection.

3. Describe methods to maximize response rates and to deal with issues of non-response. The accuracy and reliability of information collected must be shown to be adequate for intended uses. For collections based on sampling, OMB guidance requires that a non-response bias assessment be conducted to determining if the results are generalized to the universe studied.

Information collected under this generic clearance is not designed to yield generalizable quantitative findings; but procedures to maximize response will be employed so that an appropriately sized set of participants is involved in any survey or feedback collection. Survey questions will be designed so that they are easy to answer and will be structured to be as short as possible; this includes maximizing the use of nominal and ordinal scales as response modalities.

CMS continues to make every effort to reasonably reduce complexity and burden with each performance year. We anticipate these efforts will encourage ongoing participation in these activities as participants recognize the data and feedback they provide is utilized in future years in furtherance of this goal.

4. Describe any tests of procedures or methods to be undertaken. Testing is encouraged as an effective means of refining collections of information to minimize burden and improve utility. Tests must be approved if they call for answers to identical questions from 10 or more respondents. A proposed test or set of tests may be submitted for approval separately or in combination with the main collection of information.

Pretesting may be done with internal staffs, a limited number of external colleagues, and/or customers who are familiar with the programs and products. If the number of pretest respondents exceeds nine members of the public, the Agency will submit the pretest instruments for review under this generic clearance. The questions to be asked will be similar to those used by other Federal agencies in their customer surveys. If respondents are unable to supply the data, questions may be reworded.

To ensure quality while the data are being collected, special attention will be paid to: proper wording of questions to reflect intent, survey completion rates, response rates of individual survey items, and comments CMS receives regarding the survey.

5. Provide the name and telephone number of individuals consulted on statistical aspects of the design and the name of the agency unit, contractor(s), grantee(s), or other person(s) who will actually collect and/or analyze the information for the agency.

CMS will obtain information from statisticians or other experts in the development, design, conduct, and analysis of surveys and feedback collections, when appropriate. This expertise will be available from CMS staff or contractors. The names and contact information of persons consulted will be provided to OMB at the time the surveys or feedback collections are submitted.

Please contact the following CMS staff regarding the statistical and methodological aspects of the design or for agency information: Betina N. Fletcher (HCD) and Regina Chell (Physician Compare).

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