CMS-10575 Supporting Statement Part B

Supporting Statement for Paperwork Reduction Act Submissions – Part B

Generic Clearance for the Health Care Payment Learning and Action Network

(CMS-10575; OMB 0938-1297)

Collections of Information Employing Statistical Methods

CMS requests the extension of its current generic clearance to assist in monitoring and characterizing the adoption of alternative payment models to meaningfully inform 1115A model decisions on the design, selection, testing, modification, and expansion of innovative payment and service delivery models in accordance with the requirements of section 1115A. Each of the four types of information requests, and the statistical methods behind them, are described below.

a) LAN Registration Information

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.

Response: The first type of information request involves collecting self-reported identification and opinion information from participants when they sign up for the LAN and associated events (LAN Summits, webinars, and other meetings). This information is being collected to understand the types of stakeholders participating in LAN activities (providers, payers, consumers, states, etc.). Although the potential universe of respondents includes all interested U.S. healthcare stakeholders (from physicians to payers to health care consultants), this collection effort does not involve any sampling or other respondent selection methods, because CMS will only collect information from organizations and individuals who voluntarily register for the LAN and associated LAN events. Therefore, the response rate will necessarily be 100%. However, this respondent information for the LAN and each LAN event will be used to estimate attendance at future LAN events and to segment respondents by stakeholder type, which will inform our ability to segment and conduct information requests for the other three LAN information requests described later in this document.

To date, approximately 7,100 public and private health care organizations (payers, providers, individuals, employers, consumers, local, state and federal agencies) interested individuals have signed up to participate in the LAN since its launch on March 26, 2015. From this pool of the LAN participants, subsets of LAN participants sign-up for LAN in-person events, webinars, and other meetings. For example, at the LAN Summit held in October 2015 approximately 800 LAN participants registered for the event. In subsequent LAN events, between 800 and 600 signed up for the annual LAN Summits. Based on these past registrations for LAN events in 2015 through 2021, and the number of LAN events planned for 2022, CMS estimates that LAN participants will register for LAN events on no more than 10,000 occasions during 2022.

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.

Response: This information collection type will not be employing any statistical/sampling methodologies or estimation procedures for this information request. However, we do expect the burden for this information request to decrease over time, because organizations and individuals who have already registered for the LAN will be able to automatically populate LAN event registration forms.

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, a special justification must be provided for any collection that will not yield 'reliable' data that can be generalized to the universe studied.

Response: LAN participant organizations who do not complete registration forms correctly will not be counted as registrants. Maximizing response rates and sample methodologies are not applicable to this information request.

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.

Response: For LAN registration information collections, CMS and its contractor will build and internally test the registration data fields and associated collection instruments for functionality and ease of use, to include the estimated amount of time required to complete each registration form. For these simple information requests, we do not plan to work with more than 10 respondents to estimate the burden. Instead, this kind of testing will be conducted internally. In addition, the LAN now has 6 years of executing LAN events to very accurately estimate the burden associated with registering for LAN events.

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. Response:

Name	Telephone	Organization
Kathryn Davidson	410-786-0000	CMS/CMMI/LDG
Rehana Gubin	410-786-3545	CMS/CMMI/LDG
Dustin Allison	303-844-7031	CMS/CMMI/LDG
Kate McNabb	571-882-5772	Deloitte
Andrea Caballero	714-815-8425	Catalyst for Payment Reform

b) LAN Participant Surveys

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.

Response: The second type of information request involves administering surveys to LAN participants to understand LAN participant opinions, priorities, and issues with respect to how to best increase the adoption of alternative payment models. These surveys inform decision making about future LAN activities, including LAN Conference sessions, webinar topics, and feedback on LAN work group ideas. The potential universe of respondents includes all LAN participants, though each survey will likely be limited to a particular LAN event. For example, in connection with a LAN webinar focused on sharing a white paper, a simple evaluation forms are sent to all attendees to better understand what went well, what could be improved, and so on. In our experience at CMS executing the LAN, these kinds of simple surveys can, at most, expect a 30% response rate. However, one event often contains multiple separate sessions that each generate separate evaluation forms. For this reason, we estimate that there will be a maximum of 3,000 LAN responses to these type of surveys during 2022, out of the total estimate of 10,000 LAN event registrants.

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.

Response: This information collection type will not be employing any statistical/sampling methodologies or estimation procedures for this information request. CMS will continually strive to increase the proportion of the LAN participants who respond to these surveys, but our intended use for informal decision making will not require generalizable data.

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, a special justification must be provided for any collection that will not yield 'reliable' data that can be generalized to the universe studied.

Response: Maximizing response rates and sampling methodologies are not applicable to this information request. CMS will continually strive to increase the proportion of the LAN participants who respond to these surveys, but our intended use for informal decision making will not require generalizable data.

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.

Response: For LAN surveys, CMS and its LAN contractor have built and internally tested the survey data fields and associated collection instruments for functionality and ease of use, to include the estimated amount of time required to complete each registration form. For these simple information requests, we do not plan to work with more than 10 respondents to estimate the burden. Instead, this kind of testing is conducted internally and based on six years of experience operating the LAN.

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.

Response:

Name	Telephone	Organization
Kathryn Davidson	410-786-0000	CMS/CMMI/LDG
Rehana Gubin	410-786-3545	CMS/CMMI/LDG
Dustin Allison	303-844-7031	CMS/CMMI/LDG
Kate McNabb	571-882-5772	Deloitte
Andrea Caballero	714-815-8425	Catalyst for Payment Reform

c) LAN Payer APM Tracking

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.

Response: The third type of information request involves collecting information from LAN payers to track the adoption of alternative payment models (APMs). Requested information from each respondent includes estimated counts and percentages of U.S. beneficiaries/consumers who are covered by alternative payment models, to include underserved populations, and the amount of payments made through alternative models. This information helps the LAN understand general market trends and the pace of progress toward alternative payment model adoption across populations and public and private payers.

Simple informational questions about current market trends in APM adoption are also collected from payers. In 2018, for example, 91% of payers participating in the APM survey said that APM activity would continue to increase going forward and identified provider willingness to take on risk as the number one barrier to increasing APM adoption.¹In 2021 and going forward, additional questions have been added to understand what payers are doing to address health equity and social determinants health with APMs.

The LAN has a payment taxonomy that describes health care payment through the stages of transition from pure fee-for-service to APMs and, ultimately, population-based payments. The resulting Refreshed APM Framework² classifies payment models into four categories according to how providers are paid:

• category 1—fee-for-service with no link of payment to quality;

• category 2—fee-for-service with a link of payment to quality;

• category 3—alternative payment models built on fee-for-service architecture;

• category 4—population-based payment.

Since the LAN’s launch in 2015, the LAN has carried out four annual APM measurement surveys in 2016, 2017, 2018, and 2019, respectively. 2020 and 2021 APM measurement surveys were combined and expected to be reported at the December 2021 LAN Summit on December 15 and 16. The publicly available results for each measurement effort can be located on the LAN’s website here.³

The LAN invites health plans across market segments, as well as state Medicaid agencies, to quantify the volume of health plan in- and out-of-network spending that flows through APMs, including key areas of available pharmacy and behavioral health spending, if such data are available. Each of the questions in the survey corresponds to the categories and subcategories of the Refreshed APM Framework, using the LAN survey tool, definitions, and methodology.

More detailed information on the LAN’s most recent 2019 APM measurement report, methodology, definitions, and survey tool can be found here.⁴

Denominator:

Total dollars paid to providers (in and out of network) for payer members in CY 2018 or most recent 12 months.

Numerator: Total dollars paid to providers in CY 2018 or most recent 12 months participating in category 1, 2, 3, and 4 payment arrangements. These data are then used to estimate annual payment amounts and proportions of payments across each category and subcategory that health plan/payers made to providers. (See the LAN’s Refreshed APM Framework White Paper to get a better sense of how plans/payers are instructed to categorize their payment arrangements)

The LAN does not have any regulatory levers at its disposal to compel participating plans to submit these data – it is purely voluntary. Even so, payer participation in the LAN APM measurement has exceeded 70% each year. For example, the 2019 LAN APM Measurement Effort includes data from the LAN’s survey, surveys fielded by major health plan associations, and Traditional Medicare. Conducted from May to July 2019, the survey process collected data from 70 participants, accounting for nearly 226.5 million Americans, or 77%, of the covered U.S. population. The data reflects payment activity in calendar year 2018.

Health plans, states, and Traditional Medicare reported the total dollars paid to providers according to the LAN’s Refreshed APM Framework, which offers a common approach to classifying payment by category and subcategory. With this data, the LAN analyzed aggregate results by category and subcategory as well as by line of business: commercial, Medicare Advantage, Medicaid, and Traditional Medicare.

The results show progress, with 35.8% of total U.S. health care payments tied to alternative payment models (APMs) in 2018, a steady increase from 23% three years ago.

The LAN APM Measurement Effort revealed the following for 2018 payments:

• 39.1% of health care dollars in category 1 (e.g., traditional FFS or other legacy payments not linked to quality)

• 25.1% of health care dollars in category 2 (e.g., pay-for-performance or care coordination fees)

• 35.8% of health care dollars in a composite of categories 3 and 4 (e.g., shared savings, shared risk, bundled payment, or population-based payments)⁵

These results highlight a continued transition from a fee-for-service system that reimburses only on volume towards patient- and value-centered APMs.

Given health plan and public payer involvement in the LAN’s APM measurement effort to date, CMS is confident a sufficient number of health plans and public payers will continue to participate in this data collection effort and continue to provide a strong indication of the national direction. Although CMS does not expect to engage in sampling a certain proportion of health plans for these data, the LAN will continually engage health plans each year throughout the life of the LAN to increase the number of participating health plans in the LAN’s APM measurement effort. The ultimate goal is for all U.S. health plans and payers (the potential respondent universe), both public and private, to participate in the LAN and commit to sharing aggregate payment data on an annual basis with the LAN and the public. Currently, based on participation between 70 and 90 plans in prior years, CMS aggressively estimates approximately 110 U.S. payers will participate in the next information request (i.e., agree to submit aggregate payment data) in 2022.

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.

Response: For this data collection, sampling is not planned. Instead, the LAN will continually strive to increase the number of payers voluntarily participating in the LAN who are willing to submit aggregate data that categorizes how plans are paying providers. At the end of each data collection, the LAN is able to say that X plans participated that represent Y beneficiaries (Z% of U.S. population) within a given calendar year. Among this proportion, A% of payment is in category 1, B% in category 2, and C% in categories 3 & 4. Subsequent annual data collections will report on the change among those plans that reported each year, and the number of new plans that are now reporting their payment categories.

2. 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, a special justification must be provided for any collection that will not yield 'reliable' data that can be generalized to the universe studied.

Response: This data collection uses those plans/payers participating LAN health plan payments as a surrogate for the US Health Care system as a whole, thereby allowing CMS to gauge the progress of APM adoption nationwide in a very straight forward manner. Complex statistical analyses will not be conducted on these data, and any discussion of LAN APM results will come with important caveats. There are a limited number of health plans in the United States (~200) with a variety of characteristics. We are only able to describe the characteristics of LAN health plans and their percentages and acknowledge that the estimate could be too high or too low. That said, because the LAN has demonstrated substantial engagement from many health plans in three prior APM measurement efforts to date, CMS expects payer participation representing well over 70% of the healthcare market to continue in future years.

2. 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.

Response: The LAN pulled together a cohort of LAN health plans and payers to participate in a collaborative in early 2016. The purpose of this payer collaborative was to educate health plans on the APM Framework White Paper to ensure alignment on APM definitions across payers and to increase understanding with respect to how the LAN proposes to measure progress towards APM adoption. From this initial cohort of health plans who agreed to participate in the LAN payer collaborative, the LAN selected 9 health plans to gather feedback on the proposed metrics, test the feasibility of the proposed survey instrument, develop more accurate collection burden estimates, and finalize an approach for a full-scale nationwide data collection effort of private and public health plans.

The pilot test was completed by April 2016 and the details of that approach were submitted to OMB and released to the public for a 30-day comment period through the LAN website, blog, newsletter, and other communication mediums. Based on this pilot, the LAN has successfully conducted four annual APM measurements to date with 2 more currently wrapping up—refining the methodological approach each year to arrive at an estimated burden of 25vhours per respondent.

2. 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.

Response:

Name	Telephone	Organization
Kathryn Davidson	410-786-0000	CMS/CMMI/LDG
Rehana Gubin	410-786-3545	CMS/CMMI/LDG
Dustin Allison	303-844-7031	CMS/CMMI/LDG
Kate McNabb	571-882-5772	Deloitte
Andrea Caballero	714-815-8425	Catalyst for Payment Reform

d) LAN APM Characteristics Tracking

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.

Response: The fourth type information request is intended to track other characteristics of alternative payment model adoption among certain LAN participant types—employers, providers, states, and so on. This information will help the LAN understand how other stakeholders are contributing to market trends and the pace of progress toward alternative payment model adoption across the U.S. healthcare system.

The universe of respondents for these type of information requests will be limited to LAN participants and/or subsets of LAN participant types. An example could be an information request on employer practices around purchasing health care for employees, to include the types of payment models used. In this case, the respondent universe would be limited to employers who voluntarily agree to participate, and CMS would not expect to engage in sampling a certain proportion of U.S. employers to obtain generalizable data. Instead, the LAN would continually engage employers to participate in the LAN and to increase the number of respondents.

To date, approximately 7,100 individuals, employers, payers, consumers, providers, local, state, and federal agencies have signed up to participate in the LAN. Each LAN organization type could be asked to provide information related to participation in alternative payment models, depending on the purpose of the information request. More information will be provided on the potential respondent universe as the actual information requests are developed during the life of the LAN.

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.

Response: The respondent universe for this information request will be limited to participating

LAN stakeholders, and CMS does not expect to engage in sampling a certain proportion of these LAN participants to obtain generalizable data. Instead, the LAN will continually engage stakeholders to participate in the LAN and to increase the number of potential respondents. More information will be provided on the information collection procedures as the actual information requests are developed in the coming weeks and months.

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, a special justification must be provided for any collection that will not yield 'reliable' data that can be generalized to the universe studied.

Response: The overarching reason for this type of data collection is for the LAN to understand how other stakeholders are contributing to market trends and the pace of progress toward alternative payment model adoption across the U.S. healthcare system—such as, in 2015, 35% of participating LAN employer health care purchases were tied to APMs. Complex statistical analyses will likely not be conducted on these data, and any discussion of LAN APM results will come with important caveats.

Maximizing response rates and minimizing non-response bias will be important. The LAN will continually engage stakeholders relevant to these information requests to participate in the LAN and to increase the number of potential respondents. More information will be provided on the information collection procedures as the actual information requests are developed during the life of the LAN.

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.

Response: The LAN plans to select fewer than 10 LAN participants, depending on the survey, to gather feedback on the proposed metrics, test the feasibility of the proposed survey instrument, develop more accurate collection burden estimates, and finalize an approach for a full-scale LAN data collection effort for information requests of this type. Once these pilot tests and the approach for full-scale data collection are finalized, the details for each approach will be submitted to OMB and released to the public for a 30-day comment period through the LAN website, blog, newsletter, and other communication mediums as needed, such as webinars and listening sessions.

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.

Response:

Name	Telephone	Organization
Kate Davidson	410-786-0000	CMS/CMMI/LDG
Rehana Gubin	410-786-3545	CMS/CMMI/LDG
Dustin Allison	303-844-7031	CMS/CMMI/LDG
Kate McNabb	571-882-5772	Deloitte
Andrea Caballero	714-815-8425	Catalyst for Payment Reform

1 https://hcp-lan.org/workproducts/apm-infographic-2019.pdf

2 https://hcp-lan.org/apm-refresh-white-paper/

3 https://hcp-lan.org/apm-measurement-effort/

4 https://hcp-lan.org/apm-measurement-effort/2019-apm/

5 https://hcp-lan.org/2018-apm-measurement/#1466615406342-d34e0eeb-f073