CMS-10695 MIPS Survey Supporting Statement A_8-8-24

Supporting Statement – Part A

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

CMS-10695, OMB Control number 0938-1399

A. Background

The purpose of this submission is to revise the generic clearance of a program of survey and feedback collections supporting the Quality Payment Program which includes the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (AAPMs). MIPS is a program for certain eligible clinicians that makes Medicare payment adjustments based on performance on quality, cost and other measures and activities, and that consolidates components of three precursor programs—the Physician Quality Reporting system (PQRS), the Value Modifier (VM), and the Medicare Electronic Health Record (EHR) Incentive Program for eligible professionals. AAPMs are a track of the Quality Payment Program that offer incentives for achieving threshold levels of payments or patients in Advanced APMs or Other Payer Advanced APMs. Under the AAPM path, eligible clinicians may become Qualifying APM Participants (QPs) and are excluded from MIPS. Partial Qualifying APM Participants (Partial QPs) may opt to report and be scored under MIPS. This generic clearance will cover a program of surveys and feedback collections designed to strategically obtain data and feedback from MIPS eligible clinicians, third-party intermediaries, Medicare beneficiaries, and any other audiences that would support the Agency in improving MIPS or the Quality Payment Program. The specific collections we intend to conduct are: Human Centered Design (HCD) User Testing Volunteer Sign-Up Survey; HCD User Satisfaction, Product Usage, and Benchmarking Surveys; and compare tools hosted by the U.S. Department of Health and Human Services (and/or successor website) User Testing.

The HCD user testing volunteer sign-up online survey will be used to collect background information on participants that volunteer to participate in user research in order to allow us to screen our participant panel for subsets of participants that meet our qualitative research needs. Survey respondents will be clinicians, practice staff, third-party intermediaries, and APM entities or participants within APM entities who have submitted data to the Quality Payment Program. This background information will be used to target participants for the HCD User Satisfaction, Product Usage, and Benchmarking surveys. The intent of these online surveys is to obtain feedback information on users' reporting, product usage, and overall satisfaction during the submission or feedback windows in order to expand our knowledge beyond the low number of qualitative research activities we are able to conduct. These surveys will allow us to collect the aforementioned information from more users, faster and with greater breadth and depth than typical qualitative research activities can achieve. This data collected will inform CMS about ways to improve user experience, assess methods for improving the process of data submission, improve and enhance the utility of web-based tools, and increase the effectiveness of communication with stakeholders.

The compare tool user testing will be used to collect feedback on website features, organization, and display which will allow us to identify areas for improvement in the design and layout of website information to make the compare tool website more user-friendly. Information collected will be used to assess which measures, activities, and other website content are appropriately interpreted and which of the data available for public reporting resonate with users. The feedback collected will also inform the language used to publicly report information on compare tool and/or successor website to ensure information is presented in plain language that is meaningful to Medicare patients and caregivers. Respondents will include Medicare beneficiaries, caregivers, and members of the general public who will participate in one-on-one in-depth interviews. Using this method, we are able to show new information available for public reporting on compare tool and/or successor website to users and assess how users interpret the information presented, identify ways to adjust language to promote user understanding, and assess if the measures and information resonate with website users. The interviews will include free exploration and directed tasks to allow us to closely observe a user’s interactions with compare tool and/or successor website to identify areas for improvement in the design and layout of website information.

Associated PRA packages include OMB control number 0938-1222, 0938-1314 and 0938-1343. These packages include a number of collections where the agency may wish to improve user experience, enhancing current processes, and implementing new processes to further improve quality and reduce complexity.

This package is a revision because there were GenIc added to it while it was out for 60-day public comment period. Some of the GenIc that were being carried forward were completed thus subtracted from the package. Also, the Supporting Statement Part B was changed to the Research version.

B. Justification

1. Need and Legal Basis

Authority for collection of this information is provided under sections 1848(q), 1848(k), 1848(m), 1848(o), 1848(p), and 1833(z) of the Social Security Act (the Act).

Section 1848(q) of the Act, as added by section 101(c) of the MACRA, requires the establishment of the MIPS beginning with payments for items and services furnished on or after January 1, 2019, under which the Secretary is required to: (1) develop a methodology for assessing the total performance of each MIPS eligible clinician according to performance standards for a performance period; (2) using the methodology, provide a final score for each MIPS eligible clinician for each performance period; and (3) use the final score of the MIPS eligible clinician for a performance period to determine and apply a MIPS adjustment factor (and, as applicable, an additional MIPS adjustment factor) to the MIPS eligible clinician for a performance period. Under section 1848(q)(2)(A) of the Act, a MIPS eligible clinician’s final score is determined using four performance categories: (1) quality; (2) cost; (3) improvement activities, and (4) the advancing care information. In order to work continuously to ensure the Quality Payment Program is meeting these requirements while reducing complexity and reporting burden for clinicians, CMS seeks to obtain approval of a generic clearance to conduct surveys and feedback collections to obtain data and feedback on user experience and effectiveness of current and potential future processes. By data and feedback, we mean information that provides useful insights on respondent perceptions and opinions but are not statistical surveys that yield quantitative results that can be generalized to the population of study.

Based on an assessment of CMS’ currently approved generic clearances, there is no currently approved generic clearance for which this program of survey and feedback collections meets approved criteria¹. This collection of information is necessary to enable CMS to garner customer and stakeholder feedback in an efficient, timely manner, in accordance with our commitment to improve quality and reduce complexity and burden. The information collected from MIPS eligible clinicians, third-party intermediaries, Medicare beneficiaries, and any other audiences that would support CMS in improving MIPS or the Quality Payment Program will help ensure that all stakeholders have an effective and efficient experience. This feedback will help improve user experience, assess methods for simplifying participation including data submission, improve and enhance the utility of web-based tools, and increase the effectiveness of communication with stakeholders.

CMS will only submit a collection for approval under this generic clearance if it meets the following conditions:

• Information gathered will be used internally and is not intended for release outside of CMS;

• Information gathered will not be used for the purpose of substantially informing influential policy decisions. The information obtained will be used to enhance stakeholder experience, for example, develop user friendly websites;

• Information is not a collection described in the regulatory or rulemaking process;

• Information gathered will yield qualitative information; the collections will not be designed or expected to yield statistically reliable results or used as though the results are generalizable to the population of study;

• The collections are voluntary;

• The collections are low-burden for respondents (based on considerations of total burden hours, total number of respondents, or burden-hours per respondent) and are low-cost for both the respondents and the Federal Government;

• The collections are non-controversial and do not raise issues of concern to other Federal agencies;

• Any collection is targeted to the solicitation of opinions from respondents who have experience with the program or may have experience with the program in the near future; and

• With the exception of information needed to provide renumeration for participants, personally identifiable information (PII) is collected only to the extent necessary and is not retained.

If these conditions are not met, CMS will submit an information collection request to OMB for approval through the normal PRA process.

2. Information Users

For the HCD User Satisfaction, Product Usage, and Benchmarking surveys, we will collect information on users' reporting, product usage, and overall satisfaction during the submission or feedback windows in order to expand our knowledge. These surveys will allow us to collect information from more users in a less burdensome manner than typical qualitative research activities can achieve, and increase CMS’ ability to improve user experience, assess methods for improving the process of data submission, improve and enhance the utility of web-based tools, and increase the effectiveness of communication with stakeholders.

The compare tool user testing will be used to collect feedback on website features, organization, and display which will allow us to identify areas for improvement in the design and layout of website information to make the compare tool website more user-friendly. Information collected will be used to assess which measures, activities, and other website content are appropriately interpreted and which of the data available for public reporting resonate with users. The feedback collected will also inform the language used to publicly report information on compare tool and/or successor website to ensure information is presented in plain language that is meaningful to Medicare patients and caregivers.

The data collected via these surveys will be used by CMS staff as well as agency contractors and consultants. The information collected will be useful and minimally burdensome for the public as required by the Paperwork Reduction Act.

3. Use of Information Technology

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 compare tool 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.

4. Duplication of Efforts

This information collection does not duplicate any other effort, and the information cannot be obtained from any other source.

5. Small Businesses

The Merit-Based Incentive Payment System (MIPS) under the Quality Payment Program defines a Small Practice as one with fewer than 15 clinicians. In the 2024 Final Rule Regulatory Impact Analysis, CMS estimates that 13% of MIPS eligible clinicians work for small practices. These practices have participated at a far lower rate than larger practices which has led to them incurring financial penalties by way of lowered payments. For this reason, it is critical to include these practices as part of research activities in order to understand their challenges. It is a priority for this team to gain these perspectives while being mindful to minimize burden on small businesses during data collection. 

For example, we intend to maximize use of brief online surveys in preference to telephone surveys or in-person interviews. Online surveys can be taken when time permits at the leisure of the study participant. Similar accommodations to minimize burden will be made when other research methods are applied.

6. Less Frequent Collection

For each data collection under MIPS, 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 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.

7. Special Circumstances

There are no special circumstances.

8. Federal Register/Outside Consultation

The 60-day Federal Register notice published May 21, 2024 (89 FR 44684).

The 30-day Federal Register notice published August 7, 2024 (89 FR 64466).

9. Payments/Gifts to Respondents

For the compare tool user testing, to encourage participation and timely responses, respondents will receive $85 for 90-minute user testing sessions and $60 for 60-minute user testing sessions. No payment or gift will be provided to participants for the HCD user testing volunteer sign-up and user satisfaction, product usage, and benchmarking surveys.

10. Confidentiality

No Personally Identifiable Information (PII) or proprietary information will be collected under this PRA. Some descriptive information will be collected as part of the HCD user testing volunteer sign-up survey such as zip code, current role in clinical practice (clinician, practice manager, Physician Assistant, etc.), typical job duties, type of practice, and practice size. This data will be used to target participants for the HCD User Satisfaction, Product Usage, and Benchmarking surveys.

11. Sensitive Questions

The surveys and feedback collections under this generic clearance will not include any questions of a sensitive nature.

12. Burden Estimates (Hours & Wages)

The purpose of the project is to obtain feedback from MIPS eligible clinicians, voluntary reporters, third-party intermediaries, payers, APM entities or participants within APM entities, Medicare beneficiaries, and any other audiences that would support the Agency in improving MIPS and the Quality Payment Program as well as providing information on how these audiences are currently meeting or plan to meet requirements to inform future rulemaking.

The HCD user testing volunteer sign-up survey, and HCD user satisfaction, product usage, and benchmarking surveys will utilize online survey techniques. The compare tool user testing will employ one-on-one interviews for data collection.

Estimate of Burden Hours

Type of Collection	No. of Respondents	Annual frequency per response	Hours per response	Total # of Respondents	Total hours
HCD User Testing Volunteer Sign-Up Survey	600,000	1	0.083	600,000	50,000
HCD User Satisfaction/Product Usage/Benchmarking Surveys	30,000	1	0.25	30,000	7,500
Compare Tool (or Successor Website) User Testing	300	1	1.5	300	450
TOTAL	630,300			630,300	57,950

The total burden hours being requested in this submission are 61,035 (57,950 + 3,085). The 3,085 hours represent the GenICs approved in the previous iteration and are still being used.

13. Capital Costs

There is no capital cost associated with this information collection request.

14. Cost to Federal Government

The estimated cost to the government for conducting the research covered in this request will be approximately $3,850,758 per year in contract costs including labor hours, materials and supplies, overhead, general and administrative costs, and fees.

15. Changes to Burden

This is a revision for a Generic information collection. The following surveys have already been approved under this generic.:

The total burden(57,950) approved under this Generic was decrease by 3,085 hours prior to the 60-day comment period and includes the following packages:

Title of Collection	Burden Hours Already approved under Generic
Submission Experience Survey and Pre-submission Survey (CMS-10805 and CMS-10806)	750
QPP User Registration User Panel Registration Form (CMS-10807)	1660
QPP Submission Experience Survey (CMS-10850)	250
QPP Feedback Survey (CMS-10860)	375
Post Webinar Satisfaction Survey (CMS-10862)	50
Subtotal Burden Hours	3,085
The following GenICs were approved subsequent to the 60-day notice.
Quality Payment Program Performance Feedback Survey (CMS-10860 revised)	188
Non-participating Small and Solo Practice Survey (CMS-10898)	83
Quality Payment Program MVP Registration Feedback Survey (CMS-10899)	83
Total Burden Hours	3,439

Subsequent to the publishing of the 30-day Federal Register notice, CMS has completed the use of the following surveys: CMS-10805, CMS-10806, CMS-10850, and CMS-10860 (original) therefore there is a decrease in the burden hours of 1,375 which makes the remaining (carry over) burden hours 2,064.

16. Publication/Tabulation Dates

Results from the analysis of these data will be presented in reports and briefings for senior CMS management, other government staff, CMS contractors, and consultants involved in Quality Payment Program policy, communication, and process development. There are no publication dates.

17. Expiration Date

We are requesting approval for this generic clearance for a period of three years. The expiration date will be displayed on each collection instrument and instruction.

18. Certification Statement

There are no exceptions to the certification statement.

1 Applicability of CMS’ currently approved generic clearances (OMB 0938-1275, 0938-1148, 0938-1247, 0938-1331, and 0938-1185) is based on alignment with stated purpose or utility and/or availability of unallocated burden.

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