Supporting Statement A_2900-0609_Survey of Veteran Enrollees' Health & Use of Health Care_updated Dec 2024

SUPPORTING STATEMENT A

Survey of Veteran Enrollees’ Health and Use of Health Care

VA Form 10-400

OMB Control Number 2900-0609

Summary of Changes:

• The average annual number of responses and burden hours have decreased based upon historical and projected program data.

• The survey questions have been updated to remove some questions and add other questions, as noted in a supplementary document included in the ICR in ROCIS.

• VA received two comments on the 60-day FRN; the program office provided a response to each but did not make changes to the survey based on the comments.

JUSTIFICATION

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

The VA Survey of Veteran Enrollees’ Health and Use of Health Care (“Survey of Enrollees”) gathers information from Veterans enrolled in the VA Health Care System (enrollees) about factors which influence their health care utilization choices. Data collected are used to gain insights into Veteran preferences and to provide VA and Veterans Health Administration (VHA) management guidance in preparing for future Veteran needs. In addition to factors influencing health care choices, the data collected include enrollees’ perceived health status and need for assistance, available insurances, self-reported utilization of VA services versus other health care services, reasons for using VA, barriers to seeking care, ability and comfort level with accessing virtual care, as well as general demographics and family characteristics that may influence utilization but cannot be accessed elsewhere.

Information provided by the Survey of Enrollees supports critical VA policy decisions. The survey was originally designed to form the foundation of the Enrollee Health Care Project Model (EHCPM) projections, which, in turn, supports the VA Secretary’s annual enrollment level decision necessitated by the Veterans’ Health Care Eligibility Reform Act of 1996 (P.L. 104-262) as well as approximately 95 percent of VHA’s medical care budget estimates every budget cycle. Survey data is still required for the EHCPM and also has been used to support the requirements of the Caregivers and Veterans Omnibus Health Services Act of 2010, the Patient Protection and Affordable Care Act of 2010, the Veterans Access, Choice, and Accountability Act of 2014, and the market assessments required by the Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act of 2018.

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.

The data gathered through the Survey of Enrollees continues to be critical to making Veteran-centric policy and planning to meet future demand and preferences of all eligible Veterans.

Although the core purpose and questions remain the same, the CSO undertook a process of reconfirming data needs with users to assure we were not unnecessarily creating a burden on respondents. This allowed CSO to delete some questions and to identify other questions that can be asked in alternating years. As a result, the length of the survey for any one year has been reduced from 130 questions (counting individual questions within multi-part questions) to 75 individual questions. In addition, we modelled some questions on the American Community Survey in order to simplify them for respondents. A one-page summary of changes is included in this package.

In addition to supporting cost and utilization projections, the survey data is used annually by the Congressional Budget Office for the purposes of estimating the cost of Veteran related legislation and the VHA Office of Community Care for the purposes of estimating third party collections. Further, the data is used on an ad hoc basis by VHA Program Offices and by the Veterans Integrated Service Network (VISN) and medical facility strategic planners and has informed the foundation of several strategic planning efforts. Data is made available to VISN and facility planners throughout the country via the Health Systems Planning Application and in the form of Pyramid Analytics cubes and Power BI reports through the VHA Service Support Center (VSSC).

Finally, each year, the data is shared with VHA senior leadership as an update for enrollees’ health care preferences and planned future use of VHA.

A report of aggregate findings is made available to the public, and focused analysis and profiles are developed and posted on the VA intranet. These internal reports are used in VISN and program planning.

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.

The survey continues to follow the Census model of a sequential-ordered, multi-mode approach to data collection using web and mail (paper survey) data collection methods. A copy of the most recent survey (2023) methodology report is included for reference.

The Survey of Enrollees was designed as a uni-mode Computer Assisted Telephone Interview (CATI) survey. In 2012, VHA shifted to a multi-mode, CATI, web-based, and paper based survey in an effort to more fully reflect the enrollee population. This shift was introduced incrementally so that some level of trending could continue to be done. The increasing preference of Veterans for either a paper based or web based survey resulted in a 2015 shift to a sequential multi-mode approach, first offering enrollees the opportunity to complete the survey on a web site and then via a paper based survey. Approximately 45 percent of enrollees in the sample opted to complete the survey via the web, dramatically reducing survey administration time, while enabling Veterans to use the survey method of their choice. CATI administration remains an option and is only used at the end of data collection in the event that minimum targets (at least 350) in markets are not met or that a Veteran specifically requests to provide survey responses via telephone.

The Chief Strategy Office also coordinates with the VA Patient Experience Surveys so that Veterans do not receive multiple contacts in any one year.

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.

Data collected by the Survey of Enrollees either is not available in other VA databases or VA administrative files are generally not complete or valid for all segments of the VHA enrollee population to be of sufficient utility for policy and planning purposes. No information on the total health care utilization of services of all enrolled Veterans, both within VA and in the private community, is available. Other surveys have not covered the entire enrollee population and have not focused on the necessary geographically specific information needed to plan to meet enrollee demand throughout the country. The necessity of questions is confirmed with users on a routine basis.

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

There is no impact on small businesses or small entities.

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.

The Survey of Enrollees is conducted annually and fielded in the first quarter of the calendar year to assure optimal recall about the previous year on the part of respondents. This allows for VA to trend the changing needs of an increasingly diverse Veteran population.

The Veteran population has wide ranging needs and expectations of their health care providers and indicate varying planned use of health care. Changes to the national health care landscape, adjustments to Medicare/Medicaid, the enactment of the Veterans Choice Act and the subsequent MISSION Act, and shifts in the state of our nation’s economy, affect Veterans’ opinions about whether or not VA is best able to meet those needs and expectations. The need for real time information on key health care utilization drivers necessitates the annual Survey of Enrollees to capture this critical information for input into data-driven policy and budgetary analyses.

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.

There are no special circumstances as described in VA Handbook 6309 Appendix A, 2.a.(7)(a-f) associated with this survey.

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.

A 60-Day Federal Register Notice (FRN) for the collection published on Wednesday, October 9, 2024. The 60-Day FRN citation is 89 FR 81991. VA received two public comments regarding increasing the frequency of the survey. The program office provided response to each comment but will continue to administer the survey just once per year.

A 30-Day Federal Register Notice for the collection published on Tuesday, December 17, 2024. The 30-Day FRN citation is 89 FR 102253.

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.

This is an update to an existing survey instrument. In order to develop the initial Survey of Enrollees in 1999, a VHA representative attended the consultant panel meeting of internal and external agency participants conducting VA’s SF-36V survey, including scientists with the VA Health Services Research and Development Service (HSR&D Service); the Health Care Finance Administration (HCFA), the Foundation for Accountability (FACCT), the Health Institute at the New England Medical Center, the Rand Corporation, the National Center for Health Promotion at Duke University, and the National Committee for Quality Assurance (NCQA) Washington, D.C. Various individuals are consulted over time in the planning and development of the enrollee surveys regarding the availability of data, frequency of collection, clarity of instructions, internal VA record keeping, disclosure, or reporting format, and on the data elements. This includes individuals both inside and outside of the agency.

The Chief Strategy Office periodically tests the survey in-house for continued relevancy, considers comments from respondents, and requests input from other VA offices in an effort to continuously improve the survey.

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

There are no plans to provide any payment or gift to respondents.

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

An assurance is made in writing that answers provided are strictly confidential and that VA will protect the enrollee’s identity to the extent allowed under the law. Furthermore, respondents are assured that their answers will in no way affect their benefits and that no information provided will be released to the general public in a way that can be traced back to the respondent. The information collected will become part of the system of records identified as 97VA105, “Consolidated Data Information System-VA” as set forth in the Compilation of Privacy Act Issuances via online GPO access at http://www.gpoaccess.gov/privacyact/index.html

9. 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.

There are no questions of a sensitive nature.

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

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

Veteran Enrollee Survey 10-400	No. of respondents	x No. of responses	x No. of minutes	÷ by 60 =	Number of Burden Hours
Veteran Respondent	40,000	1	20 min = 800,000		13,333 hours

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.

This request covers only one form = VA Form 10-400.

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.

VA cannot make assumptions about the population of respondents because of the variability of factors, such as the educational background and wage potential of respondents.  Therefore, VHA used general wage data to estimate the respondents’ costs associated with completing the information collection.

The Bureau of Labor Statistics (BLS) gathers information on full-time wage and salary workers.  According to the latest available BLS data, the mean hourly wage is $31.48 based on the BLS wage code – “00-0000 All Occupations.”  This information was taken from the following website: https://www.bls.gov/oes/current/oes_nat.htm.  

Legally, respondents may not pay a person or business for assistance in completing the information collection. Therefore, there are no expected overhead costs for completing the information collection. VHA estimates the total cost to all respondents to be $419,722.84 (13,333 burden hours x $31.48 per hour).

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

a. There are no capital, start-up, operation, or maintenance costs.

b. Cost estimates are not expected to vary widely. The only cost is that for the time of the respondent.

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

13. 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.

The total cost to the Federal Government is estimated at $1.5 million. This is the current contractor cost and includes travel, survey improvements, programming of the questionnaire for telephone, print, and web administration, questionnaire pretest, data collection, validation, mailing activities, help desk maintenance, data processing, providing a clean data file, project management, production of final report, staff education, and supervision.

13. Explain the reason for any burden hour changes or adjustments reported in items 13 or 14.

Higher than anticipated inflation has increased the cost of collecting the data. In addition, national decreases in survey response rates have required larger samples, creating more mailing costs. After consultation with our primary stakeholder, the actuary that calculates the Enrollee Health Care Model, we have lowered our target sample from 42,000 to 40,000. In addition to reducing our expected costs in 2025, it will reduce burden on Veterans while maintaining the integrity of the data.

13. 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.

This data collection’s primary purpose is not that of publication. A copy of aggregate results is posted on the VA internet site within a year of final data collection. Other reports may be developed and shared for the purposes of communicating complex issues to key policy makers and planners. Data will also be used for VA internal policy and budget scenario development and related analyses. Data is weighted to adjust for response and non-response bias.

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

The expiration date is included on the data collection.

13. 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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