Net Providers Resposne

SUPPORTING STATEMENT FOR PAPERWORK REDUCTION ACT SUBMISSION

Public Information Collection Requirements Submitted for Public Comments and Recommendations: TRICARE Network Provider Satisfaction Survey (TNPSS)

March 17, 2008

Points of Contact:

Doug McAllaster, MS, Project Manager.

Kim Frazier, Information Management Control Officer.

Office of Secretary of Defense (Health Affairs)

TRICARE Management Activity

Health Program Analysis & Evaluation

(703) 681-3636.

1. JUSTIFICATION

1. Needs and Use

The Government Accountability Office (GAO) reported on TRICARE’s purchased care (civilian) network on several occasions. GAO report #GAO-03-928 (July 2003) recommended that TRICARE improve oversight of its civilian provider network. The report indicated that low reimbursement rates and administrative requirements make it difficult for TRICARE to maintain an adequate network of civilian physicians, thus contributing to access problems faced by TRICARE beneficiaries. The TNPSS will allow TRICARE to measure providers’ satisfaction with reimbursement, and interactions with TRICARE and their managed care support contractor (MCSC) and its effect on their participation in the TRICARE network.

Furthermore, the National Defense Authorization Acts (NDAAs) from 2004 through 2006 directed DoD to improve the TRICARE health care benefit for Reservists. The expanded benefit for Reservists and their families increase demands on the MCSCs and their civilian networks, which provide health care in locations far from military facilities. Given the increased demand for health care in the civilian network, a survey of network providers is needed to ensure that MCSC’s policies and practices are adequate to accommodate the expanding and increasingly dispersed beneficiary population.

The TRICARE health care benefit is provided through facilities owned and staffed by personnel of the uniformed services (direct care), and by civilian providers at civilian facilities financed by the Department of Defense (purchased care). To deliver the purchased care benefit, the TRICARE Management Activity (TMA) maintains sole source contracts with MCSCs in each of three U.S. regions. The MCSCs in turn, maintain networks of civilian health care providers to offer services through TRICARE Prime, the HMO benefit, and TRICARE Extra, which is a PPO. The ability of MCSCs to recruit health care providers into their networks to provide care needed by TRICARE beneficiaries depends on providers’ satisfaction with the level of reimbursement and with the business functions performed by MCSCs. A survey of network physicians regarding their satisfaction with their MCSCs will enable to TMA to measure their satisfaction and identify opportunities to increase it, thereby improving the quality of care delivered through the TRICARE program.

The study population will be network providers who have recent contacts with TRICARE patients. The survey sample will be drawn from a sample frame consisting of network providers who have encounters with TRICARE patients in the 6 months prior to the survey, identified from claims data maintained by TMA.

The survey questionnaire (Attachment A) will be based on CMS’s Medicare Contractor Provider Satisfaction Survey (MCPSS) core instrument, with additional DOD specific questions. The MCPSS is a standardized instrument measuring providers' satisfaction with their Medicare Contractors. Adapting the instrument for use with TRICARE’s network enables TMA to measure network providers’ satisfaction using an instrument validated on a similar civilian study population, and to make statistically valid comparisons of results to national benchmarks.

2. Purpose and use of the information

The immediate goals of the proposed survey effort are 1) to assess TRICARE Network Provider’s satisfaction with MCSCs, 2) to identify the contribution of practices and policies of the MCSCs on the satisfaction of network providers, and 3) to identify actions that could be undertaken by MCSCs or by TMA to improve satisfaction of network providers. Ultimately, by improving satisfaction of network providers, TMA expects to improve services provided by its civilian network to TRICARE beneficiaries. The survey addresses basic business functions provided by the MCSCs such as

• inquiries,

• provider communications,

• claims processing,

• appeals,

• provider enrollment,

• medical review,

• provider audit and

• reimbursement.

All of these functions are hypothesized to contribute substantially to providers’ satisfaction.

The sample design and reporting plan will enable policymakers to identify problems and opportunities for improvement in performing these functions for each of the MCSCs, within and outside of the catchment areas in which beneficiaries and networks are concentrated, and according to whether physician or non-physician providers are involved.

3. Information Collection Techniques

The contractor will mail one questionnaire to each individual sampled. Prior to the questionnaire, a pre-notification letter will be sent. All sampled network providers will then receive a paper questionnaire through the U.S. mail with an accompanying cover letter that provides information about the survey effort, its purpose, and a message to encourage participation. Questionnaires will be mailed in hard copy, but recipients will be invited to complete the survey on a secure web site. The computer- assisted interview on the web minimizes respondent error through control over questionnaire logic. The questionnaire may be completed and returned via mail, fax or web to the contractor. Two weeks after the initial mailing, questionnaires will again be mailed to non-responders. A reminder note will be sent to non-responders one week after the 2^nd mailing. A 3^rd mailing is planned for two weeks after the reminder note.

4. Duplication and Similar Information

There is no duplication of data collection. Other related surveys do not address the particular research questions addressed by this study. A previous survey of civilian physicians, mandated by section 723 of the 2004 NDAA, included both network and non-network physicians, and asked only about their acceptance of TRICARE Standard and Extra patients and Medicare patients. Another survey mandated under the 2008 NDAA, will include both network and non-network physicians and mental health providers, and will also ask only about acceptance of new Standard, Extra and Medicare patients. The MPCSS asks a sample of health care providers about their satisfaction with services provided by their contractors, but only services provided on behalf of Medicare patients. That survey does not address TRICARE. The proposed survey is the first time TRICARE network providers will be surveyed concerning their satisfaction with services provided by MCSCs on behalf of TRICARE patients.

5. Small Business

This collection of information will involve small businesses. Many network providers are operators or employees of small businesses.

6. Less Frequent Collections

The proposed survey is planned for one time only. Individuals are requested to provide one response per survey. Contacts will be repeated only to increase the likelihood of response to this one-time survey and will be the minimum consistent with this objective.

7. Special Circumstances

There are no special circumstances that require the collection to be conducted in a manner inconsistent with the guidelines in 5 CFR 1320.5 (d) (2)

8. Federal Register Notice/Consultations

The Federal Register Notice for this collection of information was published on January 26, 2007 (Vol 72, No. 17, p 3796-3797). Copy attached (Attachment B). No public comments were received.

9. Payment/Gift to Respondents

No payments or gifts will be provided to respondents.

10. Confidentiality

Network providers selected to participate in this data collection effort will receive complete confidentiality, except as required by law. Respondents’ names will not appear on the data collection instrument. Results will be reported only at an aggregate level. Information that could be used to identify the participant will be removed when data and analytic results are reported. The relevant statutory authority for protection of identifiable data within DoD and the Federal Government is the Privacy Act of 1974. This survey does not request any Protected Health Information (as defined by HIPAA), and the data being collected similarly are not patient or beneficiary-specific.

11. Sensitive Questions

There are no questions of sensitive nature in the survey questionnaire.

12. Burden Estimated (hours)

The estimated burden of 2,790 hours is based on a projected response from a sample of 9,000 respondents of 60 percent times a response time of 31 minutes per completed survey.

Table A-1. Estimated Response Burden

Questionnaire	Number of Respondents	Number of Responses per Respondent	Hours per Response	Total Burden (Hours)
Paper	4,860	1	0.517	2,511
Web	540	1	0.517	279
Total	5,400	--	--	2,790

13. Cost to Respondents

The total cost is estimated to be $49,950. It is expected that most of the work of responding will be delegated to office personnel. The estimated cost is based upon 19 minutes to complete the survey at an hourly rate of $17.34 (General Schedule 7 Step 5).

14. Cost of Federal Government

The Department of Defense has contracted with NRC+PICKER to conduct this survey. The estimated contract amount to conduct the survey proposed is $162,684. The cost of time expended by federal employees in developing analyzing and reporting on survey results will not exceed $100,000.

15. Change in Burden

This is the first time TRICARE network providers are to be surveyed by DOD to collect this specific information, therefore there is a program change of plus 2790 hours.

16. Publication/Tabulation

Information gathered through this collection will be aggregated and analyzed for the purposes of answering the questions of leadership and to compare to similar information collected from CMS network providers. The research questions include:

• What characteristics of network provider influence satisfaction?

• Does geography, provider type, or any other network provider characteristic, such as how long has the provider been a TRICARE Provider, effect satisfaction?

• What is the relationship between claims volume and satisfaction?

• What business function drives overall satisfaction with Contractors?

Findings will be presented in the form of composite scores for each business function. These composites will be calculated as equally weighted means for valid responses to questions relating to that business function and contained in the MCPSS. Calculations will be performed using sampling weights to account for stratification of the survey sample, and variations in non-response. We will also use SUDAAN software or replication methods to adjust standard errors of survey estimates for the effects of the sample design.

Findings will be reported to the MCSCs in the form of summary worksheets. These work sheets will include scores at the contractor level and within each contractor at the provider type level. Each score that is presented will be accompanied by the number of respondents in that reporting cell, the standard error for that cell and the percentile ranking. In addition to the scores, there will also be a benchmark score. The benchmark will be the mean taken from the most recent MCPSS available. We will also report the overall scores and scores by provider type for TRICARE as a whole. The reports will give each MCSC an idea of their relative position compared to contractors performing business functions for physicians on behalf of Medicare patients and as compared to the other MCSCs performing business functions for TRICARE.

Table A-2. Contractor Report

Scores: Contractor Level
Contractor		Score	Number of Respondents	Standard Error
	XYZ CONTRACTOR
	Business Function	Score	Number of Respondents	Standard Error	Benchmark
	Provider Inquiries
	Provider Communications
	Claims Processing
	Appeals
	Provider Enrollment
	Medical Review
	Provider Audit and Reimbursement
	Overall Satisfaction Item

Scores: Provider Level
Contractor			Score	Number of Respondents	Standard Error	Benchmark
		XYZ CONTRACTOR
Provider Type
	Physicians
		Business Function	Score	Number of Respondents	Standard Error	Percentile
		Provider Inquiries
		Provider Communications
		Claims Processing
		Appeals
		Provider Enrollment
		Medical Review
		Provider Audit and Reimbursement
		Overall Satisfaction Item
	Non-physician providers
		Business Function	Score	Number of Respondents	Standard Error	Percentile
		Provider Inquiries
		Provider Communications
		Claims Processing
		Appeals
		Provider Enrollment
		Medical Review
		Provider Audit and Reimbursement
		Overall Satisfaction Item

These findings will be reported to the Department of Defense and the MCSCs.

The analysis will also include a national report that will include tables comparing results by region, by physician-type and by catchment and non-catchment areas The report will compare among these analytic domains composite scores for satisfaction with business functions performed by MCSCs:

Table A-3. TRICARE Report

Scores: TRICARE Level
Business Function	Inpatient	Outpatient	Non-Physician	Benchmark
Provider Inquiries
Provider Communications
Claims Processing
Appeals
Provider Enrollment
Medical Review
Provider Audit and Reimbursement
Overall Satisfaction Item

Responses to individual items will also be tabulated to precisely define the reason for regional variations. In addition, results will be analyzed using regression methods to evaluate the relative role of factors such as characteristics of the provider’s health care market, the length of time the provider has participated in TRICARE, claims volume and the number of TRICARE patients they treat. We will also use regression methods to investigate the relation between composite scores and the overall satisfaction item. These results will be reported to the Department of Defense and will be considered for scientific publication in relevant peer-reviewed journals.

17. Expiration Date

DoD is not seeking an exception to displaying the expiration date of this information collection.

18. Exceptions to Certification for Paperwork Reduction Act Submissions.

There are no exceptions to the certification statement in Item 19 of OMB Form 83-1.

2. COLLECTION OF INFORMATION EMPLOYING STATISTICAL METHODS

1. Respondent Universe and Sampling.

In this section we describe the target population and sample frame, the sample design, the sample size, and the selection method.

The target population will be all TRICARE network providers. The sample frame will be constructed from a database of all TRICARE network participating providers with at least 1 claims in the last six months. From these TRICARE purchased care claims, we will extract information needed for the sample frame for each provider: tax id, business address, claim type and provider type. We estimate that this population is about 180,000 providers.

The sample design will be a stratified random sample of network providers. A sample of 9,000 will be selected from the sample frame, stratified by region, whether the provider’s business address lies within a military treatment facility (MTF) catchment area, whether the provider is a physician or not, and if a physician, whether that physician is associated with a contracted hospital. The sample will be allocated among strata according to the precision objectives described below.

Table B-1. Sample Allocation

	Sample Size	Completed Interviews	Design Effect	Confidence Interval Half-Length
Total Sample	9,000	5,400	1.3	1.6
Strata:
-- Region (3: N,S,W)	3,000 each	1,800 each	1.3	2.7
-- Catchment area (2:Y,N)	1,500 each	900 each	1.3	3.8
-- Provider type (3): Physician: -Inpatient facility -Outpatient facility Non-physician	1,000 1,000 1,000	600 600 600	1.3 1.3 1.3	4.6 4.6 4.6

Response rates are expected to be approximately 60 percent overall and in each stratum. This estimate is based experience with the MCPSS, on which the current survey is based and which yielded a 65 percent response rate in 2007 and on the survey of physicians on acceptance of TRICARE Standard, which resulted in a response rate of over 50 percent between 2005 and 2007.

Our precision objectives are that estimates for the catchment area and non-catchment area providers within each region have 95 percent confidence intervals with a half-length of 0.04 around a proportion of 0.5. Our objective for each provider type by setting within each region is a 95 percent confidence interval half-length of 0.05 around a proportion of 0.5.

Assuming a design effect of 1.3, this objective can be achieved by 1800 responses from each region, equally divided between physicians located within MTF catchment areas and outside catchment areas, and equally divided by provider type and setting. With this design effect and a sample of 9,000 our precision objectives would be met with a response rate of approximately 53 percent.

2. Procedures for Collecting Information. Once network providers with at least one claim in the previous six months have been identified, a list will be created by sampling stratum and tax id. A random sample will be drawn and matched to name and address information, and contact information will be sent to the contractor. The address used will be that included on claims submissions so we expect that it will be a business address. The contractor will mail one questionnaire to each individual sampled. Prior to the questionnaire, a pre-note will be sent. All target population members will then receive a paper questionnaire through the U.S. mail with an accompanying cover letter that provides information about the survey effort, its purpose, and a message to encourage participation. Questionnaires will be mailed in hard copy, but recipients will also be invited to complete the survey on line. The mailings will be addressed to the provider, but we expect that many questions will be answered by office staff. The questionnaire may be completed and returned via mail, fax or web to the contractor. Two weeks after the initial mailing, questionnaires will again be mailed to non-responders. A reminder note will be sent to non-responders one week after the 2^nd mailing. A 3^rd mailing is planned for two weeks after the reminder note.

3. Methods to Increase Response Rates. Response rates will be increased by enhancing contact information, by offering several response modes, by cover letters designed to encourage participation and by repeated mailings. Mailing addresses will be verified using the National Change of Address database. Basing the sample frame on claims data also improves the accuracy of addresses for the target population. Because providers who have recently submitted claims are actively engaged with the network, they are more likely to respond than others. Permitting response by mail, fax or internet increases convenience to recipients and with that, the likelihood of participation. Physicians will be invited to delegate the work of responding to office personnel. The initial contact letter will discuss the importance of the study and its scientific purpose. With up to three questionnaire mailings, a pre-note and a reminder, providers may be reminded many times of the importance of their participation. In addition, the contractor conducting the survey will provide a toll-free fax number for receiving written address corrections, status updates, re-mailing requests, or completed surveys. The contractor will include these numbers in the cover letters for all mailings of the surveys, and will provide a method to receive telephone calls and facsimiles from respondents 24 hours a day.

4. Methods to Evaluate Bias Due to Non-Response. We will compare characteristics of providers who responded with characteristics of those who did not. Characteristics will include stratifying variables and other characteristics taken from the frame. From this comparison, a model of non-response using frame elements can be constructed. Survey weights adjusted for non-response using variables identified in this analysis will be calculated and assigned to each observation. Analysis and reporting of survey results will be conducted using the non-response adjusted weights. These adjustments will allow the sample results to be generalized to the study population.

5. Tests: No tests (focus groups, etc) are planned for this survey effort. An almost identical survey (MCPSS) was field tested by the CMS. Results from the TNPSS survey will be compared to results from the MCPSS.

6. Points of Contact. Office of Secretary of Defense Health Affairs, TRICARE Management Activity, Health Program Analysis & Evaluation. (703) 681-3636. Doug McAllaster, MS, Project Manager. Kim Frazier, Information Management Control Officer.