DOD Revised Survey Materials

Facilitating Provider Acceptance of TRICARE Standard

A. JUSTIFICATION

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

Congress has directed that the TRICARE Management Activity (TMA), a part of the Office of the Assistant Secretary of Defense for Health Affairs (OASD/HA), examine and determine whether a sufficient number of authorized TRICARE providers participate in the TRICARE program. Indeed, there is a requirement in the fiscal year (FY) 2006 National Defense Authorization Act (NDAA, Public Law 109-163) that TRICARE Regional Offices conduct “outreach to community health care providers to encourage their participation in the TRICARE Program.” TMA is interested in ensuring that Department of Defense (DoD) beneficiaries who participate in the TRICARE programthe health plan for uniformed service members, retirees from the uniformed services, and their eligible family membershave ready access to providers under the TRICARE Extra or Standard options. TRICARE Extra provides a preferred provider organization (PPO) type of plan in which a network of authorized providers is made available and TRICARE Standard is the fee-for-service option that gives beneficiaries the opportunity to see any authorized provider.

Some beneficiaries live in areas where the TRICARE Prime or Extra networks are not available and TRICARE Standard may be their only option for using the TRICARE benefit. However, in some cases authorized providers choose not to participate in TRICARE, causing problems for some TRICARE beneficiaries. TMA has an ongoing project to survey physicians throughout the United States to determine the percent who participate in TRICARE Standard and their reasons for non-participation.

In order to supplement the findings from TRICARE’s survey of providers, and respond to the concerns of Congress as described in the FY 2006 NDAA, we propose drawing on the direct responses from providers or their staff to determine why they choose or choose not to participate in TRICARE Extra and Standard. In addition to TMA’s use of the annual provider surveys, this submission concerns the use of focus groups in six locations throughout the continental U.S., in which providers or their staff will be asked a set of questions, a few of which may be similar to those on the survey. But, in addition, the focus groups will allow the researchers to probe further in order to understand the nature of problems that the physician practices may have had in the past or believe they will have in the future with participation in TRICARE. Focus groups were not specified in the NDAA, but they are one important method of asking and receiving answers directly from the health care community, which will then be used to develop effective messages/methods for increasing the number of practices and providers who will accept TRICARE. Ultimately, TMA, in conjunction with the CNA Corporation (CNAC) a nonprofit, independent organization that operates a federally funded research and development center (the Center for Naval Analyses) specializing in military issues and which is leading the study, will use the results of the focus groups to help devise solutions and increase access to additional providers throughout the country.

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 collected from these focus groups will be used by TMA to meet the requirements stipulated by the fiscal year 2006 NDAA. The data will provide information for sound decision-making that will affect the procedures used to ensure sufficient numbers of providers and general access to healthcare services to those TRICARE beneficiaries not enrolled in the TRICARE Prime program. By providing a better understanding of whether there are specific reasons for their non-participation, including reimbursement amounts and procedures or simply a lack of knowledge of the TRICARE program, CNAC and TMA can potentially design methods for increasing the number of providers available.

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.

This data collection does not involve the use of automated, electronic, and mechanical or other technological collection techniques or other forms of information technology. Focus groups were chosen as the research method for this task because they allow for in-depth discussion of the issues important to this research with individuals of interest, namely, providers or their business representatives who may consider providing the healthcare services to DOD beneficiaries. The focus groups will be a one-time discussion of relatively short duration with individuals in key sites around the country.

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.

CNAC has conducted an extensive review of the issues associated with TRICARE and any past and ongoing problems of access to providers under the TRICARE Standard/Extra programs. Other information, including the surveys of providers that has been specifically undertaken by TMA during 2004, 2005, and 2006, have also been examined and the results included in the CNAC database. Other parts of the project will examine administrative claims records and other data gathering activities will also be undertaken to supplement what can be found from the use of focus groups. However, all of these activities will be used in conjunction with, and not as an alternative to, the focus groups and the information to be obtained. The nature of a face-to-face data gathering activity will provide key details and information that will be hard to replace by other activities as mentioned above.

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

There will be some, because we will be recruiting for the focus groups staff members most likely of small physician practice offices, but the amount of time will be approximately one and a half hours in total per participant, including travel to and from our meeting site. CNAC will also do its best to find times that best suit the time constraints faced by expected participants.

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.

As indicated above, the information gathered from the focus groups is not the only information to be gathered, but CNAC proposed the use of focus groups because it offered the prospect of gathering information not otherwise readily available. If the information were not collected, it would make it much harder to design policies intended to facilitate the acceptance of providers, which the project is designed to accomplish. Speaking directly to providers and/or their staff would be hard to duplicate by other methods.

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 such special circumstances. This is a one-time data collection.

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.

The 60-day notice published in the Federal Register on June 1, 2007 (72 FR 30554).

No comments were received.

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.

TMA, as the original contracting agency on this particular research effort, concurred that this method of data collection was well suited to obtaining the information desired. Because this is a one-time data collection effort, we see no circumstances that might preclude consultation with representatives of those from whom information is to be obtained.

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

A small payment or honorarium of approximately $50 will be made to respondents for their participation. In paying this honorarium to participants we acknowledge that their time (and the information they provide to us) is valuable.

10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statue, regulation, or agency policy.

An assurance of strict confidentiality is made in the introductory letter or phone call to respondents before participation in the focus groups and as a part of the introduction to each of the groups. Participants are assured that answers given will be kept confidential and used for research purposes only. The information that participants supply is protected by law (the Privacy Act of 1974, 5 U.S.C. 522a and section 5701 of Title 38 of the United States Code). Participants will be informed that CNAC researchers involved with the study have the professional responsibility to keep answers confidential, that they are bound to do so by law and that they have signed a legal agreement to keep respondent information confidential. Participants will be further informed that only CNAC analysts will have access to individual responses and that CNAC will only report aggregated results that do not permit the identification of individual participants.

11. Provide additional justification for any questions of a sensitive nature, 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.

No questions of a sensitive nature, such as sexual behavior and attitudes, or religious beliefs, will be asked as part of the focus groups. Questions will be asked about their knowledge and experience, if any, with the TRICARE program.

Respondents will be asked to give informed consent to participate in the study. As such, there is a description of any foreseeable risks or discomforts to the respondent and a statement that participation in the focus groups is voluntary and refusal to participate will involve no penalty. The informed consent will be obtained in two steps. First, an introductory letter or direct contact will be made to providers or members of their staff. The letter or direct phone call will outline the purpose, nature, and sponsorship of the research project, the confidentiality of the responses and the methods used to ensure it, as well as the description of the potential benefits of the participation to the providers and to TRICARE beneficiaries (representing current or potential patients). The second step in obtaining the informed consent involves reading an introduction to the respondents when recruiting participants for the focus groups. All respondents will have a chance to review and discuss the informed consent with the data collectors, as well as actively consent to research participation before the actual focus group meets.

The study report will not include any information that could identify specific participants. The report will include statistical and other aggregated data for addressing issues about concerns with the TRICARE program, but any statistical results will not be derived from the analysis of the focus groups. The report will be used by the TMA in conjunction with the TRICARE Regional Offices and the managed care support contractors in each of the three regions to try and increase the number of providers who participate in the program.

12. Estimate of the hour burden of the collection of information.

The total burden hours for the data collection with physician practice providers or, more likely, their business staff, is based on an estimated sample of no more than 72 focus group participants, depending on how many actually show up for the meetings (the optimal number is approximately 8, but we will recruit as many as 12 to account for expected no-shows). We expect the length of the focus groups to be an hour, but will assume another one-half hour of travel time to reach and then return from the focus group meeting.

Participant Burden Estimate

General locations of the focus groups (by region)	Focus group participants (Per focus group)	Number of focus groups	Frequency of response	Participant burden hours
North	8 to 12	2	1	36
South	8 to 12	2	1	36
West	8 to 12	2	1	36
Total				108

The estimate of annual costs to respondents for the proposed data collections is calculated as the product of the total burden hours for each focus group and mean participant wage rate. For the focus group participants, the annual cost to respondents was calculated as 108 hours * $30.00/hour = $3,240.¹

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

There are no capital or maintenance costs.

14. 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 table below presents the labor and contracting costs for conducting the focus groups. We expect that some of the operational costs will be outsourced to a contractor specializing in setting up focus groups, which are included in the row labeled contracting. CNAC may outsource to firms specializing in recruiting potential participants and reserving conference room space in six sites across the country.

There will be travel and lodging costs for two CNAC staff members for approximately three days per focus group. That would imply 12 trips to various parts of the country and a total of roughly 144 hours time for CNAC employees to actually travel to and from and conduct the focus groups. The time spent could be less for more local trips (i.e., near the Washington, D.C. area) but we include the higher, and more conservative, estimate.

Item	Hours	Cost
Honorarium fees		$3,600
Contracting (not including travel)		$15,000
Time spent conducting focus group	144	$46,500
Other travel costs (plane fares, hotel accommodations, etc.)		$10,000
Total		$75,100

We estimate that the amount paid to focus group participants, CNAC employees and any other contractors potentially hired to help set the focus groups up will cost approximately $75,100. We have not estimated the cost of analyzing and reporting results since that is part of our overall analysis of facilitating additional providers and will be hard to disentangle from the other parts of our analysis of the problem.

15. Explain the reason for any changes reported in Items 13 or 14 above.

There are no changes. The focus groups discussed in this supporting statement are a new one-time data collection.

16. 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.

The schedule for data collection and reporting is shown in the table below.

Data Collection and Reporting Schedule

Activity	Time schedule
Develop focus group protocols	3/7/07
Submit OMB clearance package for focus groups	3/7/07
Conduct interviewer training for focus groups	4/10/08-4/15/08
Conduct focus groups in six sites	05/01/08-06/15/08
Analysis of data on focus group discussions	06/15/08-07/31/08
Produce final report for TMA	07/31/08

17. If seeking approval to not display the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.

We are not seeking this approval.

18. Explain each exception to the certification statement identified in Item 19, "Certification for Paperwork Reduction Act Submissions," of OMB Form 83-I.

There are no exceptions to the certification statement identified in Item 19, “Certification for Paperwork Reduction Act Submissions,” of OMB Form 83-I.

B. COLLECTIONS OF INFORMATION EMPLOYING STATISTICAL METHODS

This collection does not employ statistical methods. This supporting statement concerns only one part of CNA’s overall effort for TMA. Specifically, we are requesting approval for conducting a series of focus groups with the administrative staffs of various physician and non-physician provider offices in the three TRICARE regions. We are proposing a series of focus groups because they will provide answers to questions that the current survey of physicians already conducted by TMA cannot provide. The survey, which goes out to as many as 40,000 physician offices, is designed to provide a basic understanding of how physician offices in the three TRICARE regions feel about TRICARE. It asks a few key questions on their knowledge and interest in seeing TRICARE beneficiaries as patients. But, because of the nature of the survey, it cannot deal in any depth with physicians’ knowledge and interest. The purpose of our focus groups is, for a relatively small number of participants, to learn as much as possible about their views and concerns when it comes to treating TRICARE beneficiaries.

The questions we plan to ask of participants in the focus groups, and which were attached as part of this supporting statement, have been designed to learn additional details on what the providers know about TRICARE. We hope to find out if they view TRICARE Standard/Extra as they would any other healthcare plan or whether it is viewed differently, perhaps because of its reimbursement policies or other factors that they feel limit their participation. We recognize that focus groups provide only qualitative information, but this kind of information is very important to CNA’s project. This is only one part of the overall project that is examining the extent to which TRICARE may have too few providers supporting the several million beneficiaries who do not enroll in TRICARE (as part of TRICARE Prime), but who are nonetheless entitled to benefits. In our other work on this project, CNA has been examining administrative records in order to quantify the extent to which civilian providers have seen TRICARE beneficiaries, which will also allow us to compare the number of TRICARE providers to providers in other healthcare plans (such as one of the fee-for-service plans under the Federal Health Benefits Program) as well as to all providers in certain areas all over the country. We also plan to use statistical methods in order to determine the possible reasons why some areas may have too few providers willing to participate, including the urban-rural nature of the local area, the number of all providers who practice there, and the local per capita income.

However, even if this very detailed analysis uncovers reasons that suggest why there may be fewer participating providers than would be desirable, this information does not directly suggest how TRICARE can obtain greater participation. We plan to use the focus groups to provide the kind of qualitative information directly from those participating physician and non-physician provider offices to possibly alter policies or target information to providers so they learn more about the program and hopefully participate more actively in the future. We believe direct contact with providers’ staff is the best way to achieve an understanding of provider concerns and how to address them, allowing us to recommend changes that will result in additional participation in the most efficient and effective way. Raising reimbursement for services provided to TRICARE beneficiaries, for example, will probably entice additional providers into the program, but at great cost. We hope to learn whether other less costly, but more focused, options may be available to TMA as it seeks to increase civilian provider participation.

1. Describe the potential respondent universe and any sampling or other respondent selection method to be used.

The focus groups will be conducted with the administrative staffs of providers in each of the three regions. This is a focused and limited information gathering effort; the focus groups will be conducted in two sites in each of the three TRICARE regions. We plan to go to areas in which the TMA survey of providers has already indicated smaller than desired provider participation. These will be in mid- to large-population areas that should have sufficient numbers of practices to provide the 8 to 12 participants per focus group. Sampling methods are not needed here. Once we receive OMB approval, we will begin the process of contacting provider offices to try and recruit them for the focus groups.

2. Describe the procedures for the collection of information.

We have already designed the focus group questions. The CNA analysts conducting the focus groups will keep track of the discussion and answers at the time and, in addition, we plan to (after asking first) record the sessions (which will last no longer than 1 hour) so that the analysts’ impressions and notes can be verified before drawing any conclusions.

3. Describe methods to maximize response rates and to deal with issues of non-response.

As we’ve described, our goal is to recruit interested individuals with the knowledge of what their practice knows about TRICARE and why it chooses to participate or not. Our questions have been designed to put participants at ease so they do respond to questions and we will be sure to inform them that their responses will be held in confidence. But we do not believe there should be any major problems here. If they decide to participate in the first place, we believe them likely to participate fully in the discussions.

4. Describe any test of procedures or methods to be undertaken.

Recognizing that responses to questions posed in focus groups are qualitative in nature means we do not plan to perform any form of testing on them. We only hope to learn what they think about TRICARE and the nature of its policies through their responses. For those who do not participate in Tricare, we hope to learn what might be done to encourage participation. We understand that we cannot just assume that the responses can be generalized across all providers across the entire country. At the same time, each region’s TRICARE benefit is administered a bit differently because a different managed care support contractor (i.e., a different healthcare plan) is in charge and we believe that some useful and critical information can be obtained by talking to providers about their perceptions of the plan in which they do or do not participate.

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.

Because this request pertains to focus groups, there is no statistical aspect of design, so no outside individuals or groups have been consulted as part of that. CNA personnel will conduct the focus groups and analyze the results to the questions posed to focus group participants.

1 As an estimate of the per hour wage paid to administrative staff who are the most likely to participate, we used an average value of $30.00 for the occupation code pertaining to business operations specialists, all other (SOC 13199). The actual simple average over the four regions of the country listed was $30.05.

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