Supporting Statement for the Title X Sustainability Assessment Tool
For Grantees and Service Sites
Submitted To
Office of Management and Budget
Office of Information and Regulatory Affairs
Submitted By
Department of Health and Human Services
Office of the Assistant Secretary for Health
Office of Population Affairs
May 20, 2015
1. Circumstances Making the Collection of Information Necessary 5
2. Purpose and Use of Information Collection 6
3. Use of Improved Information Technology and Burden Reduction 7
4. Efforts to Identify Duplication and Use of Similar Information 7
5. Impact on Small Businesses or Other Small Entities 7
6. Consequences of Collecting the Information Less Frequent Collection 7
7. Special Circumstances Relating to the Guidelines of 5 CFR 1320.5 8
8. Comments in Response to the Federal Register Notice/Outside Consultation 8
9. Explanation of any Payment/Gift to Respondents 8
10. Assurance of Confidentiality Provided to Respondents 8
11. Justification for Sensitive Questions 8
12. Estimates of Annualized Hour and Cost Burden 8
Circumstances Making the Collection of Information Necessary
The Title X Family Planning Program (“Title X program” or “program”) is the only Federal grant program dedicated solely to providing individuals with comprehensive family planning and related preventive health services (e.g., screening for breast and cervical cancer, sexually transmitted diseases (STDs), and human immunodeficiency virus [HIV]). The program’s purpose is to assist individuals in determining the number and spacing of their children, thereby contributing to positive birth outcomes and healthy families. The program is designed to provide access to contraceptive services, supplies, and information to all who want and need them. By law, priority is given to persons from low-income families (Section 1006[c] of Title X of the Public Health Service Act, 42 USC 300).2 The Office of Population Affairs (OPA) within the Office of the Assistant Secretary for Health administers the Title X program.
In fiscal year 2014, Congress appropriated approximately $296.8 million for Title X family planning activities under a continuing resolution (as of December 29, 2014). In accordance with the statute and regulations (42 Code of Federal Regulations [CFR] Part 59),3 at least 90% of the appropriation is used for clinical family planning services.2 In 2013, 93 Title X grantees provided family planning services to five million women and men through a network of 4,200 community-based centers that include state and local health departments, tribal organizations, and other public and private nonprofit agencies. There is at least one clinic that receives Title X funds and provides services as required under the Title X statute in 73% of U.S. counties.5
The American health care system is experiencing unprecedented levels of change as a result of the Patient Protection and Affordable Care Act (ACA). The exact impact of these health system changes to the Title X service sites is unknown but can be hypothesized as follows:
OPA expects that the number of uninsured clients in Title X will drop. Currently 63% of clients in Title X centers are uninsured. Some have hypothesized that the need for Title X may decline after ACA is implemented fully. However, the experience in Massachusetts, which implemented coverage-expanding health reform in 2006, shows that disproportionate share of uninsured clients continue to utilize Title X centers even when coverage is made available more broadly.1,2 Although the current Family Planning Annual Report (FPAR) data will provide OPA with information on the insurance status of clients, FPAR data will not allow OPA to understand how changing insurance status is affecting the center’s financial viability. For example, a greater number of insured clients will mean that Title X centers will have to contract with private insurers to a greater degree than they have in the past. Title X sites have anecdotally reported significant challenges with contracting with private health plans that are part of the Marketplaces, including negotiating adequate payment terms. However, most of the 93 grantees that administer the 4200 centers have not assessed their networks to determine the extent of the problem or the impact to the revenue of individual centers. FPAR data also does not indicate whether centers who continue to see a high rate of uninsured clients have made efforts to enroll clients into affordable health insurance programs. This data collection will provide both OPA and the grantees with information on what’s happening at the individual center level to better explain shifts in revenue sources and payer mixes seen in FPAR data.
For States expanding Medicaid a greater percentage of the Title X centers will see shifts in revenue sources. According to data collected through FPAR, Medicaid accounts for 40% of total revenue for Title X funded centers and private third party reimbursements accounted for 5%. Client fees accounted for 6% of the revenue. It is unclear how the revenue streams will change for Title X sites in 2015 and beyond. In terms of Medicaid, varying reimbursement policies around onsite dispensing of contraceptives and education and counseling are continuing challenges for Title X providers. Reimbursement under Medicaid alternative benefit plans (ABPs) may also vary from traditional Medicaid reimbursement. The effect of these ongoing issues and how they will translate to the financial operations of Title X centers is not well understood by OPA or by the 93 grantees for their individual centers.
The majority (92%) of family planning users are women who, for those with coverage through Medicaid or a non-grandfathered health insurance plan or policy, have access to a broad range of preventive services as a result of the ACA. Six out of ten women who use publicly funded family planning centers cite the family planning center as their usual source of medical care.3 Thus, Title X clearly serves as an access point to healthcare. There may be a greater demand for primary care services and given the geographic diversity and existing relationships Title X centers in the community, OPA has encouraged centers to partner with primary care providers or consider expanding their own services. Again, OPA, nor the 93 grantees have assessed to what degree such primary care partnerships exist within individual Title X centers.
There has been a national focus on investing in health information technology to improve care quality. OPA has encouraged grantees to invest in Electronic Health Records (EHR) but anecdotal information indicates that a significant portion of individual centers have not made such investments. In 2013, OPA provided competitive grants for purchases and upgrades to EHR systems. In 2017, OPA plans to OPA has no concrete information on the prevalence of EHR’s within individual Title X centers or how those with EHR’s actually use them (i.e. are they maximizing use of their EHR’s for evaluating patient care quality). Care quality will be an important factor in ensuring that Title X centers retain their current clients but OPA does not know how many centers routinely evaluate such data.
Given the changing health system landscape, OPA believes it’s important for Title X grantees to be involved at the local level so they understand how their individual health system is changing and what they need to do in response. However, OPA has no mechanism to understand whether grantees are involved within their local health systems.
OPA requires information in all of the aforementioned areas in order to understand the impact of health system changes to the Title X network to better assist grantees in ensuring sustainability of the centers that provide much needed family planning services to low income populations.
As indicated in the background, The implementation of the Patient Protection and Affordable Care Act (ACA)—PL 111-148 has resulted in myriad changes for the American healthcare system, and the Title X network must adapt to become resilient to these changes. Currently, the majority of Title X family planning service providers to not have diversified revenue streams, the ability to bill private health insurance plans, or the electronic health record systems infrastructure that is now requisite for contracting with private health insurance agencies.
This is a request to the Office of Management and Budget (OMB) for approval of a new data collection and grantee assessment tool to assist Title X grantees and sub-recipient service sites in understanding their readiness to respond and adapt to health system changes. This annual reporting requirement is for family planning services delivery projects authorized and funded by the Title X Family Planning Program ["Population Research and Voluntary Family Planning Programs" (Public Law 91-572)], which was enacted in 1970 as Title X of the Public Health Service Act (Section 1001 of Title X of the Public Health Service Act, 42 United States Code [USC] 300).1
Title X grantees and sub-grantee service sites vary widely in terms of the state funding contexts in which they operate, the number of revenue sources they have, respective billing policies, use of electronic health records systems, quality improvement efforts, and changing client dynamics. OPA is not currently collecting data on these important sustainability elements for grantees and service sites. The proposed survey tool will inform OPA around which forms of technical assistance will be most useful to grantees, and help OPA better inform the department as to the financial viability of Title X centers. OPA will not use collected data to make funding decisions, but will utilize it to assess the need for additional resources to improve the sustainability of the Title X network.
Data will be collected electronically using two sets of survey questions. One set will be questions for overall grantees to assess their role and knowledge of local and state level policies and their monitoring of enrollment efforts care quality for the service sites they oversee.
Data will separately be collected from services sites to assess their efforts related to; 1) assisting individuals in obtaining health insurance; 2) partnerships with primary care providers; 3) availability and use of electronic health records; 4) monitoring patient care quality; 5) factors affecting revenue sources; and 6) the way that sites conduct analyses to consider the cost of providing services.
Attachment A to this statement contains a copy of the authorizing Title X program regulations that necessitate the collection of the information, Attachment B is the proposed data collection survey for Title X grantees, and Attachment C is the proposed data collection survey for Title X service sites.
This data collection is necessary to explain trends in client volume, insurance status of clients and revenue sources for Title X centers (data already collected in FPAR). FPAR data is collected in aggregate for the 4200 centers through 93 grantees. This data will be collected directly from individual centers in order to explain national trends in FPAR data.
OPA will utilize these data in three main ways:
First, OPA needs to prepare grantees to operate in the new healthcare environment. OPA is unable understand where to direct resources without fully understanding the status of the network. For example, without quantitative data on where Title X centers are related to being able to contract with private health insurance plans, OPA can not assess what revenue sources will look like for Title X funded centers. This hinders OPA’s ability to advise HHS as to the future funding needs of Title X centers. OPA also needs this information to understand where to direct resources to grantees. In 2013, OPA provided funding for sites to purchase and upgrade EHR systems. Without quantitative information on the state of EHR use amongst all the Title X centers, OPA can not assess whether this is a good investment in future years.
Second, OPA funds five national training centers through six cooperative agreements .The training centers are charged with providing national training, resources and technical assistance to grantees. One training center is specifically dedicated to management and systems improvement. They are charged with providing one on one technical assistance to grantees in addition to national training and resources. OPA does not have specific data to inform the activities of these training centers to where they will be most useful. For example, without specific information on what types of EHR systems exist within the Title X network, training centers can not develop resources to help grantees understand how to use their EHR’s. Data collected from this effort will be used to inform the work of the training centers so they can better support the Title X grantees.
Third, OPA works with several partners within HHS and external stakeholders to assist publicly funded family planning centers and provide leadership in the area of family planning. OPA needs information on challenges Title X centers are facing to more effectively work with our partners. For example, one such area is assisting Title X and similar centers with obtaining contracts with health insurance plans, including those who sell qualified health plans in the new health care marketplace. In order to better work with national stakeholders and provide needed assistance, OPA needs to understand how Title X centers contract with private plans and challenges they are facing so we can work with the appropriate HHS entities to address these barriers.
In conclusion, OPA will utilize this information to better understand factors that are affecting the long term financial viability of Title X centers and better channel resources to provide assistance to Title X centers and better inform HHS of the future needs of the Title X program.
OPA central staff will utilize a web-based survey platform called SurveyMonkey to collect the proposed sustainability assessment data efficiently from Title X grantees and services sites. OPA utilized this survey platform to collect data in Spring 2014 on Title X Outreach and Enrollment efforts and grantees appreciated the straightforward, electronic survey format. This data collection and reporting method reduces the time burden on grantees, as they only need to respond to multiple choice or brief fill-in-the blank questions, as opposed to drafting narratives and data tables in Microsoft Word or Excel. Survey respondents do not need to do any further follow-up after clicking “submit,” and the results become immediately available to OPA without the need for additional data entry.
The survey monkey site is available from any computer with an internet connection and survey responses can be saved.
Efforts to Identify Duplication and Use of Similar Information
Aside from OPA, there are no other entities within HHS that collect data from Title X centers generally. The Health Resources and Services Administration (HRSA) collects information from federally qualified health centers (FQHC). Approximately 20% of Title X centers are also FQHC’s, however HRSA does not collect this data.
OPA has ensured that this data collection complements and does not duplicate data already collected through FPAR. Since the FPAR data collection system is designed to collect aggregate data from grantees, this is a new request and can not be added to FPAR. In order to understand the national trends seen in FPAR data, OPA needs qualitative information directly from service sites on the factors affecting these trends. Thus this separate data collection system is needed.
OPA has also worked with private entities that collect data from publicly funded family planning clinics to ensure that they are aware of this data collection and it does not duplicate any data they are planning to collect.
This data will be collected from Title X centers using a mechanism that has been used before. There is no specific impact to small businesses.
In order to reduce the burden on Title X centers, OPA is requesting annual data collection. Less frequent collection will hinder OPA’s ability to analyze trends nationally, particularly at a time when there are significant health system changes happening nationally. The purpose of this data collection is to help grantees respond to such changes so annual data checks are necessary to ensure OPA is responsively assisting grantees.
The proposed data collection will be consistent with guidelines set forth in 5 CFR 1320.5. There are no special circumstances related to this request. Grantees will be notified of the intent to collect data at least 60 days in advance and will not be required to submit multiple copies. They will submit one electronic form.
OPA received comments from one organization in response to the ICR 60-day FRN issued Federal Register Volume 80, Number 15 issued Friday, January 23, 2015) on pages 3593-3594. The organization also expressed general support for collecting the information generally but requested clarification on the following: 1) effort required to complete this data collection, noting it would take longer for their organization than the burden estimate; 2) whether this survey will collect data that are distinctly different from other OPA data collection efforts, and 3) whether sub-recipient agencies would be allowed to complete the data for the service sites.
OPA addressed the comments as follows; 1) we piloted this survey tool with Title X grantees and service sites and found that respondents took an average of 0.66 hours (39.9 minutes) per respondent to complete the survey. 2) The data collected is distinct from the data OPA collects for enrollment and through the Family Planning Annual Report (FPAR); and 3) OPA will allow organizational level staff to report the requested data, as long as one survey form is completed per service site. This means that Title X grantees may complete the survey form on behalf of service sites in their respective networks, reducing potential burden placed directly on clinical service sites.
No payment or gifts will be provided to respondents in this proposed survey.
Data will be submitted directly to OPA via the web-based survey platform, Survey Monkey. No data will be collected at the client level, to protect the confidentiality of individuals who receive the Title X-funded services (42 CFR Part 59). No individual identifiers will be collected in the surveys, and no Title X client can be identified based on the information requested from the grantees and service sites.
There are no sensitive questions on the form. All questions relate to center level characteristics. Individual client information is not collected.
In August 2014, OPA requested grantee volunteers to pilot the sustainability assessment survey via the web-based platform and the respondents took an average of .66 hours (39.9 minutes) per one respondent to complete the survey. The total hour burden on grantee and service site respondents will be 2,811.60 hours (see Exhibit 1). The hour burden estimates include the time spent by the grantee or service site staff to retrieve, compile, verify, and report the data and exclude any hour burden associated with customary and usual practices that the grantee or service site would carry out in the absence of the reporting requirement (e.g., regular communications with service sites).
12A. Total Hour Burden for Requested Data
Type of Respondent |
Form Name |
Number of Respondents |
Number of Responses per Respondent |
Average Annualized Burden per Response (Hours) |
Annualized Total Burden (Hours) |
Grantees |
Sustainability Assessment- Grantees |
92 Grantees |
1 |
40 minutes (0.66 hours)
|
60.72 |
Service Sites |
Sustainability Assessment-Sites |
4,168 |
1 |
40 minutes (0.66 hours)
|
2,750.88 |
Totals |
|
4,260 |
|
|
2811.60 |
12B. Estimated Annualized Respondent Cost Burden
The estimated total annualized labor cost to respond to the outreach and enrollment form is $112,817 or an average of $25.90 per respondent (see Exhibit 2). The estimated hourly wage rate ($40.12) is a weighted average based on the distribution of the hour burden across four different categories of grantee labor (i.e., clerical/unskilled, skilled/technical, managerial or professional, and executive). This hour burden across labor categories is based on findings from the 2009 FPAR Burden Study22 which was conducted for a larger data collection effort by an OPA contractor. The average wage rate for each labor category was obtained from the U.S. Bureau of Labor Statistics 2011 wage rates for the health care and social assistance sector.23
Exhibit 2–Estimated Annualized Cost to Respondents for Information Collection
Type of Respondent |
Total Burden Hours |
Average
(Weighted) |
Total Respondent Cost |
Grantees |
61 |
$40.12 |
$2,447 |
Service sites |
2751 |
$40.12 |
$110,370 |
Total |
|
|
$112,817 |
Estimated Annualized Respondent Nonlabor Cost Burden
The estimated total annualized non-labor cost of this reporting are negligible because grantees are already expected to collect data for reporting to the Family Planning Annual Report (FPAR) (OMB No. 0990-0221, expiration January 31, 2016) and have the infrastructure (computer, phone lines etc.) to do so.
Annualized Cost to Federal Government
The estimated annualized cost to the federal government for collecting this data is $8,000. Exhibit 2 presents a breakdown of this total. The estimate includes costs by federal staff at the regional and central levels and by a contractor for the following activities:
Regional Office–To review, correct, and approve grantee submissions and assisting grantees in understanding data definitions.
Central OPA Staff–To review and final submissions, oversee and coordinate the work of the contractor, analyze and report collected data.
Exhibit 3–Annualized Cost of FPAR Reporting to Federal Government
Source |
Amount ($) |
FPAR review/approval and validation resolution, seed data review by OPA central and Regional Office Staff (200 hours x $40/hour) $25,200 |
$8,000 |
Total Annualized Cost |
$8,000 |
Explanation for Program Changes or Adjustments
This is a new data collection.
Plans for Tabulation and Publication and Project Time Schedule
Annually, OPA may tabulate, analyze, and disseminates the data in the form of a national summary and a regional summary for each HHS region. The data may also be analyzed for publication in a peer reviewed format such as a medical journal. All data will be presented in aggregate form with no individual information presented.
This request is for a 3-year clearance. Data will be submitted semi-annually each year. The data collection period will include prior open outreach and enrollment periods. Exhibit 4 presents the timetable for key activities following OMB approval.
Exhibit 6–Timetable for Data Collection, Analysis, and Publication
Activity |
Expected Date of Completion |
End of reporting period |
0 months following OMB approval |
Due date for data submission |
2 months following OMB approval |
Export initial data to regional staff for review and validation |
2-3 months following OMB approval |
Resolve validation issues |
2-3 months following OMB approval |
Analyze and report final data |
3-6 months following OMB approval |
Reason(s) Display of OMB Expiration Date Is Inappropriate
The 3-year expiration date for OMB approval will be displayed on all versions of the form (i.e., electronic, Web-based, and hard-copy).
Exceptions to Certification for Paperwork Reduction Act Submissions
There are no exceptions to the certification.
1 Gold RB. Family Planning Centers Meet Health Care Reform: Lessons from Massachusetts. Guttmacher Policy Review 2009;12(3):2-10.
2 Carter, M, Desilets K, Gavin L, Moskosky S, Clark J. Trends in Uninsured Clients Visiting Health Centers Funded by the Title X Family Planning Program—Massachusetts, 2005-2012. Morbidity and Mortality Weekly Report. January 24, 2014. 63 (03); 59-62.
3 Guttmacher Institute. Next Steps for America’s Family Planning Programs. Available at http://www.guttmacher.org/pubs/NextSteps.pdf Accessed May 22, 2013.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Emily Jones |
| File Modified | 0000-00-00 |
| File Created | 2021-01-25 |