Response to Comments

D epartment of Health & Human Services

Centers for Medicare & Medicaid Services

Center for Beneficiary Choices

7500 Security Boulevard

Baltimore, Maryland 21244-1850

C enter for Medicare

TO: Office of Management and Budget

FROM: Elizabeth Goldstein, Director

Division of Consumer Assessment and Plan Performance

DATE: June 30, 2010

SUBJECT: Response to CMS-R-246 Comments

CMS appreciates the comments provided on the Paperwork Reduction Act (PRA) package CMS-R-246, Consumer Assessment of Health Care Providers and Systems (CAHPS). Our responses to the comments submitted are below.

General Comments

1. Formatting issues

1.a. Several comments related to the formatting of the introduction of question labeled PPO d in the MA PD survey. In all cases these comments said that the introduction was not a question and its placement in the survey was therefore confusing.

CMS RESPONSE: We agree with the general statement that the introduction could be confusing for a survey respondent as it is currently presented in the survey. We further agree that adding it to the beginning of the question itself would be less confusing and provide for smoother introduction of the issue being asked about. The question will be changed to:

XX. Some insurance plans have a network or group of doctors who belong to the plan. You pay less if you use doctors who belong to the network, and more if you use doctors who are not part of the network. In the last 6 months, did you visit any specialists who were not part of <NAME OF YOUR HEALTH PLAN> network?

 Yes

 No

 I don’t know

1.b. Several comments stated that not all of the questions nor response categories were aligned in the surveys provided with the OMB package of materials.

CMS RESPONSE: The surveys provided in the OMB package should have been aligned presented in such a way that was clearer to the reader. In the final electronic sets of surveys the CMS will provide to approved vendors a set of formatting requirements and examples of such formatting will be included. These requirements will provide vendors the means by which they will be able to format the surveys that will be the same for all vendors and comparable across survey types.

1.c. Two comments suggested that the question regarding coordination of care, i.e. “How satisfied are you with the help you received to coordinate your care in the last 6 months? Very dissatisfied, Somewhat dissatisfied, Neither dissatisfied nor satisfied, Somewhat satisfied, Very satisfied,” that currently resides as the last question in the “GETTING HEALTH CARE FROM SPECIALISTS” section, would best be placed in the “YOUR HEALTH PLAN” section, and specifically worded as “How satisfied are you with the help you received from your health plan to coordinate your care in the last 6 months?,” with the same response categories provided.

CMS RESPONSE: CMS believes this suggestion has merit and will raise it with our analytic team. We would like to point out that this question as it now is included in the Medicare CAHPS is placed directly prior to the “YOUR HEALTH PLAN” section.

1.d. Several comments suggested that the surveys were too long and made recommendations to delete several specific questions including the questions about insurance agents.

CMS RESPONSE: CMS has carefully reviewed the lengths of all survey and all survey questions. We concur that as originally proposed all of the surveys were too lengthy and we deleted several questions that were used in the past for internal analytic purposes but that were not used in public reporting. These include all of the questions related to insurance agents. The full set of questions we have deleted can be seen in the cross-walk provided of questions in the original OMB package presented in April 2010 and the full set of questions in our revised questionnaires to be used for 2011. The 2011 MA survey now includes 67 questions as opposed to the 77 submitted with the original 2011 OMB package. The 2011 MA PD survey now has 83 questions as opposed to the 97 originally proposed in the OMB package. We have retained the four PPO questions for enrollees who have selected a PPO option, so the PPO survey will have 87 questions. The 2011 Stand Alone PDP survey will have 37 questions as opposed to the 51 originally proposed. (Please see the cross-walk of the originally proposed and current 2011 sets of MA, MA PD, and Stand Alone PDP questions attached to this package.)

1.e. A comment recommended that Medicare FFS enrollees be included in the Medicare CAHPS survey and “contain the same questions as other instruments so [one] can better understand the health experiences of Medicare enrollees and their awareness of their rights..”

CMS RESPONSE: CMS, since 2000, has included the Medicare FFS enrollees in the Medicare CAHPS survey and will continue to do so in 2011. Since 2006, many Medicare FFS enrollees were also enrolled in Medicare Stand Alone PDPs. The 2011 Medicare CAHPS survey will include both a Medicare FFS only and a Medicare Stand Alone PDP survey that will be fielded separately to persons with Medicare enrolled in the Medicare FFS Only plan or enrolled in a Medicare Stand Alone PDP plan. Medicare FFS enrollees will be asked about their care experiences in the Medicare FFS plan. The 2011 Medicare FFS CAHPS survey will be 59 questions, including the core CAHPS survey questions and several demographic and other questions for analyzing the Medicare FFS enrollees’ experiences with the Medicare program. The 2011 Medicare Stand Alone PDP CAHPS survey, which will be fielded among Medicare FFS enrollees who have also enrolled in a Medicare PDP plan, will include 37 questions.

2. Data File Requests:

2.a. Several comments requested that vendors provide sets of de-identified data of all responses to all of the CAHPS surveys that vendors conduct for their client Medicare MA, MA PD, and/or Stand Alone PDP plan contractors.

CMS RESPONSE: CMS is working with both our analytic team and experts within the Department of Health and Human Services to determine the level, type, and timing of data it can permit be provided to MA, MA PD, and Stand Alone PDP contracts once the survey results are compiled within data files that conform to standards and all legal requirements that protect the identities of the respondents. We understand that the some forms of the data beyond the health plan reports could be helpful to development of quality improvement efforts and monitoring of those efforts. We will, however, need to balance the utility of providing such information with the legal and privacy issues involved in the linking of data to respondent by individual. More on these issues will become available on Medicare’s MA & PD CAHPS Web Site: www.ma-pdpcahps.org prior to the dates when the 2011 survey will be completed.

2.b. One comment included the suggestion that along with allowing approved vendors to provide “a de-identified raw data file” to their contractor Medicare plan, that “submission of the data to the NCQA Quality Compass tool would [also] serve as a value add to the plans.”

CMS RESPONSE: As noted above, CMS is examining the legal, privacy, and confidentiality issues that we are required to abide by with regard to release of data from the Medicare CAHPS survey in any form other than the Health Plan Reports that have been historically provided to each plan. These are issues that go beyond the single authority of CMS and must be adhered to in any release of data from the survey.

2.c. One comment regarding the release of individual level data from the survey “strongly urges CMS to provide CAHPS data from membership within a particular Medicare contract number to include a geographic indicator.” Additional commentary in this set of comments states that “If CMS decides not to release individual-level data files [with geographic indicators], we request that CMS provide [each plan] with separate reports and summary level data files for [each] of the regions under [which their contract provides services, with the example being Northern and Southern California].

CMS RESPONSE: Legal, privacy, and confidentiality issues will drive the decisions CMS will make regarding release of information from the Medicare CAHPS surveys in the future as these issues have in the past. CMS would like to point out that the 2009 Health Plan Reports provided to each plan in the Medicare CAHPS survey that year included mappings of several of the reportable CAHPS measures depicting regional measurements. We understand the utility of such information and will continue to provide information at the level permitted within the privacy and legal requirements we also must adhere to in this survey.

2.d. Several comments stated that changes in the Medicare CAHPS survey have made it difficult to conduct trend analyses citing specifically the change from 3.0 to 4.0 CAHPS.

CMS RESPONSE: CMS attempts to keep the core set of questions in its survey similar or identical from year to year, unless there are compelling reasons for making a change. The change from 3.0 to 4.0 CAHPS was to be compatible with the NCQA commercial CAHPS program that made these changes following analysis of some issues related to the earlier version of the survey.

Specific Survey Question Comments

1.a. MA only Survey “q. 30. How satisfied are you with the help you received to coordinate your care in the last 6 months?” Several comments suggested this be placed within the Your Health Plan section and not the Specialist section. One comment requested that the measure developed from this question be case-mix adjusted “for presence or number of chronic conditions as well as health status.”

CMS RESPONSE: CMS will look into the issue of placement for the question and consider moving it to an appropriate location in the Your Health Plan section. In regards to CMS of this measure, it is likely that the measure will employ similar CMA factors as other measures for reportable items on the survey, including health status. It is unlikely that the number of chronic conditions a person has will be included among the CMA factors used for making an adjustment. The number of chronic conditions may be an indicator of the number of differing providers the respondent has seen in the past six months, especially if these conditions require differing specialist expertise in their treatment. CMS has been careful not to adjust for factors may directly impact on a responses to questions that may be under the control of the health plan. While the issue of having a number of chronic conditions is not under a plan’s control, the fact that it could be an indicator of the number of different types of providers the respondent sees within the plan is an important issue for which coordination of the services provided by these differing providers should be within the plan’s control. More coordination should be provided by the plan for those with multiple chronic conditions.

1.b.c.d. Several comments suggested CMS drop questions 41, 42, and 43 on the MA Only Survey and the comparable questions on MA PD and Stand Alone PDP surveys. These questions ask “Did an insurance agent or broker ever call you without your asking them to, to tell you about insurance or prescription medicines?” along with two followup questions regarding such unsolicited contacts by an insurance agent.

CMS RESPONSE: CMS has decided to drop these three questions from all of our Medicare CAHPS surveys and they will not be in any of the surveys employed in 2011.

2.a. Q, 41, 43, and 44, ask about issues related to whether the respondent asked to have an decision reconsidered by the plan if they plan had not provided a specific service to the respondent. Several comments requested that the word “resolve” in q. 41, 43 and 46 be changed to “settled” since the respondent may interpret resolved as being resolved in their favor. Several comments on these questions also noted that the response “I am still waiting for it to be settled” is too open-ended since the complaint could have been made recently and the response alludes to a lengthier time for the complaint to be settled.

CMS RESPONSE: CMS will consider the issue of whether to change the word “resolve” to “settled” in the questions noted. This specific issue has been tested in another survey being developed for CMS within the complaint tracking module system and from those tests “settled” did appear to be a less misunderstood word. It is an issue we will make a decision on based on the full review of those tests.

2.b. Several related to the “Your Medicare Rights” section of the surveys. One of these comment stated that the questions that asks “Was there ever a time when you believed that you needed care and services that your plan decided not to give you? is too open-ended, especially since most of the other services questions ask about the last six months. Another comment stated that all of the above question as well as the follow-up “Have you ever asked anyone at your plan to reconsider a decision not to provide or pay for health care or services?” “leads the member to think the plan has a right to interfere with the physician’s clinical decisions or plan of treatment” and suggests “these questions be eliminated entirely [since] they would potentially promote unnecessary and potentially dangerous care for patients.”

CMS RESPONSE: The specific questions on Your Medicare Rights are worded in such a way that the respondent is asked whether their health plan has ever decided not to provide services they thought they needed, not whether their physician did not provide them these services. CMS would like to know whether the respondent’s plan decided not to cover services that the respondent felt were needed and whether the respondent inquired about the decision of the plan regarding these services. CMS will look at whether the questions regarding whether there was “ever a time” when the respondent’s plan decided not to provide a service is too open-ended and whether a time-frame, similar to the six months time frame on most other services questions, should be added to the question.

2.c. A comment asked why the Your Medicare Rights set of questions were not asked of the Medicare FFS enrollees.

CMS RESPONSE: The questions in Your Medicare Rights section were added to the Medicare CAHPS survey in response to a legal case raised on behalf of enrollees of Medicare HMOs (early Medicare Advantage plans). In March, 1996 a judgment was issued in favor of Medicare HMO enrollees by U.S. District Judge Alfredo C. Marquez, who ordered that HCFA (now CMS) require its contracting HMOs (now MAs) to provide improved notices and expedited appeals procedures to Medicare beneficiaries. [Grijalva v. Shalala, 946 F.Supp. 747 (D.Ariz. 1996).] Because the ruling related to enrollees in Medicare HMO (now MA) plans these questions were added to Medicare CAHPS in direct result of the requirements of this case.

2.d. A comment recommends deleting the question asking sample members if a doctor ever told them they had one or more specified medical conditions, particularly for

A Stand Alone PDP enrollees. This question is actually asked of all sample members regardless of the type of plan in which they are enrolled.

CMS RESPONSE: CMS asks this question of all sample members, regardless of the type of plan in which they are enrolled. The question does not relate necessarily to the personal or the current doctor of the sampled member, but whether any doctor has provided a diagnoses of any of the conditions listed. CMS uses this question to analyze sample members and has compared the self-reported measures obtained from the survey with other prevalence rates for the given conditions. The survey rates compare favorably with other prevalence and therefore provide valuable information that can be used to compare all Medicare beneficiaries and their care experiences, regardless of the type of plan in which they are enrolled.

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