S3

Memorandum

Per the 2013 Medicare Physician Fee Schedule (PFS) final rule, CMS intends to publicly report, starting in calendar year 2014, the Clinician & Group Surveys Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) patient experience of care measures for group practices of 100 or more professionals and for Accountable Care Organizations [ACOs] (submitted under the Shared Savings Program [SSP]) for program year 2013. The 2013 Medicare PFS final rule finalized the following set of patient experience of care measures for program year 2013:

• Getting Timely Care, Appointments, and Information

• How Well Your Doctors Communicate

• Patients’ Rating of Doctor

• Access to Specialists

• Health Promotion and Education

• Shared Decision Making (applicable to ACOs only)

To ensure that only quality measures that are scientifically sound and statistically reliable are selected for public reporting on Physician Compare, the Physician Compare team will conduct quality assurance checks and additional analyses to assess the empirical properties of the data, including:

• Performing data quality assurance checks (e.g., confirming that the consistency between measures and measure components, cross validating beneficiary information with Medicare claims and enrollment if feasible, etc.);

• Analyzing the data’s descriptive statistics (e.g., size and composition of group practices/ACOs submitting the data, average number of beneficiaries eligible for each measure, the mean and standard deviation of performance rates, etc.) and ;

• Assessing the extent to which differences in each quality measure are due to actual differences in group practice performance versus variation that arises from measurement error;

Once this information is analyzed, it will be presented to CCSQ/P3/CM Leadership to receive approval on which patient experience of care measures are appropriate for public reporting. Once the data are approved, the Physician Compare team will create measure files in XML format that include all groups and ACOs who meet the requirements for public reporting and all measures and measure components as they will be displayed on Physician Compare. These files will be shared with CMS contractors to facilitate measures preview and public reporting.