Crosswalk

Attachment E: Revisions Made to the MAPCP Provider Survey in Response to Comments

First Page of Survey
Original Wording
Public Burden Statement: According to the Paperwork Reduction Act of 1995, a federal agency may not conduct, and a person is not
required to respond to, an information collection request unless it displays a currently valid OMB control number. The valid OMB control
number for this information collection is [XXXX-XXXX]. The time required to complete this information collection is estimated to average 15
minutes per respondent, including the time to review instructions and complete and review the information collection. If you have
comments concerning the accuracy of this burden estimate or any suggestions for reducing this burden, please write to: CMS, 7500
Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, MD 21244-1850.
OMB No.:[xxxx-xxxx]
Expires: [3 yrs from OMB approval date]

Revised Wording
(Deletions struck out, insertions underlined and italicized)

Begin New Survey
Resume Previous Survey
Public Burden Statement: According to the Paperwork Reduction Act of 1995, a federal agency may not conduct, and a person is not
required to respond to, an information collection request unless it displays a currently valid OMB control number. The valid OMB control
number for this information collection is [XXXX-XXXX]. The time required to complete this information collection is estimated to average 15
18 minutes per respondent, including the time to review instructions and complete and review the information collection. If you have
comments concerning the accuracy of this burden estimate or any suggestions for reducing this burden, please write to: CMS, 7500
Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, MD 21244-1850.
OMB No.: [xxxx-xxxx]
Expires: [3 yrs from OMB approval date]

Reason for Revision
In the course of building and then beta-testing a web-based version of this survey, which we have now done, we realized we needed to
add a button to the first page of the survey that respondents could click to initiate a survey and another to allow them to continue
working on a survey they previously started filling out. Therefore, we have added a “Begin New Survey” button and a “Resume
Previous Survey” button to this page.
We have also revised the Public Burden Statement to increase the estimated time needed to complete our survey (formerly “15
minutes”). MAPCP physician pilot testers in fact needed 17 minutes on average to complete our survey, and since we are now adding
a few short questions (shown on later pages), we are adding an additional 1 minute to this estimate to take them into account, for a
revised estimate of “18 minutes.”

1

Second Page of Survey
Original Wording
(Text that is the focus of comments is underlined.)
Your Participation in this Survey
This survey is being fielded among all health care providers participating in the Centers for Medicare and Medicaid Services’ Multi-payer
Advanced Primary Care Practice Demonstration, which includes providers participating in [state]’s [state-specific name of MAPCP
demonstration].
This survey is designed to measure the extent to which the practice you work for engages in activities associated with the patient-centered
medical home model of care.
There is no “passing grade” for this voluntary survey, nor will your responses have any consequences for payment. We are
genuinely interested in your candid observations of the way your practice operates today.
Your responses will be analyzed by researchers contracted to evaluate this demonstration (RTI International, The Urban Institute, and the
National Academy for State Health Policy). Results will not be shared with anyone besides these researchers, and will not be used
for any purposes other than the evaluation of the demonstration. They will report the results of this survey to CMS in a nonidentifiable, aggregated form.
We estimate that this survey will take 15 minutes to complete.
If you are willing to participate in this research, please complete this survey by April 22, 2014.
If you have difficulty or questions when completing this survey, please contact Stephen Zuckerman at [email protected] or 202-2615679.

The Questions in this Survey
This survey asks about how your practice currently manages your patients’ health needs. The questions are organized into two sections:
Section A: Practice Functions asks you to identify your practice’s care processes and approach to managing change and improving
quality.
Section B: Practice Infrastructure asks about practice finances and organizational characteristics, participation in other initiatives,
current practice staff and roles, and contact information.

2

Please complete all questions in the survey to the best of your knowledge. If your practice has multiple physical locations, please respond
based on the physical location where you practice most frequently. For practices with more than one physical location participating in
[state]’s [state-specific name of MAPCP Demonstration], we will contact each location to complete the survey.
All medical doctors, doctors of osteopathy, nurse practitioners, and/or physician’s assistants in your practice have been asked to complete
this survey. Input can be requested from other staff in the practice as needed but please complete as much of the survey as you can from
your perspective.

Revised Wording – New Third Page of Survey
Your Participation in this Survey
This survey is being fielded among all health care providers participating in the Centers for Medicare and Medicaid Services’ Multi-payer
Advanced Primary Care Practice (MAPCP) Demonstration, which includes providers participating in [state]’s [state-specific name of
MAPCP demonstration].
This survey is designed to measure the extent to which the practice you work for engages in activities associated with the patient-centered
medical home model of care.
There is no “passing grade” for this voluntary survey, nor will your responses have any consequences for payment. We are
genuinely interested in your candid observations of the way your practice operates today.
Your responses will be linked to claims data using an encrypted identifier, and analyzed by researchers (at RTI International, The Urban
Institute, and the National Academy for State Health Policy) contracted to evaluate this demonstration. Results These data will not be
shared with anyone besides these researchers, and will not be used for any purposes other than the evaluation of the
demonstration. Researchers They will report the results of this survey and their analyses in reports to CMS that will be made available to
other federal agencies, state governments, and the general public in a non-identifiable, aggregated form that will assure your full
confidentiality.
We estimate that this survey will take 15 18 minutes to complete.
If you are willing to participate in this research, please complete this survey by April 22, 2014.
If you have difficulty or questions when completing this survey, please contact Stephen Zuckerman at [email protected] or 202-2615679.

PREVIOUS

NEXT

HELP

3

Revised Wording – New Fourth Page of Survey
The Questions in this Survey
This survey asks about how your practice currently manages your patients’ health needs. The questions are organized into two sections:
Section A: Practice Functions asks you to identify your practice’s care processes and approach to managing change and
improving quality.
Section B: Practice Infrastructure asks about practice finances and organizational characteristics, participation in other
initiatives, and current practice staff and roles, and contact information.
Please complete all questions in the survey to the best of your knowledge. If your practice has multiple physical locations, please respond
based on the physical location where you practice most frequently practice site that is participating in [state]’s [state-specific name of
MAPCP Demonstration initiative]. For practices with more than one physical location participating in [state]’s [state-specific name of
MAPCP Demonstration], we will contact each location to complete the survey.
All medical doctors, doctors of osteopathy, nurse practitioners, and/or physician’s assistants in your practice have been asked to complete
this survey. Input can be requested from other staff in the practice as needed but please complete as much of the survey as you can from
your perspective.

PREVIOUS

NEXT

HELP

Reason for Revision
In the course of building the online version of this survey, we decided to split the text that appears above into two separate webpages,
to increase the likelihood that users will read through all of this text and not get overwhelmed by the large quantity of text to read.
We also have opted to make some minor revisions to text that appears under the “Your Participation in this Survey” heading:
•

•

We have revised some of the text in the underlined paragraph above to be more specific about how the survey data being collected from
respondents will be used, to ensure respondents are accurately informed about our study before consenting to proceed. Specifically, we
are now noting that survey responses will be “linked to claims data using an encrypted identifier,” and we note that we will not only
provide CMS with the results of this survey, but also the results of “analyses.” We now clarify that because the results we will provide to
CMS will be aggregated, they “will assure your full confidentiality.”
We have also updated the text to reflect our new “18 minutes” estimate of the length required to complete this survey, explained earlier.

4

The edits we have opted to make to the text that appears under the “The Questions in this Survey” heading are as follows:
•
•

We are deleting language telling survey respondents that we will be asking for their “contact information” since we have determined that
it is unnecessary to ask for this information after all.
We have revised some instructions for clinicians that practice out of multiple physical locations, and instead of asking them to respond
based on the location where they practice most frequently, we will be asking them to respond based on the practice site that is
participating in the MAPCP Demonstration.

5

Section A’s “General Instructions”
Original Wording
General Instructions. For each row, please circle the point value that best describes the level of advanced primary
care/medical home that currently exists in your practice. Within each box there is a range of responses indicating the extent of
implementation. Assign higher point values to indicate that the actions described in that box are more fully implemented.

Revised Wording
General Instructions. For each row, please circle Please select the point value that best describes the level of advanced
primary care / medical home that currently exists in your practice. Within each box there is a range of responses indicating
the extent of implementation. Assign higher point values to indicate that the actions described in that box are more fully
implemented.

Reason for Revision
In the course of building and then beta-testing a web-based version of this survey, we realized that some of the instructions needed to
be edited slightly to reflect the fact that this survey will be completed online, as opposed to in hard copy paper format. In the above
instructions paragraph, this necessitated changing “For each row, please circle” to “Please select.”
We have also opted to repeat this instructions paragraph at the top of each online page of Section A of the survey, so that respondents
can easily reference the instructions at any time during that section. (We have also opted to display each question on its own online
page, to minimize the amount of survey data that will be lost if a user closes their web browser, either inadvertently or on purpose, in
the middle of taking this survey.)

6

Survey Question #A1.
Original Wording
Patient-clinician continuity

For ambulatory/outpatient care, patients
are not assigned to a specific clinician
and care team.

For ambulatory/outpatient care, patients
are assigned to a specific clinician and
care team, and patients are encouraged
to seek care from this designated
clinician and practice team. Limited
practice involvement with patient’s care
during hospital and post-acute care
facility stays.

For outpatient/ambulatory care, patients
are assigned to a specific clinician and
care team, and are encouraged to seek
care from this designated clinician and
practice team. Practice is actively
involved with patient’s care during
hospital and post-acute facility stays.

1

4

7

2

3

5

6

8

9

Revised Wording
Patient-clinician continuity

For ambulatory/outpatient care, patients
are not assigned to a specific clinician
and care team.

1

2

3

For ambulatory/outpatient care, patients
are assigned to a specific clinician and
care team, and patients are encouraged
to seek care from this designated
clinician and practice team.

For ambulatory/outpatient/ambulatory
care, patients are assigned to a specific
clinician and care team, and are
encouraged to seek care from this
designated clinician and practice team.

There is limited practice involvement
with patients’s care during hospital and
post-acute care facility stays.

The practice monitors is actively
involved with patients’s care during
hospital and post-acute facility stays,
and is involved as needed.

4

5

6

7

8

9

Reason for Revision
This question is being revised primarily in response to comments from two MAPCP Physician Pilot Testers. Their specific feedback
and our description of the revisions we are making appear below.
Feedback from a MAPCP Physician Pilot Tester: Have to read carefully to determine the difference between the second and third
category. With 2 or more readings, the intent is clear.

7

Survey Developer’s Response: We will use exactly the same wording in the first parts of the second and third answer options to make
it clear that the first part of both of these answer options is the same. We will also break the second and third answer options into two
paragraphs each, to make it more obvious that these two answer options have the same first sentence and different second sentences.
Feedback from another MAPCP Physician Pilot Tester: In the third answer option, instead of “Practice is actively involved with
patient’s care during hospital and post-acute facility stays,” maybe… “Practice gets regular and timely updates or data feeds from
hospitals or post-acute facilities.” Most suburban family docs don’t follow patients in the hospital, etc. – we have hospitalists, etc.
Also, move this question to later in the survey, right before the “Registries” question, to align better with the PCMH standards.
Survey Developer’s Response: We recognize that it’s rare for primary care providers to be actively involved in their patients’ care
during hospital stays – we don’t expect many survey respondents to be able to answer “9” on this question. We want to be able to give
credit to the few providers who are actually doing this. However, we also recognize that involvement in a patient’s care in hospital
and post-acute facilities is not always required, so we will be revising the third answer option slightly. Also, we will move the question
to the suggested spot in our survey.

8

Survey Question #A2.
Original Wording
Appointment systems

…are limited to pre-scheduled
appointments.

1

2

3

…have pre-scheduled appointments and
the ability to schedule urgent visits.

… have pre-scheduled appointments,
the capacity for walk-ins or same-day
visits, the ability to schedule urgent
visits; and patients can see multiple
members of the care team during a
single visit.

4

7

5

6

8

9

Revised Wording
Appointment systems

…are limited to pre-scheduled
appointments.

1

2

3

…have pre-scheduled appointments and
the ability to schedule urgent visits.

… have pre-scheduled appointments,
the capacity for walk-ins or same-day
visits, the ability to schedule urgent
visits; and the capacity for walk-ins or
same-day visits, and patients can see
multiple members of the care team
during a single visit.

4

7

5

6

8

9

Reason for Revision
This question is being revised primarily in response to comments from an MAPCP Physician Pilot Tester. Their specific feedback and
our description of the revisions we are making appear below.
Feedback from a MAPCP Physician Pilot Tester: In the second answer option box, add “(double-book patients).” In the third
answer option box, amend “the capacity for walk-ins or same-day visits” by adding after it: “(that are built into the schedule
template)” and move after “the ability to schedule urgent visits.” Delete “, and patients can see multiple members of the care team
during a single visit” since I think that last bit leaves out a lot of solo or two-person practices and they would not know what to do
with the question.
Survey Developer’s Response: We would prefer not to use the terms “double book” or “schedule template” since they are more
technical and operational terms than we have been using in the rest of this survey; in addition, there are alternatives to doublebooking that provide access for urgent visits, so we are hesitant to present these as the only ways to offer patients access to urgent
9

visits. However, we do agree to move the text “the capacity for walk-ins or same-day visits” to the location suggested. We also agree
to remove the requirement that patients be able to see multiple members of their care team during a single visit, as that has not been a
MAPCP demonstration-wide expectation.

10

Survey Question #A3.
Original Wording
Alternate types of contact
(email, web-portal, textmessage) with the practice
team

…are not regularly available.

1

2

… are available but not encouraged, or
selectively available, and there is no
guarantee of timely response.
3

4

5

… are a core component of patientpractice team communication, and timely
responses are guaranteed.
6

7

8

9

Revised Wording
Alternate types of contact
(email, web-portal, textmessage) with the practice
team

…are not regularly available.

1

2

3

… are available but not encouraged, or
selectively available, and there is no
guarantee of timely response responses
are not provided within a timely and
consistent timeframe.

… are a core component of patientpractice team communication, and timely
responses are guaranteed responses
are provided within a timely and
consistent timeframe.

4

7

5

6

8

9

Reason for Revision
This question is being revised primarily in response to comments from an MAPCP Physician Pilot Tester. Their specific feedback and
our description of the revisions we are making appear below.
Feedback from a MAPCP Physician Pilot Tester: I wouldn’t say “guaranteed.” I would say “held to the practice’s (internal)
standard” or something to that affect. Also, move this question later in the survey, after the “After-hours access” question.
Survey Developer’s Response: We will revise this answer to avoid using the term “guaranteed” – we will instead identify whether
responses are “provided within a timely and consistent timeframe” or not. We will also move this question to the location suggested.

11

Survey Question #A4.
Original Wording
Respond to urgent
problems

Clinician/practice team responds to
urgent problems as time permits.

1

2

3

Clinician/practice team has a system in
place to triage patient problems, but with
limited availability for same-day
appointments.

Clinician/practice team has a system in
place to triage patient problems, with
same-day appointments usually
available.

4

7

5

6

8

9

Revised Wording
Respond to urgent
problems

Clinician/practice team responds to
urgent problems as time permits, and
otherwise directs patients to the
emergency department or urgent care
centers.
1

2

3

Clinician/practice team has a system in
place to triage patient problems through
phone or email communications or faceto-face visits, but with limited availability
for same-day appointments.

Clinician/practice team has a system in
place to triage patient problems though
phone or email communications or faceto-face visits, with same-day
appointments usually available.

4

7

5

6

8

9

Reason for Revision
This question is being revised primarily in response to comments from two MAPCP Physician Pilot Testers. Their specific feedback
and our description of the revisions we are making appear below.
Feedback from a MAPCP Physician Pilot Tester: Maybe more clarification in the first category. What does "time permits" mean?
Feedback from another MAPCP Physician Pilot Tester: Not sure how to say this, but you HAVE to respond to urgent/emergent
problems – it’s not as time permits. I might phrase this as “Clinician/practice team responds to urgent problems, but it severely
disrupts patient flow” – or “…can back up patient flow significantly”. ??
Survey Developer’s Response: Many practices do not respond to urgent/emergent problems and simply direct patients to the ER, so
we would like to retain the intent of our original wording for the first answer option, but with some edits. We would also like to take
this opportunity to reword the second and third answer options to make the difference between these two choices clearer, by inserting
new text (underlined below) and italicizing the parts of these two answer options that differ (“but with limited availability for sameday appointments” in the second answer option vs. “with same-day appointments usually available” in the third answer option).
12

Survey Question #A5.
Original Wording
After-hours access (24
hours, 7 days a week) to
practice team for urgent
care

…is not available after-hours during
evenings and/or weekends. Practice
does not actively coordinate emergency
department care nor does it follow up
after urgent problems.

…is available by phone for urgent care,
but not for actively coordinating
emergency department care or following
up after urgent problems. Practice does
not offer after-hours care in person
during evenings and/or weekends.

…is available by phone for urgent care,
and there is active participation from the
practice team in coordinating emergency
department care and following-up after
urgent problems. Practice offers afterhours care in person some evenings
and/or weekends.

1

4

7

2

3

5

6

8

9

Revised Wording
After-hours access (24
hours, 7 days a week) to
practice team for urgent
care

…is not available after-hours during
evenings and/or weekends.

…is available by phone for urgent care.

Practice does not actively coordinate
emergency department care nor does it
follow up after urgent problems follow-up
with patients after visits to the
emergency department.

1

2

3

Practice does but not for actively
coordinateing emergency department
care nor following up after urgent
problems. practice does it follow-up with
patients after visits to the emergency
department not offer after-hours care in
person during evenings and/or
weekends.

4

5

6

…is available by phone for urgent care,
and in-person during some evenings
and/or weekends. and there is
The practice actively participatesion from
the practice team in coordinating
emergency department care, and
following-up after urgent problems
follows-up with patients after visits to the
emergency department. Practice offers
after-hours care in person some
evenings and/or weekends.
7

8

9

Reason for Revision
This question is being revised primarily in response to comments from an MAPCP Physician Pilot Tester. Their specific feedback and
our description of the revisions we are making appear below.
Feedback from a MAPCP Physician Pilot Tester: More clarification on “following up after urgent problems.” What kind of follow
up do you mean?

13

Survey Developer’s Response: Follow-up involves many activities that we don’t have space to list. However, we will revise the
wording of our answer options to clarify the difference between the three choices.

14

Survey Question #A7.
Original Wording
Visit focus

…is organized around the specific
reason for a patient’s visit.

1

2

…is organized around the specific
reason for a patient’s visit, but
sometimes with attention to ongoing
chronic care and prevention needs if
time permits.
3

4

5

…is organized around the specific
reason for a patient’s visit, but with
consistent to ongoing chronic care and
prevention needs.

6

7

8

9

Revised Wording
Visit focus

…is organized around the specific
reason for a patient’s visit.

1

2

…is organized around the specific
reason for a patient’s visit, but
sometimes with attention to ongoing
chronic care and prevention needs if
time permits.
3

4

5

…is organized around the specific
reason for a patient’s visit, but with
consistent attention to ongoing chronic
care and prevention needs (e.g., through
the use of EHR care alerts).
6

7

8

9

Reason for Revision
This question is being revised primarily in response to comments from an MAPCP Physician Pilot Tester. Their specific feedback and
our description of the revisions we are making appear below.
Feedback from a MAPCP Physician Pilot Tester: In third answer option, change “but with consistent to ongoing chronic care and
prevention needs” to “but with consistent attention to ongoing chronic care and prevention needs through the use of EMR care alerts,
etc.”
Survey Developer’s Response: We will make edits along these lines.

15

Survey Question #A9.
Original Wording
Care plans for patients with
chronic conditions

…are not routinely developed or
recorded.

1

2

3

… are developed collaboratively with
patients, and include self-management
and clinical goals, but they are not
routinely recorded or used to guide
subsequent care.

…are developed collaboratively with
patients and families, include selfmanagement and clinical goals, are
routinely recorded in the medical record,
and guide ongoing care.

4

7

5

6

8

9

Revised Wording
Care plans* for patients
with chronic conditions

…are not routinely developed or
recorded in patient medical records.

1

2

… are developed collaboratively with
patients and families and include selfmanagement and clinical goals, but they
are not routinely recorded in patient
medical records nor used to guide
subsequent care.

…are developed collaboratively with
patients and families, recorded in patient
medical records, include selfmanagement and clinical goals, are
routinely recorded in the medical record,
and are used to guide ongoing care, and
are given to the patient and family to
support their care.

4

7

3
5

6

8

9

* A “care plan” summarizes a patient’s treatment goals and treatment plan, and identifies the responsibilities of each of the various health care providers involved
in the patient’s care. A care plan is developed in collaboration with patients/families, and is based on a patient health risk assessment.

Reason for Revision
This question is being revised primarily in response to comments from two MAPCP Physician Pilot Testers. Their specific feedback
and our description of the revisions we are making appear below.
Feedback from a MAPCP Physician Pilot Tester: Define “care plan.”
Survey Developer’s Response: We will add new text (which paraphrases how NCQA defines a “care plan” in their PCMH standards)
to the question: “A care plan summarizes a patient’s treatment goals and treatment plan, and identifies the responsibilities of each of
the various health care providers involved in the patient’s care. A care plan is typically developed in collaboration with
patients/families, and is based on a patient health risk assessment.”
16

Feedback from another MAPCP Physician Pilot Tester: At the end of the third answer option, add “as well as being given to the
patient and family to support their care.”
Survey Developer’s Response: We will make an edit along these lines, and will also make some clarifying edits to the answer options.

17

Survey Question #A10.
Original Wording
Clinical care management
for complex patients

…is not done

1

2

3

…is generally not done by practice
providers, but practice may refer patients
to care coordination elsewhere.

…is accomplished by identifying
patients for whom care management
might be beneficial; actively coordinates
care management with other providers
and caregivers; and provides
educational resources and ongoing
support to assist with self-management.

4

7

5

6

8

9

Revised Wording
Clinical care management
for complex patients

…is not done.

1

2

3

… is generally not done by practice
providers, but practice may refer patients
to care coordination elsewhere involves
assisting patients with educational
resources and self-management, but
does not involve the use of any care
management services by the practice.

…is accomplished by identifying
patients for whom care management
might be beneficial. The practice actively
coordinates care management with other
providers and caregivers; and provides
educational resources and ongoing
support to assist with self-management.

4

7

5

6

8

9

Reason for Revision
This question is being revised primarily in response to comments from an MAPCP Physician Pilot Tester. Their specific feedback and
our description of the revisions we are making appear below.
Feedback from a MAPCP Physician Pilot Tester: Replace the first answer option with “…is generally not done by practice
providers, and practice will typically refer patients for care elsewhere.” Replace the second answer option with “… assists patients
with educational resources and assists with self-management, but does not involve the use of any care management services.”
Survey Developer’s Response: We would like to leave the first answer option as is, but will edit the second and third answer option in
response to the pilot tester’s suggestions.

18

Survey Question #A11.
Original Wording
Assessing patient and
family values and
preferences

…is not done systematically.

1

2

…is done for only some patients with
significant health problems or who
articulate values and preferences
themselves. The practice team
incorporates patients’ preferences and
values into planning and organizing care.

3

4

5

6

…is systematically done for all patients
with significant health problems or who
articulate values and preferences
themselves. The practice team
incorporates patient preferences and
values into planning and organizing
care.
7

8

9

Revised Wording
Assessing patient and
family values and
preferences (e.g.,
preferences for last-stageof-life care, role in clinical
decision-making)

…is not done systematically.

1

2

…is done for only some patients with
significant health problems or who
articulate values and preferences
themselves. The practice team
incorporates these patients’ preferences
and values into planning and organizing
care.
3

4

5

6

…is systematically done for all patients
with significant health problems or who
articulate values and preferences
themselves. The practice team
incorporates patient preferences and
values into planning and organizing
care.
7

8

9

Reason for Revision
This question is being revised primarily in response to comments from an MAPCP Physician Pilot Tester. Their specific feedback and
our description of the revisions we are making appear below.
Feedback from a MAPCP Physician Pilot Tester: In the second answer option, replace “practice team incorporates patients’
preferences…” with “practice team sometimes incorporates patients’ preferences…”
Survey Developer’s Response: We will italicize “some” and “all” in the second and third answer options, respectively, to make the
difference between these two answer options clearer. We will also take this opportunity to add some examples to the question’s
wording to maximize reader comprehension.

19

Survey Question #A12.
Original Wording
Involving patients and
caregivers in health care
decision-making

…is not a priority.

1

2

3

…is recognized as important but practice
does not use any systematic approach
(e.g., decision aids) to support patients.

… is systematically done. Patients are
supported to deliberate the likely
outcomes of treatment options through
the use of clinical decision aids.

4

7

5

6

8

9

Revised Wording
Involving patients and
caregivers in health care
decision-making

…is not a priority.

1

2

3

…is recognized as important but practice
does not use any systematic approach
(e.g., decision aids) to support patients.

… is a priority and systematically done.
Patients are supported to consider
deliberate the likely outcomes of
treatment options through the use of
clinical decision aids, motivational
interviewing, and/or teach-back
techniques.

4

7

5

6

8

9

Reason for Revision
This question is being revised primarily in response to comments from an MAPCP Physician Pilot Tester. Their specific feedback and
our description of the revisions we are making appear below.
Feedback from a MAPCP Physician Pilot Tester: At the end of the third answer option, add “or motivational interviewing or teachback techniques.”
Survey Developer’s Response: We will make an insertion along these lines. We will also take this opportunity to revise the third
answer option to add that involving patients and caregivers in health care decision-making is not only systematically done but “is a
priority,” and will change the verb “deliberate” to “consider.”

20

Survey Question #A14.
Original Wording
Tracking and follow-up for
important referrals

…is not generally done.
1

2

…is sometimes done.
3

4

5

…is consistently done.
6

7

8

9

Revised Wording
Tracking and follow-up with
patients for important
referrals

…is not generally done.
1

2

…is sometimes done.
3

4

5

Reason for Revision
We would like to take this opportunity to make a clarifying edit.

21

…is consistently done.
6

7

8

9

Survey Question #A16.
Original Wording
Patient referral information
to specialists, other
providers

…is transmitted by the patient.

1

2

3

…is usually transmitted by the practice,
but referrals do not always contain
reason for referral, relevant clinical
information or other core patient
information.

…is consistently transmitted by the
practice. Referrals contain reason for
referral, clinical information relevant to
the referral (e.g., test results, medical
history), and core patient information
(e.g., medications, allergies).

4

7

5

6

8

9

Revised Wording
Patient referral information
to specialists, hospitals,
and other medical care
providers

…is transmitted by the patient.

1

2

3

…is usually transmitted by the practice,
but referrals do not always contain
reason for referral, relevant clinical
information or other core patient
information.

…is consistently transmitted by the
practice. Referrals contain reason for
referral, clinical information relevant to
the referral (e.g., test results, medical
history), and core patient information
(e.g., medications, allergies).

4

7

5

6

8

9

Reason for Revision
This question is being revised primarily in response to comments from CMS. Their specific feedback and our description of the
revisions we are making appear below.
Feedback from CMS: A16 and A17 are very similar.
Survey Developer’s Response: The intent was that A16 referred to classic medical care by specialists and hospitals whereas A17
referred to health care and patient well-being more broadly though behavioral health support, social services, housing, etc. To make
this clearer, we will revise A16’s question wording to read: “Patient referral to specialists, hospitals and other medical care providers.”
A17 will also be revised – see next page.

22

Survey Question #A17.
Original Wording
Patients in need of
specialty care, hospital
care, behavioral health, or
supportive communitybased resources

…are referred to partners with whom the
practice has a relationship

1

2

3

…are referred to partners with whom the
practice has a relationship and relevant
information is communicated in advance.

4

5

6

…are referred to partners with whom the
practice has a relationship, relevant
information is communicated in advance,
and timely follow-up after the visit
occurs.
7

8

9

Revised Wording
Patients in need of
specialty care, hospital
care, behavioral health
support, or supportive
community-based
resources (e.g., social
services)

…are only provided names of some
organizations for patients to contact on
their own referred to partners with whom
the practice has a relationship

1

2

…are referred to partners with whom the
practice has a established relationships
and relevant patient information is
communicated to these
organizations.and relevant information is
communicated in advance.

3

…are referred to partners with whom the
practice has a established relationships,
relevant information is relevant patient
information is communicated to themed
in advance, and timely follow-up with
patients after the visit occurs where
necessary.
7

4

5

8

9

6

Reason for Revision
This question is being revised primarily in response to comments from CMS. Their specific feedback and our description of the
revisions we are making appear below.
Feedback from CMS: A16 and A17 are very similar.
Survey Developer’s Response: The intent was that A16 referred to classic medical care by specialists and hospitals whereas A17
referred to health care and patient well-being more broadly though behavioral health support, social services, housing, etc. To make
this clearer, we will revise A16’s question wording, as noted on the previous page, and revise A17’s question wording to read:
“Patients in need of behavioral health support or community-based resources (e.g., social services).” Revisions to answer options will
also be made, to better differentiate these three options.
23

Survey Question #A18.
Original Wording
Follow-up with patients
seen in the Emergency
Department (ED) or hospital

…occurs only if ED, hospital, patient, or
caregiver alerts the practice.

…generally occurs on an ad hoc basis.
Practice has arrangements in place with
the hospitals and facilities patients most
commonly use.

…is done routinely within a few days
after receiving notification from the ED or
hospital. Practice has arrangements in
place with the hospitals and facilities
patients most commonly use. Practice
tracks patients and ensures that
appropriate follow-up is conducted either
by visit, phone or other forms of
communication.

1

4

7

2

3

5

6

8

9

Revised Wording
Follow-up with patients
seen in the Emergency
Department (ED) or hospital

…occurs only if ED, hospital, patient, or
caregiver alerts the practice.

…generally occurs on an ad hoc basis.
Practice has agreements with the
hospitals and facilities patients most
commonly use to alert them when their
patients are seen there.

…is done routinely within a few days
after receiving notification from the ED or
hospital. Practice has arrangements
agreements in place with the hospitals
and facilities patients most commonly
use. Practice tracks patients and
ensures that appropriate follows-up with
them is conducted either by visit, phone
or other forms of communication within a
short and specified timeframe.

1

4

7

2

3

5

6

8

9

Reason for Revision
This question is being revised primarily in response to comments from an MAPCP Physician Pilot Tester. Their specific feedback and
our description of the revisions we are making appear below.
Feedback from a MAPCP Physician Pilot Tester: In the third answer option, delete “within a few days” and add to the end of the
first sentence: “and monitored regularly against the practice’s (internal) standard.”
Survey Developer’s Response: We will make an insertion along these lines.
24

Survey Question #A19.
Original Wording
Quality improvement
activities (e.g., Plan-DoStudy-Act cycles, or
tracking performance on
quality measures)

…are not organized or supported
consistently.

1

2

…are conducted in reaction to specific
problems and do not use proven quality
improvement approaches.

3

4

5

6

…are based on proven quality
improvement approaches and are used
systematically in meeting organizational
goals.
7

8

9

Revised Wording
Quality improvement
activities (e.g., Plan-DoStudy-Act cycles, or
tracking performance on
quality measures)

…are not organized or supported
consistently.

1

2

…are conducted in reaction to specific
problems and do not use systematic
proven quality improvement approaches.

3

4

5

6

…are based on proven systematic
quality improvement approaches (e.g.,
Plan-Do-Study-Act cycles, or tracking
performance on quality measures) and
are used systematically in meeting
organizational goals.
7

8

9

Reason for Revision
This question is being revised primarily in response to comments from an MAPCP Physician Pilot Tester. Their specific feedback and
our description of the revisions we are making appear below.
Feedback from a MAPCP Physician Pilot Tester: Clarify meaning of “proven quality improvement approaches.”
Survey Developer’s Response: We will replace “proven” with “systematic” and move our parenthetical example “(e.g., Plan-DoStudy-Act cycles, or tracking performance on quality measures)” into the third answer option

25

Survey Question #A20.
Original Wording
Feedback to the practice
from patients and their
families

…is not collected.

1

2

…is collected and incorporated into
practice improvements but not in a
systematic way.

3

4

5

…is regularly collected through a formal
approach (e.g., patient survey, focus
group), and through specific patients’
concerns, and is incorporated into
practice improvements.
6

7

8

9

Revised Wording
Feedback to the practice
from patients and their
families

…is not collected.

1

2

3

…is noted collected and incorporated
into practice activities improvements, but
not in a systematic way.

…is regularly collected through a formal
approach (e.g., patient survey, focus
group), and through specific patients’
concerns, and is incorporated into
practice improvements.

4

7

5

Reason for Revision
We are taking this opportunity to revise the second answer option slightly.

26

6

8

9

Survey Question #B1.
Original Wording
B1.

Please indicate which category (or categories) describes your practice organization.
CHECK ALL THAT APPLY

□
□
□
□
□
□
□
□

Solo practice
Single-specialty primary care practice
Multiple specialty group practice
Group or staff model HMO
Community health center established to serve low-income or rural patients
Hospital or hospital system
Faculty practice plan/Medical School/Teaching Hospital
Other (specify):___________________________________________________

Revised Wording
B1.

Please indicate which category (or categories) describes your practice organization.
CHECK ALL THAT APPLY

□
□
□
□
□
□
□
□

Solo practice
Single-specialty primary care practice
Multiple specialty group practice
Group or staff model HMO
Community health center established to serve low-income or rural patients
Hospital or hospital system
Faculty practice plan / residency / mMedical sSchool / tTeaching clinic Hospital
Other (specify) ____________________________________________________

27

Reason for Revision
We are taking this opportunity to revise the next-to-last answer option slightly.

28

Survey Question #B2.
Original Wording
Please indicate the types of organizations with which your practice is affiliated.
CHECK ALL THAT APPLY

□
□
□

Independent Practice Association (IPA)
Physician-Hospital Organization (PHO)
Other
Specify:____________________________

Revised Wording
Please indicate the types of organizations with which that your practice is part of or affiliated with.
CHECK ALL THAT APPLY

□
□
□
□
□
□
□

Hospital
Integrated health care system
Multi-specialty group practice
Independent Practice Association (IPA)
Physician-Hospital Organization (PHO)
Accountable Care Organization (ACO)
Other
Specify:____________________________

Reason for Revision
This question is being revised primarily in response to comments from an MAPCP Physician Pilot Tester and CMS. Their specific
feedback and our description of the revisions we are making appear below.
Feedback from a MAPCP Physician Pilot Tester: Add as an answer option: “Accountable Care Organization.”
Survey Developer’s Response: We agree to add an answer option for “Accountable Care Organization.”
29

Feedback from CMS: In the response options, add boxes for: Health system/integrated organization, multi-specialty group practice.
Survey Developer’s Response: Our original question asked only about organizations that a practice was “affiliated” with, which
necessarily limited the answer options, but we can revise this question to also ask about organizations that own practices as well.

30

Survey Question #B4.
Original Wording
Is your practice accepting all, most, some, or no new patients who are insured through the traditional Medicare fee-forservice (FFS) program (not Medicare Advantage)?
CHECK ONE ONLY

□
□
□
□

No new Medicare FFS patients
Some new Medicare FFS patients
Most new Medicare FFS patients
All new Medicare FFS patients

Revised Wording
Is your practice accepting all, most, some, or no new patients who are insured through the traditional Medicare fee-forservice (FFS) program (not Medicare Advantage)?
CHECK ONE ONLY

□
□
□
□

All new Medicare FFS patients
Most new Medicare FFS patients
Some new Medicare FFS patients
No new Medicare FFS patients

Reason for Revision
We would like to take this opportunity to change the order that these answer options appear in, to match the order that they are
presented in the question text.

31

Survey Question #B5.
Original Wording
What percentage of your practice's total revenue for clinical services comes from the following sources? Please provide your
best estimate.

Fee-for-service payments ......................................................... ………………………………………………………………

|

|

|

|%

Capitation (e.g., a fixed monthly payment for physician services for a patient.)…………………………………...................

|

|

|

|%

Episode-based payments (e.g., a fixed payment for all physician services related to a specific condition, such as
diabetes) ............................................................................... ………………………………………………………………...

|

|

|

|%

Care management fees for patients with complex conditions ... ………………………………………………………………

|

|

|

|%

Incentive bonuses for reductions in patients' costs and/or utilization)…………………………………………………………..

|

|

|

|%

Incentive bonuses for quality performance ............................... ………………………………………………………………

|

|

|

|%

Other payments (Please describe)__________________________________________________________________

|

|

|

|%

32

Revised Wording
What percentage of your practice's total revenue for clinical services comes from the following sources? Please provide your
best estimate. TOTAL SHOULD EQUAL 100%

Fee-for-service payments ......................................................... ………………………………………………………………

|

|

|

|%

Capitation (e.g., a fixed monthly payment for physician services for a patient.)…………………………………...................

|

|

|

|%

Episode-based payments (e.g., a fixed payment for all physician services related to a specific condition, such as
diabetes) ............................................................................... ………………………………………………………………...

|

|

|

|%

Care management fees for patients with complex conditions ... ………………………………………………………………

|

|

|

|%

Incentive bonuses for keeping reductions in patients' costs and/or utilization below a
target…………………………………………………………..

|

|

|

|%

Incentive bonuses for quality performance ............................... ………………………………………………………………

|

|

|

|%

Other payments (Please describe)__________________________________________________________________

|

|

|

|%

Reason for Revision
This question is being revised primarily in response to comments from an MAPCP Physician Pilot Tester. Their specific feedback and
our description of the revisions we are making appear below.
Feedback from a MAPCP Physician Pilot Tester: In reference to the answer option that reads: “Incentive bonuses for reductions in
patients’ costs and/or utilization,” some docs may not know this information – particularly those employed by large organizations
(hospitals, etc.) and some may be getting incentive payments from third parties, but not be aware of it if they are part of a large
organization.
Survey Developer’s Response: We recognize that survey respondents will only be providing us with estimates and may not provide us
with perfectly accurate information. We are also taking this opportunity to revise one of the answer options to increase its technical
accuracy.

33

Survey Question #B6.
Original Wording
Within your practice, which of the following disciplines are available to you and your patients? If a staff member at your practice
fits into more than one job category, divide his or her full-time equivalent (FTE) time across the appropriate categories (for
example, an RN that spends 20 hours a week serving as a clinical nurse and 20 hours a week serving as a care manager would
be reflected as an 0.5 FTE registered nurse and an 0.5 FTE care manager). In the third column, please check Yes if any staff have
joined your practice during the past 12 months for each job category.

Revised Wording
Within your practice, which of the following disciplines are available to you and your patients? If your practice has multiple
physical locations, please respond based on the practice site that is participating in [state]’s [state-specific name of MAPCP
Demonstration initiative]. If a staff member at your practice fits into more than one job category, divide his or her full-time
equivalent (FTE) time across the appropriate categories (for example, an RN that spends 20 hours a week serving as a clinical
nurse and 20 hours a week serving as a care manager would be reflected as an 0.5 FTE registered nurse and an 0.5 FTE care
manager). In the third column, please check Yes if any staff have joined your practice during the past 12 months for each job
category.

ANY IN
PRACTICE?

NUMBER OF FTE
STAFF

JOINED
PRACTICE
WITHIN PAST 12
MONTHS?

…
Administrative (reception, medical records, appointment, health IT, finance,
management, etc.)

□

|

|

□

Reason for Revision
We would like to take this opportunity to clarify what we meant by “within your practice,” by inserting the sentence (reproduced from
the introductory instructions to this survey): “If your practice has multiple physical locations, please respond based on the physical
location where you practice most frequently.” We would also like to amend one of the answer options for this question to add a few
additional examples of types of administrative staff that a practice could employ, by adding “health IT,” and “management.”
34

Survey Question #B7.
Original Wording
What is the total number of different patients you, as a clinician, have in your patient panel, regardless of type of insurance
coverage? Your best estimate is fine.
|

|,|

|

|

| TOTAL NUMBER OF PATIENTS SEEN IN PAST YEAR

Revised Wording
What is the total number of different patients you, as a clinician, have in your patient panel, regardless of type of insurance
coverage? Your best estimate is fine.
|

|,|

|

|

| TOTAL NUMBER OF PATIENTS IN YOUR PATIENT PANEL

Reason for Revision
This question is being revised primarily in response to comments from two MAPCP Physician Pilot Testers. Their specific feedback
and our description of the revisions we are making appear below.
Feedback from a MAPCP Physician Pilot Tester: Question regarding # patients in panel then subtext says # of patients seen in the
past year--2 different questions. Not all patients are likely seen in the calendar year.
Feedback from another MAPCP Physician Pilot Tester: This question is confusing. Do you want the panel # or patient visits in
past year?
Survey Developer’s Response: We will revise the answer option text to match the question text.

35

Survey Question #B16.
Original Wording
In a typical week, how many hours are you scheduled to work at the practice?
SELECT ONE ONLY
□
20 hours or less
□
21 to 40 hours
□
41 to 50 hours
□
More than 50 hours

Revised Wording
In a typical week, how many hours are you scheduled to work at the practice?
□
□
□
□
□

Less than 20 hours or less
20 21 to 29 40 hours
30 41 to 39 50 hours
40 to 49 hours
More than 50 hours or more

Reason for Revision
We would like to take this opportunity to add some additional answer options to this question.

36

Survey Questions #B17, #B18, #B19, and closing text
Original Wording
B17.

What is your name?

B18:

What is your practice name?______________________________________________

B19.

Work Phone Number: |

TODAY’S DATE:

Date: |

_____________________________________________

|

|

|-|

|

|

| |/| | |/|
Month
Day

|-|
|

|

| |
Year

|

|

| EXT: |

|

|

|

|

|

…
If you have additional information about your experience with [state]’s [state-specific name of MAPCP Demonstration] that you
think may be of interest to evaluators, please enter it here or email it to Stephen Zuckerman at [email protected].

Revised Wording
B17.

What is your name?

B18:

What is your practice name?______________________________________________

B19.

Work Phone Number: |

TODAY’S DATE:

_____________________________________________

|

|

|-|

Date: | | | / | |
Month
Day

|
|/|

|

|-|
| |
Year

|
|

|
|

37

|

| EXT: |

|

|

|

|

…
If you have additional information about your experience with [state]’s [state-specific name of MAPCP Demonstration] that you
think may be of interest to evaluators, please enter it here or email it to Stephen Zuckerman at [email protected].

Reason for Revision
We have dropped questions B17, B18, and B19, since we have decided that we do not need to ask for respondent’s contact information
and dropping these questions from our survey will reduce risk to respondents. We have also deleted text that asked respondents to fill
in today’s date, since our online survey will be able to record this information automatically. Finally, we have also deleted text that
asked respondents to write-in any additional information they want to share with us since, realistically, we do not expect to have the
manpower to review, analyze and synthesize hundreds of written comments from survey respondents, and asking this question
increases respondent burden.

38

Attachment F: New Questions Added to the MAPCP Provider Survey in Response to Comments

New Question Added
How long has your practice had an electronic health record (EHR) system?
□ No EHR
□ Less than 1 year
□ Between 1 and 3 years
□ More than 3 years

Reason for Addition
We are taking this opportunity to add a question about the presence of electronic health records (EHRs).

39

New Second Page of Survey
Your Respondent ID is:
[#######]
Please write this number down in case you need to return to your survey.
NEXT

HELP

Reason for Addition
In the course of building and beta-testing our online survey, we also realized we needed to have the ability to automatically generate a
Respondent ID# for each unique survey respondent – which is essentially a password that we automatically generate for users (to save
them the time of having to create a password). The purpose of the Respondent ID# is to allow respondents to close the survey before
completing it and then later resume filling it out.

40

New Question Added
Tracking and follow-up with
patients about test results

…is not generally done.
1

2

…is done for some tests.
3

4

5

Reason for Addition
We are taking this opportunity to add a question that asks about the tracking of test results.

41

…is consistently done for all tests.
6

7

8

9

New Question Added
Preventive services (e.g.,
cancer screenings)

…are delivered at visits specifically
scheduled for this purpose.

…are delivered at visits specifically
scheduled for this purpose.

……are delivered at visits specifically
scheduled for this purpose.

Practice staff also identify needed
preventive services at other visits.

Practice staff also identify needed
preventive services at other visits.

4
1

2

5

6

In addition, registries or other clinical
decision support tools are used to
identify patients who have not received
recommended preventive services, and
reminders are given to patients to
schedule these.

3
7

Reason for Addition
We are taking this opportunity to add a question about the delivery of preventive services.

42

8

9

New Question Added
Electronic health records

…are not used.

1

…are used for basic functions such as
documenting services rendered, using
computerized provider order entry,
printing information for patients, and eprescribing.

2

3

4

5

…are used for basic functions plus more
advanced functions such as clinical
decision support (e.g., medication
guides/ alerts, preventive services alerts,
clinical guidelines) and generating
quality measure data for quality
improvement purposes.
6

7

Reason for Addition
We are taking this opportunity to add a question that asks about use of electronic health records (EHRs).

43

8

9