Supporting Statement – Part B
Merit-Based Incentive Payment System (MIPS)
CMS-XXXX, OCN 0938-1222
Collections of Information Employing Statistical Methods
The Centers for Medicare & Medicaid Services (CMS) requests a revision to a previously approved survey under the Paperwork Reduction Act of 1995 to implement the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey for the Merit-based Incentive Payment System (MIPS). Specifically, the Center for Medicare & Medicaid Services (CMS) will use the CAHPS for MIPS survey to collect data on fee-for-service Medicare beneficiaries’ experiences of care with providers participating in the MIPS for use in quality reporting, the Physician Compare website, and annual statistical reports describing MIPS data for all MIPS eligible clinicians.
Under MIPS, groups of two or more eligible clinicians may choose to use the CAHPS for MIPS survey to fulfill part of the requirements for data submission for the quality performance category. Groups that elect to include the CAHPS for MIPS survey as a quality measure must use a CMS-approved survey vendor to submit CAHPS data but other quality data may be reported by any single one of the other available submission mechanisms for the quality performance category. For the 12-month performance period, a group who wishes to voluntarily elect to participate in the CAHPS for MIPS survey measures must use a survey vendor that is approved by CMS for a particular performance period to collect and transmit survey measures data to CMS.
The CAHPS for MIPS survey counts for one measure towards the MIPS quality
performance category and also fulfills the requirement to report at least one cross-cutting
measure (and in the absence of an applicable outcome measure, the requirement to report at least
one high priority measure as a patient experience measure). Groups that elect the CMS-approved vendor reporting mechanism must select an additional group data submission mechanism in order to meet the data submission criteria for the MIPS quality performance category.
This request for a revision to a previously approved package takes the OMB control number 0938-1222. The currently approved CAHPS for Physician Quality package expires on 02/28/2017.
1. Describe (including a numerical estimate) the potential respondent universe and any sampling or other respondent selection method to be used. Data on the number of entities (e.g., establishments, State and local government units, households, or persons) in the universe covered by the collection and in the corresponding sample are to be provided in tabular form for the universe as a whole and for each of the strata in the proposed sample. Indicate expected response rates for the collection as a whole. If the collection had been conducted previously, include the actual response rate achieved during the last collection.
Because historical participation rates for quality data submission under PQRS have never reached 100 percent, we anticipate that MIPS will not achieve full participation. Under the 2014 PQRS, 834,358 of approximately 1.3 million eligible professionals (EPs) (including those who belonged to group practices that participated under the group practice reporting option (GPRO), EPs within an accountable care organization (ACO) participating under the Shared Savings Program or Pioneer ACO Model, and EPs participating through the comprehensive primary care (CPC) initiative. The 2014 PQRS participation rate was 62.8 percent, quadruple the 15 percent participation rate in the program’s first year (2007).1
Given that in the first MIPS performance period, the CAHPS for MIPS survey instrument will have the same questions as the CAHPS for PQRS survey, we assume that the group practices that previously contracted with a CMS-approved survey vendor to collect and report CAHPS data under PQRS data will continue to do so under MIPS. We assume that some practices will voluntarily submit quality performance category data, including CAHPS for MIPS data, because MACRA permits any EP under PQRS who is not a MIPS eligible clinician the option to volunteer to report on applicable measures and activities under MIPS. 2 Voluntary reporters will be scored and receive performance feedback under MIPS, but will not be subject to payment adjustments.
Because the MIPS program has not yet been implemented, we estimate the potential universe of practices containing MIPS eligible clinicians required to report and the potential universe of practices that can voluntarily report using 2014 data from the PQRS, VM Program and other CMS data. The potential universe of MIPS eligible clinicians, within these group practices, subject to reporting requirements includes between approximately 716,613 and 775,613 (among the 1,009,623 MIPS eligible clinicians). The potential universe of clinicians whose group practice may voluntarily report use of a CAHPS survey includes approximately 187,990 Medicare professionals not in eligible specialties. Clinicians may voluntarily submit MIPS quality data to get feedback on their performance relative to national benchmarks.
Based on 2014 PQRS data, we anticipate that 434 groups will contract with CMS-approved survey vendors to collect CAHPS for MIPS data.
2. Describe the procedures for the collection of information including:
- Statistical methodology for stratification and sample selection,
- Estimation procedure,
- Degree of accuracy needed for the purpose described in the justification,
- Unusual problems requiring specialized sampling procedures, and
- Any use of periodic (less frequent than annual) data collection cycles to reduce burden.
Groups submitting quality measures data using the CMS Web Interface or a CMS-approved survey vendor to report the CAHPS for MIPS survey would need to meet the data
submission requirements on the sample of the Medicare Part B patients.
TABLE 1: Summary of Proposed Quality Data Submission Criteria f
or CAHPS for MIPS Survey
Submission Criteria, including Sampling
Jan 1 – Dec 31
Groups of 2 or more eligible clinicians
CMS-approved survey vendor would have to be paired with another reporting mechanism to ensure the minimum number of measures are reported. CAHPS for MIPS survey would fulfill the requirement for one cross-cutting and/or high priority measure towards the MIPS quality data submission criteria.
CAHPS for MIPS survey will only count for one measure.
Sampling requirements for their Medicare Part B patients
For the CAHPS for MIPS survey, CMS plans to use the same sampling methodology as the CAHPS for PQRS survey.3 CMS will identify beneficiaries eligible for the survey from the pool of beneficiaries assigned to the group. CMS assigns original Medicare beneficiaries to a practice based on the plurality of the primary care claims during the first three quarters of the performance period. CMS will then randomly select samples from those assigned beneficiaries to create the sample for the CAHPS for MIPS survey. The sample will be limited to beneficiaries aged 18 or older and who are not known to be institutionalized or deceased. The sample is drawn at the level of the group, not at the individual provider level. The survey names a specific MIPS eligible clinician who delivered primary care to the beneficiary over multiple visits in the performance period, to help orient the beneficiary to the care he or she received.
The number of patients sampled may vary based on the size of the group.
For large groups of 100 or more MIPS eligible clinicians:
CMS will draw a sample of 860 beneficiaries
If the group has fewer than 860 beneficiaries, but more than 415 beneficiaries, all eligible beneficiaries will be surveyed in performance year (PY) 2016
If the group has fewer than 416 beneficiaries, the survey cannot be conducted
For groups with 25 to 99 MIPS eligible clinicians:
CMS will draw a sample of 860 beneficiaries
If the group has fewer than 860 beneficiaries, but more than 254 beneficiaries, all eligible beneficiaries will be surveyed in PY 2016
If the group has fewer than 255 beneficiaries, the survey cannot be conducted
For groups with 2 to 24 MIPS eligible clinicians:
CMS will draw from a sample of 860 beneficiaries
If the group has fewer than 860 beneficiaries, but more than 124 beneficiaries, all eligible beneficiaries will be surveyed in PY 2016
If the group has fewer than 125 beneficiaries, the survey cannot be conducted
3. Describe methods to maximize response rates and to deal with issues of non-response. The accuracy and reliability of information collected must be shown to be adequate for intended uses. For collections based on sampling, a special justification must be provided for any collection that will not yield 'reliable' data that can be generalized to the universe studied.
The CAHPS for MIPS survey has developed a mixed-mode data collection protocol, as described above, that uses a pre-notification letter alerting sample members that a survey will be mailed to them shortly, a first mailing of the full questionnaire booklet, followed by a second mailing to those who do not respond to the earlier mailing of the questionnaire. For those who also do not respond to the second mailing of the questionnaire, CAHPS employs a telephone follow-up through which it offers sample members the opportunity to complete the survey by phone. The mailing materials to all sample members also include a toll-free telephone number that allows recipients to call in to ask questions about the survey. CMS-approved survey vendors would be supplied with mail and telephone versions of the survey in electronic form, and text for beneficiary pre-notification and cover letters. Further, CAHPS for MIPS surveys can be administered in English, Spanish, Cantonese, Mandarin, Korean, Russian and/or Vietnamese. CAHPS for PQRS has achieved a 47 percent response rate on average, slightly higher than some CAHPS surveys of Medicare beneficiaries.
The survey vendors will be required to administer the survey according to established protocols to ensure valid and reliable results. Survey vendors would be required to use appropriate quality control, encryption, security and backup procedures to maintain survey response data. The data would then be securely sent back to us for scoring and/or validation in accordance with applicable law. To ensure that a survey vendor possesses the ability to transmit survey measures data for a particular performance period, we propose to require survey vendors to undergo this approval process for each year in which the survey vendor seeks to transmit survey measures data to us.
4. Describe any tests of procedures or methods to be undertaken. Testing is encouraged as an effective means of refining collections of information to minimize burden and improve utility. Tests must be approved if they call for answers to identical questions from 10 or more respondents. A proposed test or set of tests may be submitted for approval separately or in combination with the main collection of information.
No tests of procedures or methods will be undertaken as part of this data collection.
5. Provide the name and telephone number of individuals consulted on statistical aspects of the design and the name of the agency unit, contractor(s), grantee(s), or other person(s) who will actually collect and/or analyze the information for the agency.
We expect that the CAHPS for MIPS survey design will be very similar to the CAHPS for PQRS survey. The survey, sampling approach, and data collection procedures for the CAHPS for PQRS survey were designed by the RAND Corporation.
The CAHPS Survey for PQRS is comprised of the core Clinician & Group CAHPS Survey (CG-CAHPS) which was developed by the Agency for Healthcare Quality Research (AHRQ) and additional supplemental items covering domains of patient experience specific to the information needs of CMS and the PQRS.
1 The 2014 PQRS data are from the most recent PQRS Experience Report, available at: https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/pqrs/analysisandpayment.html
2 Section 1848(q)(1)(C) of the Act defines a MIPS eligible clinician for payment years 1 and 2 as a physician, physician’s assistant, nurse practitioner, or clinical nurse anesthetist, or a group that includes such clinicians. Specialties not listed as eligible in the Act for payment period 1 or 2 include: Audiologists, Certified Nurse Midwives, Clinical Psychologists/Counselors, Clinical Social Workers, Physical/Occupational Therapists, and Registered Dieticians/Nutritionists.
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