Supporting Statement Part A
The Home Health Care CAHPS® Survey (HHCAHPS)
CMS-10275, OMB 0938-1066
In 2001, the DHHS Quality Initiative was implemented to ensure the quality of health care for all Americans through accountability and public disclosure. The goals of the initiative are to empower consumers with quality-of-care information so they can make more informed decisions about their health care and to stimulate and support providers and clinicians to improve the quality of health care. The Quality Initiative implemented in November 2002 for nursing homes, and then implemented for home health agencies (the Home Health Quality Initiative) in 2003. From 2003 to mid-2010, home health agencies were required to report clinical quality data to CMS, and beginning in mid-2010, home health agencies were required to report HHCAHPS Survey data. Before the HHCAHPS Survey, there was no national standardized survey of the patients’ experiences in home health care.
CMS implements a survey that measures and publicly reports patients' experiences with home health care they receive from Medicare-certified home health agencies through the data collection effort described in this request: the Consumer Assessment of Healthcare Providers and Systems Home Health Care Survey (HHCAHPS). The HHCAHPS Survey was developed and tested by the Agency for Healthcare Research and Quality (AHRQ) and is part of the family of CAHPS® surveys. It is a standardized survey for home health patients to assess their home health care providers and the quality of the home health care they receive. HHCAHPS is the only national survey about home health care patients' experiences with their care in Medicare-certified home health agencies.
The survey is necessary because it fulfills the goal of transparency with the public about home health patient experiences. The survey is used by Medicare-certified home health agencies to improve their internal quality assurance in the care that they provide in home health. The HHCAHPS survey is also used in a Medicare payment program. Medicare-certified home health agencies (HHAs) must contract with CMS-approved survey vendors that conduct the HHCAHPS on behalf of the HHAs to meet their requirements in the Home Health Quality Reporting Program. If agencies do not participate fully in HHCAHPS, they receive a 2% reduction in their annual payment update
The national implementation of the Home Health Care CAHPS Survey is designed to collect ongoing data from samples of home health care patients who receive skilled services from Medicare-certified home health agencies. The data collected from the national implementation of the Home Health Care CAHPS Survey is used for the following purposes:
to produce comparable data on the patients’ perspectives of the care they receive from home health agencies (HHCAHPS is the only patient survey that has national data that is reliable and valid for comparisons. The patient survey results have been publicly reported since April 2012 and they are updated quarterly, and Star Ratings were added in January 2016),
to create incentives for agencies to improve the quality of care they provide through public reporting of survey results (home health agencies can view their data in comparison to others in their zip code, state, and the nation), and
to enhance public accountability in health care by increasing the transparency of the quality of care provided in return for the public investment (people use Home Health Compare on www.medicare.gov to view, access, and/or download HHCAHPS data for comparing home health agencies), and
HHCAHPS is used in the Home Health Quality Payment Program (HH QRP) and non-participation results in a 2% reduction in the annual payment update (APU) (used in the HH QRP for the CY 2012 APU and forward through CY 2018 (and continuing).
AHRQ uses the data in their annual report on Racial and Ethnic Disparities and in their annual reports about the demographic characteristics of the patient respondents to the HHCAHPS Survey.
Survey respondent are patients who receive or who received home health care in Medicare-certified agencies. The survey does not impact small businesses or other small entities.
The primary reason for continuous data collection is to get feedback soon after receiving home health care, or while receiving home health care. Continuous data collection gives everyone the ability to address issues of concern as quickly as possible. We cannot do this if the survey is administered once or twice a year. The data reflect the patient perspective over the whole year rather than introducing potential bias by only collecting data in one period of time.
CMS must additionally have continuous monthly collection of the survey data so that home health agencies can fulfill their requirements for the annual payment update. The reporting requirements for the Home Health Quality Reporting Program were set up to count the months of survey participation. When CMS publically reports data on Home Health Compare it is for a 12-month period of time, but we note if less than 12 months of data are publicly reported. CMS needs to continually provide recent data on Home Health Compare on www.medicare.gov so that CMS can be transparent and provide data on home health care.
We reduce survey burden to chronically ill home health patients because the HHCAHPS Survey can only be sent to the same patient once every six months. The HHCAHPS Survey was modeled after the Hospital CAHPS Survey (also a continuous survey).
There are no special circumstances that would require an information collection to be conducted in a manner that requires respondents to:
Report information to the agency more often than quarterly;
Prepare a written response to a collection of information in fewer than 30 days after receipt of it;
Submit more than an original and two copies of any document;
Retain records, other than health, medical, government contract, grant-in-aid, or tax records for more than three years;
Collect data in connection with a statistical survey that is not designed to produce valid and reliable results that can be generalized to the universe of study,
Use a statistical data classification that has not been reviewed and approved by OMB;
Include a pledge of confidentiality that is not supported by authority established in statute or regulation that is not supported by disclosure and data security policies that are consistent with the pledge, or which unnecessarily impedes sharing of data with other agencies for compatible confidential use; or
Submit proprietary trade secret, or other confidential information unless the agency can demonstrate that it has instituted procedures to protect the information's confidentiality to the extent permitted by law.
Federal Register
The 60-day notice published in the Federal Register on December 9, 2016 (81 FR 89104). Comments were received and are attached to this package along with our response.
The 30-day notice published in the Federal Register on February 21, 2017 (82 FR 11222). No comments were received.
Outside Consultations
NQF has reviewed and re-endorsed HHCAHPS twice since the first endorsement in March 2009. CMS annually calls for public comments on HHCAHPS in the annually-issued HH PPS Rule. In the past two years, for CY 2017 and for CY 2018, we did not receive any comments about HHCAHPS. In CY 2016, we received one comment about HHCAHPS from one home health agency, inquiring about why CMS does not reimburse HHAs for the survey vendor costs of conducting HHCAHPS. We replied that we follow the same model as does Hospital CAHPS, Hospice CAHPS, FFS CAHPS, and other CMS- implemented endorsed CAHPS surveys. We additionally replied that we strongly suggest that HHAs carefully shop around for their survey vendor by contacting several or more vendors listed on the HHCAHPS Approved Survey Vendor List posted on https://homehealthcahps.org. Kaiser Health News has cited HHCAHPS many times in their reviews about the quality of home health care from the patient’s perspective.
AHRQ was responsible for the development and testing of the Home Health Care CAHPS Survey. As the lead agency, AHRQ worked with three grantee organizations to develop and test the survey instrument: the American Institutes for Research, the Yale/Harvard team, and RAND. An additional contractor, Westat, also participated in a supporting role. During the survey instrument development phase, AHRQ also consulted with a range of outside organizations and individuals representing state and federal government agencies and non-profit and private sector organizations. AHRQ convened technical expert panels on February 8, 2007, and July 15, 2008. Panel members for the instrument development included representatives from the following organizations:
AARP (American Association of Retired Persons)
Abt Associates Inc.
American Academy of Home Health Care Physicians
American Association for Homecare
American Association of Homes and Services for the Aging
American Hospital Association
American Occupational Therapy Association
American Physical Therapy Association
American Speech-Language-Hearing Association
Maryland Health Care Commission
National Association for Home Care & Hospice
National Center for Health Statistics, Centers for Disease Control and Prevention (CDC)
National Quality Forum
Paraprofessional Healthcare Institute
Professional Healthcare Resources, Inc.
Quality Insights of Pennsylvania
Quality Partners of Rhode Island
Veterans Health Administration
Visiting Nurse Associations of America (VNAA)
For the national implementation, CMS has worked with RTI International, a contractor operating in the role of the HHCAHPS survey implementation coordinator. RTI, with CMS is responsible for developing the protocols and survey guidelines required to ensure the standardized administration of the Home Health Care CAHPS Survey, the review of survey vendor applicants, working with CMS to train multiple independent survey vendors, providing oversight of the approved vendors, and receiving and processing Home Health Care CAHPS Survey data collected and submitted by the approved HHCAHPS survey vendors. RTI was responsible for analyzing data from the mode experiment to determine the mode adjustment and the patient-mix adjustment model. During the national implementation, RTI adjusts the data for patient mix and nonresponse and provides comparative results for public reporting.
In addition, RTI convened a technical expert panel composed of representatives from the home health industry, consumer advocacy organizations, the government, and research organizations. Members of the committee provided guidance to RTI on the development of the design for the mode experiment and the plans for the national implementation. RTI, CMS, and members of the technical expert panel met on February 21, April 15, and June 19, 2008.
The technical expert panel members who provided input and guidance to RTI for the national implementation represented the following organizations:
AARP (American Association of Retired Persons)
American Association of Homes and Services for the Aged
Center for Medicare Advocacy, Inc.
Consumer Coalition for Quality Health Care
Health Services Advisory Group
Independent Consultant, formerly of AHRQ
National Association for Home Health Care and Hospice
RAND
Service Employees International Union
Visiting Nurse Service of New York
This data collection does not include incentive payments or gifts to survey respondents.
Individuals who are contacted as part of this data collection are assured of the confidentiality of their replies under 42 U.S.C. 1306, 20 CFR 401 and 422, 5 U.S.C. 552 (Freedom of Information Act), 5 U.S.C. 552a (Privacy Act of 1974), and OMB Circular A-130.
There are no sensitive questions associated with this collection. Specifically, the collection does not solicit questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private.
Wage Estimates
Individuals To derive average costs for individuals we used data from the U.S. Bureau of Labor Statistics’ May 2016 National Occupational Employment and Wage Estimates for our salary estimate (www.bls.gov/oes/current/oes_nat.htm). We believe that the burden will be addressed under All Occupations (occupation code 00-0000) at $23.86/hr since the group of individual respondents varies widely from working and nonworking individuals and by respondent age, location, years of employment, and educational attainment, etc.
Unlike our private sector adjustment to the respondent hourly wage (see below), we are not adjusting this figure for fringe benefits and overhead since the individuals’ activities would occur outside the scope of their employment.
Private Sector To derive average costs for HHAs, we used data from the U.S. Bureau of Labor Statistics’ May 2016 National Occupational Employment and Wage Estimates for all salary estimates (www.bls.gov/oes/current/oes_nat.htm). We believe that the burden will be addressed by a Medical Records Reviewer (occupation code 29-2071) at $19.93/hr. As indicated below we are adjusting our employee hourly wage estimate by a factor of 100 percent to $39.86/hr.
The 100 percent adjustments are rough estimates, both because fringe benefits and overhead costs vary significantly from employer to employer, and because methods of estimating these costs vary widely from study to study. Nonetheless, there is no practical alternative and we believe that doubling the hourly wage to estimate total cost is a reasonably accurate estimation method.
Burden Estimates
Home Health Care CAHPS Survey We estimate it will take 0.20 hours (12 minutes) at $23.86/hr for a home health patient to complete the Home Health Care CAHPS Survey. Our estimate is based on the written length of the survey and AHRQ’s experience conducting the field test, and RTI’s experiences with the mode experiment, with a sample of home health patients. It is also based on RTI’s experience conducting other surveys of similar length and complexity.
The total number of patients sampled in the time period of April 2015-March 2016, was 4,086,415 patients. Of the 4,086,415 patients, 1,176,699 (28.8%) returned a completed HHCAHPS survey that was submitted to the HHCAHPS Warehouse. In that same period, these patients were served by 9,933 home health agencies. If we divide 1,176,699 patients by 9,933 agencies, we have an average of 119 patients responding to the HHCAHPS survey by agency.
In aggregate, we estimate a burden of 235,340 hours (1,176,699 patients x 0.20 hr) at a cost of $5,615,212 (235,340 hr x $23.86/hr) or $4.77 per survey ($5,615,212/1,176,699 patients)
The survey instrument and procedures for completing the instrument are designed to minimize burden on all respondents.
Patient Files Section 484.250 requires that an HHA submit to CMS, HHCAHPS data in order for CMS to administer the payment rate methodologies described in §§ 484.215, 484.230, and 484.235. The burden associated with this is the time and effort put forth by the HHA to submit the HHCAHPS patient files to their approved HHCAHPS survey vendor.
Section 484.255(i) requires the submission of quality measures as specified by the Secretary. As part of this requirement, each HHA sponsoring a Home Health Care CAHPS (HHCAHPS) Survey must prepare and submit to its survey vendor a file containing data on patients served the preceding month that will be used by the survey vendor to select the sample and field the survey. This file (essentially the sampling frame) for most home health agencies can be generated from existing databases with minimal effort. For some small HHAs, preparation of a monthly sample frame may require more time. However, data elements needed on the sample frame will be kept at a minimum to reduce the burden on all HHAs. The burden associated with this requirement is the time and effort put forth by the HHA to prepare and submit the file containing patient data on patients.
No significant burden is anticipated for small agencies beyond providing their contracted vendor with a monthly file of patients served. We estimate that the monthly file will take 24 hours at $39.86/hr for a HHA Medical Records Reviewer to complete each file on an annual basis. Of the 9,933 HHAs conducting the HHCAHPS, we estimate a burden of 238,392 hours (9,933 HHAs x 24 hr) at a cost of $9,502,305 (238,392 hr x $39.86/hr).
Participation Exemption Request Form For small HHAs serving less than 60 eligible patients in an annual period, CMS requires the completion of a Participation Exemption Request form (PER form) accessible from https://homehealthcahps and submitted with an agency ID and password under the secure portal on the website. CMS estimates that it takes 20 minutes (0.33) at $39.86/hr for a HHA Medical Records Reviewer to complete the Participation Exemption Request Form.
HHAs with 59 or fewer patients complete the form to be exempt from HHCAHPS participation period so they will still get their full annual payment update. HHAs must fill out the exemption form annually because patient counts fluctuate from year-to-year.
There is a steady decline in the number of exemption forms filed since the first APU period of CY 2012. Here are the totals of the number of HHAs submitting exemption forms by the CY APU years:
CY APU Year Number of HHAs filing PER forms
CY 2012 1,918
CY 2013 1,486
CY 2014 1,138
CY 2015 1,115
CY 2016 1,038
CY 2017 883
CY 2018 815
For the Burden Summary table, we use “1,000” as the number of HHAs filing an exemption form but note that it is a fluid number given the downward trend.
Burden Summary
Requirements |
Respondents |
Total Responses per year |
Time per Response (hr) |
Total Time (hr) |
Labor Rate ($/hr) |
Total Cost ($) |
HHCAHPS Survey |
1,176,699 |
1,176,699 |
0.20 |
235,340 |
23.86 |
5,615,212 |
Monthly Patient Files |
9,933 |
119,196 |
24 |
238,392 |
39.86 |
9,502,305 |
Participation Exemption Request Form |
1,000 |
1,000 |
0.33 |
330 |
39.86 |
13,154 |
TOTAL |
1,187,632
|
1,296,895 |
24.53 |
474,062 |
varies |
15,130,671 |
Information Collection Instruments and Instruction/Guidance Documents
All of the following documents are currently approved by OMB. We are not changing any of them. Nor are we adding or removing any documents from what is currently approved.
HHCAHPS Survey: We have attached the HHCAHPS survey in English, Spanish, Simplified Chinese, Traditional Chinese, Russian, and Vietnamese.
We have attached the Supplemental Questions (there are 10 of them) that are OMB-approved, and we have attached them in the languages of English, Spanish, Simplified Chinese, Traditional Chinese, Russian, and Vietnamese.
We have attached the optional Consent to Share Question, which is then Question 35 on the HHCAHPS Survey. It is mandatory that Question 25 be on the survey, and the answer must be checked YES, if the HHCAHPS vendors are sharing the results of the individual surveys with the home health agencies. We have attached the Consent to Share Responses question in the languages of English, Spanish, Simplified Chinese, Traditional Chinese, Russian, and Vietnamese.
We have also attached the Protocols and Guidelines Manual which is the official “how-to” guide for the HHCAHPS survey implementation so that survey implementation is occurring the same way across the nation.
Monthly Patient Files: All home health agencies must give their vendors a list of their patients who are eligible for the HHCAHPS survey. We have attached the Patient Administrative Record file along with a detailed explanation of the patient lists that is from the HHCAHPS Protocols and Guidelines Manual for 2017. The Protocols and Guidelines Manual is the official “how-to” guide for the HHCAHPS survey implementation so that survey implementation is occurring the same way across the nation.
Participation Exemption Request Form: The HHCAHPS Participation Exemption Request Form for the CY 2019 Annual Payment Update is our seventh version of the exemption form, because we began HHCAHPS requirements for the CY 2012 annual payment period. If home health agencies have 59 or fewer patients eligible for HHCAHPS from April 1, 2016-March 31, 2017, then they do not have to do the required HHCAHPS for the CY 2019 payment that occurs in the period of April 1, 2017-March 31, 2018 if they complete the form and CMS verifies the home health agencies’ counts on the forms. Every year, home health agencies are asked to count their patients in the year prior to the HHCAHPS data collection period, and to file an exemption form if they have too few patients (59 or fewer patients). Most agencies that are very small do complete the exemption form and also, CMS does verify that these agencies do in fact have very small home health patient counts.
While HHCAHPS survey respondents do not incur any capital costs, every HHA has an annual cost to secure the services of an approved HHCAHPS survey vendor at an average cost of $3,000 per year. CMS has noted in the past that the annual cost is on average $4,000 a year. We have found out that the annual cost for agencies average $3,000 because agencies pay for the number of surveys and we overestimated the number of surveys that are done on average on an annual basis.
The number of participating HHAs varies from year to year which carries over to the number of completed surveys. In this iteration we are adjusting the number of HHAs based on April 2015 – March 2016 data.
We based on number of agencies on the period of April 2-15-March 2016. We think that we will not have more agencies than this in the next couple of years because there are less home health agencies now (11,802 based on April 2017 data) than there were in 2014 (nearly 13,000 home health agencies). The industry is changeable and there are mergers as well as closures.
Contract with a Survey Vendor
|
Number of HHAs |
Number of responses |
Cost per response ($) |
Total cost ($) |
Currently Approved (May 2014) |
9,890 |
9,890 |
4,000 |
39,560,000 |
Proposed (2017) |
9,933 |
9,933 |
3,000 |
29,799,000 |
Change |
+43 |
+43 |
-1,000 |
-9,761,000 |
The annual cost to the federal government for September 15, 2016 - September 14, 2017 is $1,679,832. This is CMS’ cost for the contract with the federal contractor managing the national implementation of HHCAHPS. To date, RTI International, Inc. is the federal contractor for the national implementation of HHCAHPS.
We are not proposing any program changes.
In 2014, we estimated more respondents. For this renewal, we are presenting data from the CY 2017 APU data submissions for the period of April 2015-March 2016., we are using survey data from a recent period that indicates we have a lower number of respondents to HHCAHPS.
HHCAHPS Survey
|
Number of respondents |
Number of responses |
Hours per response |
Total burden hours |
Currently Approved (May 2014) |
2,967,000 |
2,967,000 |
0.20 |
593,400 |
Proposed (2017) |
1,176,699 |
1,176,699 |
0.20 |
235,340 |
Change |
-1,790,301 |
-1,790,301 |
n/a |
-358,060 |
|
|
|
|
|
The number of participating HHAs varies from year to year which carries over to the number of completed surveys. In this iteration we are adjusting the number of HHAs based on April 2015 – March 2016 data.
For CY 2018, the Average Patients Completing the HHCAHPS Survey is 1,182,805 patients divided by 9,394 Home Health Agencies = 126 patients
Here are the most recent HHCAHPS data for CY 2018, for the period of April 2016-March 2017:
Unique HHAs = 9,394
Files Accepted = 100,786
Patients Sampled = 4,182,785
Completed Surveys = 1,182,805
Response Rate = 28.3%
Average Patients Sampled/HHA = 445
Going back to using our original example using CY 2017 data, we increased the estimated time per response based on what home health agencies have reported to CMS as the amount of time that it takes them to put together the monthly file. Typically, the monthly patient file is done electronically by the home health agencies’ software vendors that run their patient lists for many purposes in the daily operational needs of their agencies.
Monthly Patient Files
|
Number of HHAs |
Number of responses |
Hours per response |
Total burden hours |
Currently Approved (May 2014) |
9,890 |
158,240 |
1.333 |
210,934 |
Proposed (2017) |
9,933 |
119,196 |
2 |
238,392 |
Change |
+43 |
+39,044 |
+0.667 |
+27,458 |
Participation Exemption Request Form
|
Number of HHAs |
Number of responses |
Hours per response |
Total burden hours |
Currently Approved (May 2014) |
2,000 |
2,000 |
0.58 |
1,160 |
Proposed (2017) |
750 |
750 |
0.33 |
248 |
Change |
-1,250 |
-1,250 |
-0.25 |
-912 |
HHCAHPS is part of the CMS goal to share as much data as possible with the public about our Medicare-approved home health agencies, by providing valid quality data to the public. We have publicly reported HHCAHPS data since April 2012 on Home Health Compare on www.medicare.gov and the survey data is updated quarterly. Prior to public reporting each quarter, we provide HHA provider preview reports to all participating HHAs so that they will see their own survey data that will be publicly reported on www.medicare.gov and they may send comments to us if something looks incorrect in the data. On Home Health Compare, the HHCAHPS data is posted for the HHAs along with the corresponding State and National averages so people can assess how the home health agencies’ data compare with the State and National averaged HHCAHPS data. We began to post Star Ratings for HHCAHPS in January 2016 and we update the Star Ratings on a quarterly basis.
The surveys and the exemption form display the expiration date as well as the PRA Disclosure Statement.
18. Exceptions to the Certification Statement
None.
| File Type | application/msword |
| File Title | The National Implementation of the Home Health Care CAHPS Survey |
| Subject | OMB Supporting Statement for Home Health Care CAHPS Survey |
| Author | Centers for Medicare & Medicaid Services |
| Last Modified By | SYSTEM |
| File Modified | 2018-01-26 |
| File Created | 2018-01-26 |