CAHPS for MIPS Supporting Statement Part A 7.14.2017

Supporting Statement – Part A

Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey

for the Merit-Based Incentive Payment System (MIPS)

CMS 10450, OMB Control Number 0938-1222

A. Background

The Centers for Medicare & Medicaid Services (CMS) requests a three-year clearance from the Office of Management and Budget (OMB) under the Paperwork Reduction Act (PRA) of 1995 to implement the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey for the Merit-based Incentive Payment System (MIPS). CMS is submitting the shortened CAHPS for MIPS survey (version 2.0) to OMB for approval under the PRA as a revision of the previously approved CAHPS for MIPS package (0938-1222). Specifically, CMS requests a revision to the previously approved CAHPS for MIPS survey (version 1.0) used in Quality Payment Program (QPP) transition year to collect data on fee-for-service Medicare beneficiaries’ experiences of care with eligible clinicians participating in MIPS. The survey information is used for quality reporting, the Physician Compare website, and annual statistical reports describing MIPS data for all MIPS eligible clinicians.

CMS will be requesting approval for two additional PRA packages associated with the CY 2018 Quality Payment Program proposed rule. The collection of information associated with the CY 2018 Quality Payment Program proposed rule (other than virtual group election and CAHPS-related data collection) will be submitted as a revision of the currently approved MIPS PRA package (0938-1314). CMS is proposing to allow the formation of virtual groups that can elect to submit via any quality submission mechanism available to groups, including CMS-approved survey vendors administering to CAHPS for MIPS survey. The collection of information associated with virtual group election will be submitted under a new OMB control number.

Summary and Overview

The Quality Payment Program aims to do the following: (1) support care improvement by focusing on better outcomes for patients, decreased clinician burden, and preservation of independent clinical practice; (2) promote adoption of alternative payment models that align incentives across healthcare stakeholders; and (3) advance existing delivery system reform efforts, including ensuring a smooth transition to a healthcare system that promotes high-value, efficient care through unification of CMS legacy programs.

The CY 2017 Quality Payment Program final rule established policies to implement MIPS, a program for certain eligible clinicians that makes Medicare payment adjustments based on performance on quality, cost and other measures and activities, and that consolidates components of three precursor programs—the Physician Quality Reporting System (PQRS), the Medicare and Medicaid Electronic Health Records (EHR) Incentive Program for eligible professionals; and the Physician Value-based Payment Modifier (VM) Program. As prescribed by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), MIPS focuses on the following: quality – both a set of evidence-based, specialty-specific standards as well as practice-based improvement activities; cost; and use of certified EHR technology (CEHRT) to support interoperability and advanced quality objectives in a single, cohesive program that avoids redundancies.

In MIPS, eligible clinicians, groups and virtual groups are measured on four performance categories: quality, cost, improvement activities, and advancing care information (related to meaningful use of CEHRT). Pursuant to the MACRA, the payment adjustments are aligned within the MIPS performance categories.

The CAHPS for MIPS survey counts for one measure towards the MIPS quality performance category, and groups of two or more MIPS eligible clinicians can voluntarily elect to participate in the CAHPS for MIPS survey as one of their six required quality measures as finalized in the CY 2017 Quality Payment Program final rule. We also finalized in that rule the following criteria for the submission of data on the CAHPS for MIPS survey by registered groups via a CMS-approved survey vendor: for the applicable 12-month performance period, the group must have the CAHPS for MIPS survey reported on its behalf by a CMS-approved survey vendor. In the CY 2018 proposed rule, we are proposing that groups may use one or more submission mechanisms (that is, qualified registry, Qualified Clinical Data Registry (QCDR), EHR, CMS Web Interface) in addition to CAHPS to complete their quality data submission. The CAHPS for MIPS survey counts for one measure toward the MIPS quality performance category and, as a patient experience measure, also fulfills the requirement to report at least one high priority measure in the absence of an applicable outcome measure. If electing to use the CAHPS for MIPS survey, which would count as a patient experience measure, the group would be required to submit at least five additional quality measures through at least one other data submission mechanism. In other words, a group may report any five measures within MIPS plus the CAHPS for MIPS survey to achieve the six measures threshold. The data collected on the CAHPS for MIPS survey measures would be transmitted to CMS via a CMS-approved survey vendor.

Although we are not requiring groups or virtual groups to participate in the CAHPS for MIPS survey, we believe patient experience is important and we are proposing in the CY 2018 Quality Payment Program proposed rule a scoring incentive for those groups who report via the CAHPS for MIPS survey. In the CY 2017 final rule we finalized a scoring policy that provides two bonus points in calculating the quality performance category score to groups or MIPS eligible clinicians that report a patient experience measure such as the CAHPS for MIPS survey in addition to an outcome measure or another high priority measure. The quality performance category score is part of the final score, which is used to determine whether the MIPS eligible clinician receives a positive, neutral, or negative MIPS payment adjustment. The use of a CAHPS survey (including the CAHPS for MIPS survey) would be counted as a high-weighted activity under the improvement activities performance category.

In the CY 2018 Quality Payment Program proposed rule, we are proposing to allow virtual groups to submit quality data via all data submission mechanisms available to groups, including the CAHPS for MIPS survey via a CMS-approved survey vendor. For virtual groups who elect to participate in the CAHPS for MIPS survey 2.0, the survey findings will be used for the final score and the associated MIPS payment adjustment and performance feedback using the same methods as for clinician groups.

CAHPS for MIPS Survey Version 2.0

This PRA package addresses the information collection related to the statutorily required quality measurement. The CAHPS for MIPS survey version 2.0 will result in burden to three different types of entities. This supporting statement for the CAHPS for MIPS survey version 2.0 describes CMS’s proposed revisions to the CAHPS for MIPS survey and resulting burdens to groups and virtual groups, vendors, and beneficiaries associated with administering the survey.

The CAHPS for MIPS survey version 2.0 consists of the core Agency for Healthcare Research and Quality (AHRQ) CAHPS Clinician & Group Survey, version 3.0, plus additional survey questions to meet CMS’s information and program needs. The number of items in the survey has been reduced and is designed to gather only the necessary data that CMS needs for assessing physician quality performance, and related public reporting on physician performance, and should complement other data collection efforts.

In the CY 2017 Quality Payment Program final rule (see 81 FR 77120), we finalized retaining the CAHPS for MIPS survey administration period that was utilized for PQRS of November to February. However, this survey administration period has become operationally problematic for the administration of MIPS. In order to compute scoring we must have the CAHPS for MIPS survey data earlier than the current survey administration period deadline allows. Therefore, we are proposing for the Quality Payment Program Year 2 and future years that the survey administration period would, at a minimum, span over 8 weeks and would end no later than February 28th following the applicable performance period.¹

CMS’s goals for revising the CAHPS for MIPS survey include the following:

• Updating the survey to reflect AHRQ updates to the core CAHPS Clinician & Group Survey (CG-CAHPS), and

• Shortening the survey to reduce the number of questions and beneficiary burden while maintaining reliability and validity of the measurement properties of Summary Survey Measures (SSMs).

The CAHPS for MIPS survey points are calculated at the SSM level. SSMs combine one or more survey items on similar aspects of patient experience to achieve desired validity. In the CAHPS for MIPS survey version 2.0, we propose that 8 SSMs be used for measurement and two additional SSMs be used for informational purposes. The revised survey represents our proposal that the number of SSMs be reduced from 12 to 10, the number of items in some of the SSMs be reduced, and 1 item be moved to contribute to a different SSM for scoring. Under the proposed survey revisions, 23 questions are eliminated from the survey and 4 questions have single-word changes. These changes are based on research conducted by AHRQ on its core CG-CAHPS survey and CMS research on the PQRS and Accountable Care Organization (ACO) CAHPS surveys. The analyses show that the shortened survey does not reduce, and in some instances, increases, the reliability and validity of the survey while also providing actionable data for clinicians.

The main reasons for the proposed CAHPS for MIPS survey revisions include:

• To be consistent with AHRQ’s updated CG-CAHPS version 2.0 to version 3.0 on July 21, 2015. Changes include wording changes in four items, four item deletions, and an SSM with three items added. AHRQ’s changes were based on results from the CAHPS Consortium analyses of the CG-CAHPS survey version 2.0 data from the 2014 CAHPS Clinician and Group Survey Database that found comparable reliability and validity for the Provider Communication and Getting Timely Care SSMs.^2,3,4

• To maintain or improve survey reliability while reducing burden. The proposed revised survey reduces the number of SSMs from 12 to 10 and the number of questions from 81 to 58. These changes were supported by analyses of the substantively equivalent survey, the CAHPS for PQRS survey.

• To maintain consistency with CAHPS for ACOs survey two SSMs (and the 10 questions in the SSMs) were removed from the proposed CAHPS for MIPS survey version 2.0: Helping You to Take Medications as Directed (low reliability) and Between Visit Communication. These changes were supported by analyses of CAHPS for PQRS survey data (the predecessor survey under the Physician Quality Reporting System, or PQRS).

Table 1 summarizes the proposed changes for CAHPS for MIPS survey version 2.0 at the SSM level. The survey crosswalk in Appendix A provides within-SSM detail for each question change, and Appendix I provides a key reference for the analyses of reliability.

Table 1: List of CAHPS for MIPS Summary Survey Measures (SSM) for Version 2.0 and Change from Version 1.0

Summary Survey Measure	Number of Items in Version 2.0	Change from CAHPS for MIPS 1.0	Rationale for Survey Change
Getting Timely Care, Appointments, and Information	3	4 wording changes; deleted 2 questions	To align with AHRQ version 3.0
How Well Providers Communicate	5	Deleted 1 question	To align with AHRQ version 3.0
Patient’s Rating of Provider	1	No change	-
Health Promotion & Education	4	Deleted 2 questions	Improved reliability
Shared Decision Making	2	Deleted 5 questions	Improved reliability
Stewardship of Patient Resources	1	No change	-
Courteous and Helpful Office Staff	2	No change	-
Care Coordination	3	No change in number; replaced 1 question	To align with AHRQ version 3.0 number of questions
Health Status and Functional Status	9	No change	-
Access to Specialists	1	Deleted 1 question	Improved reliability
Helping You Take Medications as Directed	0	Deleted SSM	Low reliability
Between Visit Communication	0	Deleted SSM	To maintain consistency with MSSP CAHPS for ACOs

We are proposing to remove two SSMs from the CAHPS for MIPS survey, which would result in the collection of 10 SSMs in the CAHPS for MIPS survey. We are proposing for the Quality Payment Program Year 2 and future years to remove two SSMs including “Helping You to Take Medication as Directed” and “Between Visit Communication.” We are proposing to remove the SSM entitled “Helping You to Take Medication as Directed” due to low reliability. In 2014 and 2015, the majority of groups had very low reliability on this SSM. Furthermore, based on analyses conducted of SSMs in an attempt to improve their reliability, removing questions from this SSM did not result in any improvements in reliability. The SSM entitled “Between Visit Communication” currently contains only one question. This question could also be considered related to other SSMs entitled: “Care Coordination” or “Courteous and Helpful Office Staff,” but does not directly overlap with any of the questions under that SSM. However, we are proposing to remove this SSM in order to maintain consistency with the Medicare Shared Savings Program that utilizes the CAHPS Survey for Accountable Care Organizations (ACOs). The SSM entitled “Between Visit Communication” has never been a scored measure with the Medicare Shared Savings Program CAHPS Survey for ACOs.

Eight of the remaining 10 SSMs have had high reliability for scoring in prior years or reliability is expected to improve for the revised version of the measure, and they also represent elements of patient experience for which we can measure the effect one practice has compared to other practices participating in MIPS. The “Health Status and Functional Status” SSM, however, assesses underlying characteristics of a group’s patient population characteristics and is less of a reflection of patient experience of care with the group. Moreover, to the extent that health and functional status reflects experience with the practice, case-mix adjustment is not sufficient to separate how much of the score is due to patient experience versus due to aspects of the underlying health of patients. The “Access to Specialists” SSM has low reliability; historically it has had small sample sizes, and therefore, the majority of groups do not achieve adequate reliability, which means there is limited ability to distinguish between practices’ performance.

For these reasons, we propose not to score the “Health Status and Functional Status” SSM and the “Access to Specialists” SSM beginning with the 2018 MIPS performance period. Despite not being suitable for scoring, both SSMs provide important information about patient care. Qualitative work suggests that “Access to Specialists” is a critical issue for Medicare fee-for-service (FFS) beneficiaries. The survey is also a useful tool for assessing beneficiaries’ self-reported health status and functional status, even if this measure is not used for scoring practices’ care experiences. Therefore, we believe that continued collection of the data for these two SSMs is appropriate even if we do not propose to score them.

Pilot Testing

These proposed revisions for the CAHPS for MIPS survey were tested in a CAHPS for ACOs pilot survey using a survey identical to the proposed CAHPS for MIPS survey version 2.0.⁵ The CAHPS for ACOs pilot field testing was conducted from November 2016 through February 2017 with a specific goal to determine whether a shorter survey affects SSM scores, response rates, and reliability. Data collected using the CAHPS for ACOs Pilot Test Survey will only be used to assess the impact of the revised instrument and would not be used for scoring or reporting.

The pilot study participation included 18 ACOs served by seven vendors. The vendor and ACO participants were selected to represent ACOs with high and low CAHPS scores in 2015, ACOs with high and low response rates in 2015, and vendors with many and few ACO clients. Vendors followed standard CAHPS for ACOs data collection protocols and specifications to administer the ACO Pilot survey.

Currently, the ACO pilot survey data are being analyzed with results expected by August 2017. Analyses will compare the pilot test survey to the existing instrument, and will focus on changes in unit reliability, response rates and patterns, including item missingness and distribution of responses; effect on the measurement properties of the SSMs; uniformity of effects across beneficiary subgroups associated with case-mix adjustment characteristics; and changes in scores and benchmarks.

CMS will consider the findings of the CAHPS for ACO survey pilot and the public comments we receive on the proposed CAHPS for MIPS survey version 2.0 and discuss any proposals for further revisions to the CAHPS for MIPS survey in the final rule published in November 2017, and in the revised version of this PRA package.

Beyond CY 2018, CMS may make additional modifications to the CAHPS for MIPS survey. In the CY 2018 Quality Payment Program proposed rule, we are seeking comment on expanding the patient experience data available for the CAHPS for MIPS survey. Currently, the CAHPS for MIPS survey is available for groups to report under the MIPS. The patient experience survey data that is available on Physician Compare is highly valued by patients and their caregivers as they evaluate their health care options. However, in user testing with patients and caregivers in regard to the Physician Compare website, the users regularly ask for more information from patients like them in their own words. Patients regularly request that we include narrative reviews of clinicians and groups on the website. AHRQ offers a beta version of survey items that will address this, the CAHPS Patient Narrative Elicitation Protocol (https://www.ahrq.gov/cahps/surveys-guidance/item-sets/elicitation/index.html). This includes five open-ended questions designed to be added to the CG CAHPS survey, which the CAHPS for MIPS survey is modeled after. These five questions have been developed and tested in order to capture patient narratives in a scientifically grounded and rigorous way, setting it apart from other patient narratives collected by various health systems and patient rating sites. More scientifically rigorous patient narrative data would not only greatly benefit patients in their decision for healthcare, but it would also greatly aid MIPS eligible clinicians and groups as they assess how their patients experience care. We are seeking comment on adding these five open-ended questions to the CAHPS for MIPS survey in future rulemaking. We anticipate discussion of the development and testing of the protocol with AHRQ.

B. Justification

1. Need and Legal Basis

Authority for collection of this information is provided under sections 1848(q), 1848(k), 1848(m), 1848(o), 1848(p), and 1833(z) of the Social Security Act (the Act).

Section 1848(q) of the Act, as added by section 101(c) of the MACRA, requires the establishment of the MIPS beginning with payments for items and services furnished on or after January 1, 2019, under which the Secretary is required to: (1) develop a methodology for assessing the total performance of each MIPS eligible clinician according to performance standards for a performance period; (2) using the methodology, provide a final score for each MIPS eligible clinician for each performance period; and (3) use the final score of the MIPS eligible clinician for a performance period to determine and apply a MIPS adjustment factor (and, as applicable, an additional MIPS adjustment factor) to the MIPS eligible clinician for a performance period. Under section 1848(q)(2)(A) of the Act, a MIPS eligible clinician’s final score is determined using four performance categories: (1) quality; (2) cost; (3) improvement activities, and (4) the advancing care information.

2. Information Users

We will continue to use the CAHPS for MIPS survey version 2.0 to assess groups or virtual groups containing MIPS eligible clinicians’ performance in the quality performance category. For groups of clinicians electing to report CAHPS for MIPS in the quality performance category, CAHPS for MIPS will be included in the calculation of the final score as a quality measure and thus applied to calculate payment adjustments. Like other quality measures, select SSMs in the CAHPS for MIPS survey will have an individual benchmark which will be used to establish the number of points.⁶ The CAHPS for MIPS survey will be scored based on the average number of points across SSMs, up to 10 points. This is similar to how other quality measures are scored against a benchmark, which is to assign up to 10 points per measure. The CAHPS for MIPS survey is considered a patient experience measure for the quality performance category and therefore contributes 2 additional bonus points to the quality performance category score. It is also counted as a high weighted activity under the improvement activities performance category.

We also will use the CAHPS for MIPS survey data as part of performance feedback to MIPS eligible clinicians. Selected information is made available to beneficiaries, as well as to the public, on the Physician Compare website. CMS plans to use the data to produce annual statistical reports that will include national means of patient experience measures for all groups and virtual groups that elect to use CAHPS for MIPS as one of their quality measures. The MIPS annual statistical reports will be modeled after existing annual reports, the PQRS Experience Report and the Value Modifier Report.

This survey also supports the administration of the Quality Improvement Organizations (QIO) Program. The Act, as set forth in Part B of Title XI - Section 1862(g), established the Utilization and Quality Control Peer Review Organization Program, now known as the Quality Improvement Organizations Program. The statutory mission of the QIO Program is to improve the effectiveness, efficiency, economy, and quality of services delivered to Medicare beneficiaries. This survey will provide patient experience of care data that is an essential component of assessing the quality of services delivered to Medicare beneficiaries. It also would permit beneficiaries to use this information to help them choose clinicians that provide services that meet their needs and preferences, thus encouraging clinicians to improve the quality of care that Medicare beneficiaries receive.

3. Use of Information Technology

CMS-approved survey vendors are required to collect the data via a mixed mode data collection strategy that involves two rounds of mailed surveys followed by phone interviews. The mailed surveys are formatted for automated data entry. Returned surveys may be scanned into an electronic data file. Computer Assisted Telephone Interview (CATI) will be used as the secondary mode of data collection if a beneficiary does not respond to two mailed requests to complete the survey.

4. Duplication of Efforts

The information to be collected will not duplicate similar information currently collected by CMS. Administration of the CAHPS for MIPS survey for the 2018 MIPS performance period will not overlap the performance period for the CAHPS for MIPS survey 1.0 implementation. To avoid possible overlap with other FFS surveys and overburden of beneficiaries who are eligible for both surveys, the CAHPS for MIPS survey sample will be de-duplicated so that beneficiaries would not be sampled for both surveys.

5. Small Businesses

We expect that many practices (TINs) that elect to use CAHPS for MIPS will qualify for small business status under the Small Business Administration (SBA) standards. The SBA standard for a small business is $11 million in average receipts for an office of clinicians and $7.5 million in average annual receipts for an office of other health practitioners. (For details, see the SBA’s website at https://www.sba.gov/sites/default/files/files/Size_Standards_Table.pdf http://www.sba.gov/content/table-smallbusiness-size-standards/ (refer to the 620000 series)).

The support of small, independent practices remains an important thematic objective for the implementation of the Quality Payment Program and is expected to be carried throughout future rulemaking. For MIPS performance periods occurring in 2017, many small practices are excluded from new requirements due to the low-volume threshold, which was set at less than or equal to $30,000 in Medicare Part B allowed charges or less than or equal to 100 Medicare Part B patients. We have heard feedback however from many small practices that additional challenges still exist in their ability to participate in the program. We have made proposals to provide additional flexibilities including: implementing the virtual groups provisions, increasing the low-volume threshold to less than or equal to $90,000 in Medicare Part B allowed charges or less than or equal to 200 Medicare Part B patients, a hardship exception from the advancing care information performance category for small practices, and bonus points to the final score of MIPS eligible clinicians that are in small practices. We believe that these additional flexibilities and reduction in barriers will further reduce the impact on small practices within the Quality Payment Program.

6. Less Frequent Collection

If patient experience data are not collected annually as measures to support the quality performance category, we will not be able to fully implement the MACRA requirement to: (1) emphasize patient experience measures among the quality measures a MIPS eligible clinician or group may use to meet the performance criteria for a payment adjustment under MIPS, (2) calculate for payment adjustments to MIPS eligible clinicians or groups, and (3) publicly post provider performance information on the Physician Compare website.

A further consequence of collecting data on a less frequent basis than annually is that the beneficiaries will be less able to recall their specific experiences with care over longer periods of time. If the survey asks about patient experiences over longer periods, responses may be less reliable.

Additionally, if data are collected on less than an annual basis the patient experience scores information reported on Physician Compare would be less current and thus less useful to beneficiaries and consumer intermediaries who may visit the website.

7. Special Circumstances

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.

8. Federal Register/Outside Consultation

The proposed rule is serving as the 60-day Federal Register notice which was published on June 30, 2017 (82 FR 30010 through 30500, RIN 0938-AS69, CMS-5517-P). The proposed rule was placed on public inspection on June 20, 2017, whereby comments are due on August 21, 2017.

9. Payments/Gifts to Respondents

There will be no payments/gifts to respondents.

10. Confidentiality

Consistent with federal government and CMS policies, individuals contacted as part of this data collection will be 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. No personally identifiable information (PII) will be collected as part of this survey.

11. Sensitive Questions

The survey does not include any questions of a sensitive nature.

12. Burden Estimates (Hours & Wages)

1. Wage Estimates

Groups and virtual groups of eligible clinicians, vendors, and beneficiaries will experience burden under the CAHPS for MIPS survey version 2.0. Burdens for each of these segments are presented in sections 12.1, 12.2, and 12.3, respectively. To derive wage estimates, we used data from the U.S. Bureau of Labor Statistics’ (BLS) May 2016 National Occupational Employment and Wage Estimates for all salary estimates (http://www.bls.gov/oes/current/oes_nat.htm). Table 2 presents the mean hourly wages (calculated at 100 percent of salary), the cost of fringe benefits and overhead, and the adjusted hourly wage that were used for the burden estimates. For group or virtual group registration or vendor application burden estimate, we are adjusting the computer system’s analyst hourly wage estimates by a factor of 100 percent. This is necessarily a rough adjustment, 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. For the beneficiary survey burden estimate, note also that we have not adjusted the costs for fringe benefits and overhead for civilian, all occupations, as this hourly wage is used only in the calculation of beneficiary burden for time spent completing the survey, and not for direct wage costs.

TABLE 2: Adjusted Hourly Wages Used in CAHPS for MIPS Survey Version 2.0 Burden Estimates

Occupation Title	Occupational Code	Mean Hourly Wage ($/hr.)	Fringe Benefits and Overhead ($/hr.)	Adjusted Hourly Wage ($/hr.)
Computer Systems Analysts	15-1121	$44.05	$44.05	$88.10
Civilian, All Occupations	Not applicable	$23.86	N/A	$23.86

Source: Occupational Employment and Wage Estimates May 2016, U.S. Department of Labor, Bureau of Labor Statistics. https://www.bls.gov/oes/.

2. Burden for Group and Virtual Group Registration for CAHPS for MIPS Survey

As shown in Table 3, we assume that the staff involved in the group and virtual group registration for CAHPS for MIPS survey will mainly be computer systems analysts or their equivalent, who have an average labor cost of $88.10/hour. We assume the CAHPS for MIPS survey registration burden estimate includes the time to register for the survey as well as select the CAHPS for MIPS survey vendor. Therefore, assuming the total burden hours per registration is 1 hour and 0.5 hours to select the CAHPS for MIPS survey vendor that will be used, the total burden hours for CAHPS for MIPS registration is 1.5. We estimate the total annual burden hours as 692 (461 groups or virtual groups X 1.5 hours). We estimate the cost per group for CAHPS for MIPS survey registration is $132.15 ($88.10 X 1.5 hours). We estimate that the total cost associated with the registration process is $60,921 ($132.15 per hour X 461 hours per group).

TABLE 3: Burden Estimate for Group and Virtual Group Registration for CAHPS for MIPS Survey

	Burden Estimate
Estimated # of Groups or Virtual Groups Registering for CAHPS (a)	461
Estimated Total Annual Burden Hours for CAHPS Registration (b)	1.5
Estimated Total Annual Burden Hours For CAHPS Registration (c) = (a)*(b)	692
Estimated Cost to Register for CAHPS@ computer systems analyst’s labor rate of $88.10/hr.) (d)	$132.15
Estimated Total Annual Burden Cost For CAHPS Registration (e) = (a)*(d)	$60,921

3. Burden for CAHPS for MIPS Survey Vendors

In the CY 2017 Quality Payment Program final rule (81 FR 77386), we finalized the definition, criteria, required forms, and vendor business requirements needed to participate in MIPS as a survey vendor. For purposes of MIPS, we defined a CMS-approved survey vendor as a survey vendor that is approved by us for a particular performance period to administer the CAHPS for MIPS survey and transmit survey measures data to us. We also finalized a requirement that vendors undergo the CMS-approval process each year in which the survey vendor seeks to transmit survey measures data to us, and finalized the criteria for a CMS-approved survey vendor for the CAHPS for MIPS survey.

For the purposes of this burden estimate, we assume that 15 vendors will apply to participate as CAHPS for MIPS vendors, the same as the previous number of vendors for the CAHPS for PQRS survey. We estimate that it will take a survey vendor 10 hours to submit the information required for the CMS-approval process. This estimate includes the completion of the Vendor Participation Form (or for returning vendors, Vendor Renewal Participation Form) and compiling documentation, including the quality assurance plan, that demonstrates that they comply with Minimum Survey Vendor Business Requirements. The estimate also includes the completion of the vendor attestation form.⁷ This is comparable to the burden of the QCDR and qualified registry self-nomination process. As shown in Table 3, we assume that the survey vendor staff involved in collecting and submitting the information required for the CAHPS for MIPS certification will be computer systems analysts, who have an average labor cost of $88.10/hour. Therefore, assuming the total burden hours per CAHPS associated with the application process is 10 hours, the annual burden hours is 150 (15 CAHPS vendors X 10 hours). We estimate that the total cost to each CAHPS vendor associated with the application process will be approximately $881.00 ($88.10 per hour X 10 hours per CAHPS vendor). We estimate that 15 CAHPS vendors will go through the process leading to a total burden of $13,215 ($881.00 X 15 CAHPS vendors).

Based on the assumptions previously discussed, we provide an estimated number of total annual burden hours and total annual cost burden associated with the survey vendor approval process in Table 4.

Table 4: Burden Estimate for CAHPS for MIPS Survey Vendor Application

	Burden Estimate
Estimated # of New CAHPS Vendors Applying (a)	15
Estimated # of Burden Hours Per Vendor to Apply (b)	10
Estimated Cost Per Vendor Reporting (@ computer systems analyst's labor rate of $88.10/hr.) (c)	$881.00
Estimated Total Annual Burden Hours (d) = (c)*(d)	150
Estimated Total Annual Burden Cost for CAHPS Vendor Application Process (e) = (a)*(c)	$13,215

4. Burden for Beneficiary Responses to the CAHPS for MIPS Survey

Beneficiaries that choose to respond to the CAHPS for MIPS survey will experience burden. The usual practice in estimating the burden on public respondents to surveys such as the CAHPS for MIPS survey is to assume that respondent time is valued, on average, at civilian wage rates. To calculate the costs to beneficiaries for their time, we have used BLS estimates for employer costs for employee compensation for civilian, all occupations. Although most Medicare beneficiaries are retired, we believe that their time value is unlikely to depart significantly from prior earnings expense, and we have used the average hourly wage to compute the dollar cost estimate for these burden hours.

The BLS data show the average hourly wage for civilians in all occupations to be $23.86. Although most Medicare beneficiaries are retired, we believe that their time value is unlikely to depart significantly from prior earnings expense, and have used the average hourly wage to compute the dollar cost estimate for these burden hours.

Table 5 shows the estimated annualized burden for beneficiaries to participate in the CAHPS for MIPS survey. Based on historical information on the numbers of CAHPS for PQRS survey respondents, we assume that an average of 287 beneficiaries will respond per group. Therefore, the CAHPS for MIPS survey will be administered to approximately 132,307 beneficiaries per year (461 groups or virtual groups X an average of 287 beneficiaries per group responding).

We are proposing to use a shorter version of the CAHPS for MIPS survey with 58 items, as compared to 81 items for the version that will be used in the transition year. Based on the results of the pilot test, the proposed shorter survey is estimated to require an average administration time of 12.9 minutes (or 0.22 hours) in English (at a pace of 4.5 items per minute). We assume the Spanish survey would require 15.5 minutes (assuming 20 percent more words in the Spanish translation). Because less than 1 percent of surveys were administered in Spanish for reporting year 2016, our burden estimate reflects the length of the English survey. Our proposal would reduce beneficiary burden compared to the transition year; we estimate that the 81-item survey requires an average administration time of 18 minutes in English and 21.6 minutes in Spanish.

Given that we expect approximately 132,307 respondents per year, the annual total burden hours are estimated to be 29,108 hours (132,307 respondents X 0.22 burden hours per respondent). The estimated total burden annual burden cost is $694,612 (132,307 X $5.13 (0.22 hours X rate of $23.86/hour)).

TABLE 5: Burden Estimate for Beneficiary Participation in CAHPS for MIPS Survey

	Burden Estimate
Estimated # of Groups or Virtual Groups Administering CAHPS for MIPS Survey (a)	461
Estimated # of Beneficiaries Per Group Responding to Survey (b)	287
Estimated # of Total Respondents Reporting (c)=(a)*(b)	132,307
Estimated # of Burden Hours Per Respondent to Report (d)	0.22
Estimated Cost Per Beneficiary Reporting (at cost rate of $23.86) (e)	$5.25
Estimated Total Annual Burden Hours (f) = (c)*(d)	29,108
Estimated Total Annual Burden Cost for Beneficiaries Responding to CAHPS for MIPS (g)=(c)*(e)	$694,612

13. Capital Costs

Beneficiaries who elect to complete the CAHPS for MIPS survey and groups and virtual groups that elect to use the CAHPS for MIPS survey as one of their quality measures will not incur capital costs as a result of participation. Survey vendors may incur capital costs in order to meet the vendor business requirements needed to participate in MIPS as a CMS-approved survey vendor.

13. Cost to Federal Government

The total annual cost to the Federal government for CAHPS for MIPS survey is estimated to be $2,120,324. This total includes CMS selecting samples of Medicare beneficiaries aligned with the groups electing to use the CAHPS for MIPS survey, and providing the list of sampled beneficiaries to CMS-approved survey vendors. The total annual cost also includes the annual approval process for survey vendors; training, oversight, and technical assistance of the approved survey vendors; preparation and cleaning of data submitted by the survey vendors; data analysis; preparation of the CAHPS for MIPS survey measures for public reporting on Physician Compare, and in the feedback reports for clinician groups reporting on the CAHPS for MIPS survey measures.

13. Program or Burden Changes

TABLE 6: Proposed Annual Recordkeeping and Submission Requirements

	Respondents/ responses	Hours per response	Total annual burden hours	Labor cost of submission	Total annual burden cost
§414.1400 CAHPS for MIPS Survey Vendor Application	15	10.0	150	$88.10	$13,215
§414.1330 and §414.1335 CAHPS for MIPS Survey Beneficiary Participation	132,307	0.22	29,108	$23.86	$694,612
§414.1330 and §414.1335 CAHPS for MIPS Survey Group Registration	461	1.5	692	$88.10	$60,921
Total for CAHPS PRA Package (0938-1222)	132,783		29,950		$768,748

As shown in Table 6, the total estimated burden associated with the three information collections submitted for approval as a revision of 0938-1222 is 29,950 hours with total annual burden cost of $768,748. The currently approved burden estimate for the transition year CAHPS for MIPS survey information collection is 43,361 hours with total annual burden cost of $1,014,252. The reduction of 13,771 burden hours and $245,504 total annual burden cost is mainly due to the proposal to use a shorter survey.

16. Publication and Tabulation Dates

To ensure that MIPS results are useful and accurate, CMS proposes to provide performance feedback to MIPS eligible clinicians that includes MIPS quality and cost data and if technically feasible to also include improvement activities and advancing care information data.  CMS plans to work collaboratively with stakeholders to design feedback reports, and to make feedback available through multiple mechanisms including qpp.cms.gov and third-party vendors.  CMS also proposes to provide performance feedback to MIPS eligible clinicians who participate in MIPS APMs in 2018 and future years as technically feasible.  This reflects our commitment to providing as timely information as possible to eligible clinicians to help them predict their performance in in MIPS.

We plan to publicly report MIPS information through the Physician Compare website. The CAHPS for MIPS survey will be used to populate the Physician Compare website, which was launched December 30, 2010 to meet requirements set forth by Section 10331 of the Patient Protection and Affordable Care Act of 2010 (Affordable Care Act). The Affordable Care Act required CMS to establish a Physician Compare website by January 1, 2011 containing information on physicians enrolled in the Medicare program and other eligible professionals who participate in the Physician Quality Reporting Initiative. By no later than January 1, 2013 (and for reporting periods beginning no earlier than January 1, 2012), CMS was required to implement a plan to make information on physician performance publicly available through Physician Compare. A key component of the reporting requirements under the Affordable Care Act is public reporting, through Physician Compare, of information on physician performance that includes patient experience measures. The collection and reporting of a CAHPS for MIPS survey 1.0 was developed to fulfill this requirement, and the CAHPS for MIPS survey version 2.0 will continue to do so. We plan to publicly report MIPS information through the Physician Compare website. The public reporting is anticipated to start in late 2019 for the 2018 performance period. We plan public reporting of some measures in a MIPS eligible clinician's MIPS data; in that for each performance period, we will post on a public website (for example, Physician Compare), in an easily understandable format, information regarding the performance of MIPS eligible clinicians or groups under the MIPS.

17. Expiration Date

We are requesting approval for this information collection for a period of three years. The expiration date will be displayed on the CAHPS for MIPS survey instruments, beneficiary letters, vendor application guidance, and group registration guidance.

18. Certification Statement

There are no exceptions to the certification statement.

1 Depending on when during the calendar year the survey administration period occurs, there could be seasonal differences in estimates across vendors or survey cycles. Before considering a change in the survey administration period from what was used in prior years, we will take these seasonal effects into consideration.

2 AHRQ June 2015: An Overview of Version 3.0 of the CAHPS Clinician & Group Survey. Retrieved from https://www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/cg/about/cg_3-0_overview.pdf

3 AHRQ July 2015: Comparability Results for the 2.0 and 3.0 Versions of the CAHPS Clinician & Group Survey. Retrieved from: https://www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/cg/Comparison_of_CG-CAHPS_v3_and_v2.pdf

4 Stucky, B. D., Hays, R. D., Edelen, M. O., Gurvey, J., & Brown, J. A. (2016). Possibilities for shortening the CAHPS clinician and group survey. Medical care, 54(1), 32-37.

5 Sections 3021 and 3022 of the Affordable Care Act state the Shared Savings Program and the testing, evaluation, and expansion of Innovation Center models are not subject to the Paperwork Reduction Act (42 U.S.C. §1395jjj and 42 U.S.C. §1315a(d)(3), respectively).

6 Note that the two SSMs, Health Status and Functional Status, and Access to Specialists, will be included in the revised CAHPS for MIPS for informational purposes, but will not be counted in the MIPS Score.

7 Vendors are required to meet additional requirements as part of the approval process that are not included in the burden estimate because they are not related to data submission. The approval process includes submitting an application, meeting minimum business requirements, participation in training(s), passing post-training evaluation(s), submitting a Quality Assurance Plan, and following the schedule and procedures for survey administration. Additional details about the vendor approval process can be found at https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/CAHPS/mips.html.

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