CAHPS®
Survey for
Merit-based Incentive Payment System (MIPS)
2018 Survey
PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1222. The time required to complete this information collection is estimated to average 12.9 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
OMB No. 0938-1222
Expiration Date: [3 years from OMB approval date]
Medicare Provider Experience Survey
Survey Instructions
This survey asks about you and the health care you received in the last six months. Answer each question thinking about yourself. Please take the time to complete this survey. Your answers are very important to us. Please return the survey with your answers in the enclosed postage-paid envelope to [VENDOR NAME]
Answer all the questions by putting an “X” in the box to the left of your answer, like this:
Yes
Be sure to read all the answer choices given before marking your answer.
You are sometimes told not to answer some questions in this survey. When this happens you will see an arrow with a note that tells you what question to answer next, like this:
[ If No, Go to Question 3]. See the example below:
EXAMPLE
1. Do you wear a hearing aid now?
☐ Yes
No If No, Go to Question 3
2. How long have you been wearing a hearing aid?
☐ Less than one year
☐ 1 to 3 years
☐ More than 3 years
☐ I don’t wear a hearing aid
3. In the last 6 months, did you have any headaches?
Yes
☐ No
Your Provider
1. Our records show that you visited the provider named below in the last 6 months.
Name of provider label goes here
Is that right?
Yes
No If No, go to #24
The questions in this survey will refer to the provider named in Question 1 as “this provider.” Please think of that person as you answer the survey.
2. Is this the provider you usually see if you need a check-up, want advice about a health problem, or get sick or hurt?
Yes
No
3. How long have you been going to this
provider?
Less than 6 months
At least 6 months but less than 1 year
At least 1 year but less than 3 years
At least 3 years but less than 5 years
5 years or more
Your Care From This Provider in the Last 6 months
These questions ask about your own health care. Do not include care you got when you stayed overnight in a hospital. Do not include the times you went for dental care visits.
4. In the last 6 months, how many times did you visit this provider to get care for yourself?
None If None, go to #24
1 time
2
3
4
5 to 9
10 or more times
5. In the last 6 months, did you contact this provider’s office to get an appointment for an illness, injury or condition that needed care right away?
Yes
No If No, go to #7
6. In the last 6 months, when you contacted this provider’s office to get an appointment for care you needed right away, how often did you get an appointment as soon as you needed?
Never
Sometimes
Usually
Always
7. In the last 6 months, did you make any appointments for a check-up or routine care with this provider?
Yes
No If No, go to #9
8. In the last 6 months, when you made an appointment for a check-up or routine care with this provider, how often did you get an appointment as soon as you needed?
Never
Sometimes
Usually
Always
9. In the last 6 months, did you contact this provider’s office with a medical question during regular office hours?
Yes
No If No, go to #11
10. In the last 6 months, when you contacted this provider’s office during regular office hours, how often did you get an answer to your medical question that same day?
Never
Sometimes
Usually
Always
11. In the last 6 months, how often did this provider explain things in a way that was easy to understand?
Never
Sometimes
Usually
Always
12. In the last 6 months, how often did this
provider listen carefully to you?
Never
Sometimes
Usually
Always
13. In the last 6 months, how often did this provider seem to know the important information about your medical history?
Never
Sometimes
Usually
Always
14. In the last 6 months, how often did this provider show respect for what you had to say?
Never
Sometimes
Usually
Always
15. In the last 6 months, how often did this provider spend enough time with you?
Never
Sometimes
Usually
Always
16. In the last 6 months, did this provider order a blood test, x-ray, or other test for you?
Yes
No If No, go to #18
17. In the last 6 months, when this provider ordered a blood test, x-ray, or other test for you, how often did someone from this provider’s office follow up to give you those results?
Never
Sometimes
Usually
Always
18. In the last 6 months, did you and this provider talk about starting or stopping a prescription medicine?
Yes
No If No, go to #20
19. When you and this provider talked about starting or stopping a prescription medicine, did this provider ask what you thought was best for you?
Yes
No
20. In the last 6 months, did you and this provider talk about how much of your personal health information you wanted shared with your family or friends?
Yes
No
21. Using any number from 0 to 10, where 0 is the worst provider possible and 10 is the best provider possible, what number would you use to rate this provider?
0 Worst provider possible
1
2
3
4
5
6
7
8
9
10 Best provider possible
Clerks and Receptionists at This Provider’s Office
22. In the last 6 months, how often were clerks and receptionists at this provider’s office as helpful as you thought they should be?
Never
Sometimes
Usually
Always
23. In the last 6 months, how often did clerks and receptionists at this provider’s office treat you with courtesy and respect?
Never
Sometimes
Usually
Always
Your Care From Specialists in the Last 6 months
24. Specialists are doctors like surgeons, heart doctors, allergy doctors, skin doctors, and other doctors who specialize in one area of health care. Is the provider named in Question 1 of this survey a specialist?
YesIf Yes, Please include
this provider as you answer these questions about specialists
No
25. In the last 6 months, did you try to make any appointments with specialists?
Yes
No If No, go to #27
26. In the last 6 months, how often was it easy to get appointments with specialists?
Never
Sometimes
Usually
Always
All Your Care in the Last 6 Months
These questions ask about all your health care. Include all the providers you saw for health care in the last 6 months. Do not include the times you went for dental care visits.
27. Your health care team includes all the doctors, nurses and other people you see for health care. In the last 6 months, did you and anyone on your health care team talk about a healthy diet and healthy eating habits?
Yes
No
28. In the last 6 months, did you and anyone on your health care team talk about the exercise or physical activity you get?
Yes
No
29. In the last 6 months, did you take any prescription medicine?
Yes
No If No, go to #32
30. In the last 6 months, how often did you and anyone on your health care team talk about all the prescription medicines you were taking?
Never
Sometimes
Usually
Always
31. In the last 6 months, did you and anyone on your health care team talk about how much your prescription medicines cost?
Yes
No
32. In the last 6 months, did anyone on your health care team ask you if there was a period of time when you felt sad, empty, or depressed?
Yes
No
33. In the last 6 months, did you and anyone on your health care team talk about things in your life that worry you or cause you stress?
Yes
No
About You
34. In general, how would you rate your overall health?
Excellent
Very good
Good
Fair
Poor
35. In general, how would you rate your overall mental or emotional health?
Excellent
Very good
Good
Fair
Poor
36. In the last 12 months, have you seen a doctor or other health provider 3 or more times for the same condition or problem?
Yes
No If No, go to #38
37. Is this a condition or problem that has lasted for at least 3 months?
Yes
No
38. Do you now need or take medicine prescribed by a doctor?
Yes
No If No, go to #40
39. Is this medicine to treat a condition that has lasted for at least 3 months?
Yes
No
40. During the last 4 weeks, how much of the time did your physical health interfere with your social activities (like visiting with friends, relatives, etc.)?
All of the time
Most of the time
Some of the time
A little of the time
None of the time
41. What is your age?
18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 69
70 to 74
75 to 79
80 to 84
85 or older
42. Are you male or female?
Male
Female
43. What is the highest grade or level of school that you have completed?
8th grade or less
Some high school, but did not graduate
High school graduate or GED
Some college or 2-year degree
4-year college graduate
More than 4-year college degree
44. How well do you speak English?
Very well
Well
Not well
Not at all
45. Do you speak a language other than English at home?
Yes
No If No, go to #47
46. What is the language you speak at home?
Spanish
Chinese
Korean
Russian
Vietnamese
Some other language
Please print:
47. Are you deaf or do you have serious difficulty hearing?
Yes
No
48. Are you blind or do you have serious difficulty seeing, even when wearing glasses?
Yes
No
49. Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?
Yes
No
50. Do you have serious difficulty walking or climbing stairs?
Yes
No
51. Do you have difficulty dressing or bathing?
Yes
No
52. Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping?
Yes
No
53. Do you ever use the internet at home?
Yes
No
54. Are you of Hispanic, Latino, or Spanish origin?
Yes, Hispanic, Latino, or Spanish
No, not Hispanic, Latino, or Spanish If No, go to #56
55. Which group best describes you?
Mexican, Mexican American, Chicano Go to #56
Puerto Rican Go to #56
Cuban Go to #56
Another Hispanic, Latino, or Spanish origin Go to #56
56. What is your race? Mark one or more.
White
Black or African American
American Indian or Alaska Native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander
57. Did someone help you complete this survey?
Yes
No Thank you.
Please return the completed survey in the postage-paid envelope.
58. How did that person help you? Mark one or more.
Read the questions to me
Wrote down the answers I gave
Answered the questions for me
Translated the questions into my language
Helped in some other way
Please print:
Thank you
Please return the completed survey in the postage-paid envelope.
[VENDOR NAME AND ADDRESS HERE]
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | ACO Pilot Survey 2016-5-31 |
| Subject | ACO Survey for 2016-2017 Pilot Test |
| Author | Julie Brown |
| File Modified | 0000-00-00 |
| File Created | 2021-01-22 |