CMS-10537 - Hospice Survey OMB_Statement_A _2017

SUPPORTING STATEMENT

CAHPS^® HOSPICE SURVEY

Introduction

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 of 1995 to continue implementation of the CAHPS^® Hospice Survey. . Under Contract Number HHSM-500-2016-00022G, the project team will continue to implement and analyze a hospice experience of care survey for primary caregivers (i.e., bereaved family members or close friends) of patients who died while receiving hospice care (“decedents”). .

A. Justification

A1. Necessity of Information Collection

CMS launched the development of the CAHPS^® Hospice Survey in 2012. Its goal is to measure the experiences of patients and their caregivers with hospice care. The survey was developed to:

• Provide a source of information from which selected measures could be publicly reported to beneficiaries and their family members as a decision aid for selection of a hospice program;

• Aid hospices with their internal quality improvement efforts and external benchmarking with other facilities; and

• Provide CMS with information for monitoring the care provided.

CMS announced its intention to implement the CAHPS^® Hospice Survey in the FY 2014

Hospice Wage Index and Payment Rate Update; Hospice Quality Reporting

Requirements; and Updates on Payment Reform. National implementation of the survey launched on January 1, 2015 with hospices administering the survey for a “dry run” for at least one month in the first quarter of 2015. Starting April 1, 2015 (second quarter), hospices were required to participate on a monthly basis in order to receive the full Annual Payment Update (APU). Implementation is ongoing and there have been no changes to the questionnaire and only very minor changes to survey administration procedures.

A2. Purpose and Use of Information

This survey supports the National Quality Strategy developed by the U.S. Department of Health and Human Services (HHS) that was called for under the Affordable Care Act to create national aims and priorities to guide local, state, and national efforts to improve the quality of health care. This strategy has established six priorities that support a three-part aim focusing on better care, better health, and lower costs through improvement. The six priorities include: making care safer by reducing harm caused by the delivery of care; ensuring that each person and family are engaged as partners in their care; promoting effective communication and coordination of care; promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease; working with communities to promote wide use of best practices to enable healthy living; and making quality care more affordable for individuals, families, employers, and governments by developing and spreading new health care delivery models. Because the hospice survey focuses on experiences of care, implementation of the survey supports the following national priorities for improving care: engaging patients and families in care and promoting effective communication and coordination. In addition, national implementation and public reporting of hospice survey results will provide data on experiences with hospice care that enable consumers to make meaningful comparisons between hospices across the nation.

A3. Technological Collection Techniques

For national implementation survey vendors collect the data from primary caregivers (i.e., bereaved family members or close friends) of patients who died while receiving hospice care in any of the following settings: (1) at home, (2) in a nursing home, and (3) in an inpatient setting (i.e., freestanding inpatient unit or acute care hospital). Three modes of survey administration are allowed: mail-only (up to two mailed surveys), telephone-only (up to 5 telephone attempts), and mixed mode (mailed survey followed by up to 5 telephone attempts beginning 21 days later). Mailed questionnaires are formatted for data scanning, and data from all returned surveys are scanned into an electronic data file. Computer Assisted Telephone Interviewing (CATI) is used for the telephone mode.

A4. Identifying Duplication

The CAHPS® Hospice Survey includes items addressing communication, care coordination, respect, spiritual and emotional support, symptom management, and overall care ratings. The survey questionnaire is unchanged from our prior submission. The survey is designed to gather only the data that CMS needs for assessing experiences with hospice care.

Though some hospices and vendors may voluntarily use the Family Evaluation of Hospice Care, the Veterans Health Administration Bereaved Family Survey, or other sitespecific surveys to collect data on experiences with hospice care, the CAHPS Hospice Survey is the only standardized instrument used to collect such data from all hospices across the country for the purposes of comparability and accountability.

A5. Impact on Small Businesses

Survey respondents are primary caregivers of patients who died while receiving hospice care. The survey should not impact small business or other small entities.

A6. Consequences of Less Frequent Data Collection

The survey will be administered once to each primary caregiver following the death of his or her family member or friend.

A7. Special Circumstances

There are no special circumstances associated with this information collection request.

A8. CMS Federal Register Notice

A Notice of Proposed Rulemaking (NPRM) titled, Medicare Program; FY 2018 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements published May 3, 2017 (82 FR 20750). The NPRM served as the 60-day comment period. No comments were received.

A final rule published on August 4, 2017 (82 FR 36638).

A9. Respondent Payments or Gifts

This data collection will not include respondent incentive payments or gifts.

A10. Assurance of Confidentiality

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.

A11. Sensitive Questions

As this survey requests information from bereaved family members or close friends of a deceased patient, the potential for distress is possible; however, CMS’ experience with the CAHPS^® Hospice Survey thus far indicates that this is a very rare event. The cover letter that vendors send accompanying mailed surveys is required to include a toll-free number which respondents may use for questions or concerns. Should a respondent experience distress significant enough for him or her to request additional support, we recommend that survey vendors’ telephone staff put the respondent in contact with the appropriate local resource (generally a bereavement counselor or social worker on the hospice team that provided care to their family member or friend). This visit and support groups for bereavement are part of the services covered under the Medicare Hospice Benefit.

A12. Burden of Information Collection

Estimated annualized burden hours and costs to respondents for the national implementation of the CAHPS^® Hospice Survey are shown in Tables 1 and 2. Based on participation in national implementation in the CAHPS^® Hospice Survey from Quarter 2 2015 through Quarter 1 2016, we assume that 3,414 hospices will administer the survey to an average of 278.7 cases. Thus, we estimate that the CAHPS^® Hospice Survey will be administered to a maximum of 951,482 individuals each year for the duration of the collection period covered by this application for the purposes of national implementation. As not all sampled cases will complete the survey, this estimate reflects the maximum burden possible. The estimated number of responses is based on actual hospice participation in national implementation of the CAHPS^® Hospice Survey. The prior

OMB filing for the CAHPS Hospice Survey, estimated a smaller number of participating hospices based on estimates calculated using CMS Provider of Services and hospice claims files (prior to the availability of national implementation data).

Table 1 shows the estimated annualized burden for the respondents' time to participate in the national implementation data collection. The survey contains 47 items and is estimated to require an average administration time of 10.4 minutes in English (at a pace of 4.5 items per minute) and 12.5 minutes in Spanish (assuming 20 percent more words in the Spanish translation), for an average response time of 10.47 minutes or 0.174 hours (assuming that 1% of survey respondents complete the survey in Spanish). These burden and pace estimates are based on CMS’ experience with the CAHPS^® Hospice Survey and surveys of similar length that were fielded with Medicare beneficiaries. As indicated below, the annual total burden hours for survey participants are estimated to be 165,959.57 for the continued national implementation of the survey.

Table 1. Estimated Annualized Burden Hours for Respondents: National Implementation of the CAHPS^® Hospice Survey

Survey Version	Number of Respondents	Number of Responses per Respondent	Hours per Response	Total Burden Hours
CAHPS® Hospice Survey	951,482	1	0.174	165,959.57
Total	951,482	1	0.174	165,959.57

Table 2 shows the cost burden to respondents associated with their time to complete a survey as part of national implementation. The annual total cost burden is estimated to be $7,710,481.60. This estimate is higher than the $3,034,789.70 estimated in the prior OMB filing, due to the increased number of hospices participating (and correspondingly, the increased number of respondents), as well as an increase in the average hourly rate.

Table 2. Estimated Annualized Cost Burden for Respondents: National Implementation

Form Name	Number of Respondents	Total Burden Hours	Average Hourly Wage Rate*	Total Cost Burden
CAHPS® Hospice Survey	951,482	165,959.57	$46.46*	$7,710,481.60
Total	951,482	165,959.57	$46.46*	$7,710,481.60

* Source: Data from the U.S. Bureau of Labor Statistics’ May 2015 National Occupational Employment and Wage Estimates for all salary estimates. This figure includes a 100% fringe benefit on an average wage of $23.23. Retrieved from https://www.bls.gov/news.release/empsit.t19.htm on February 16, 2017

In addition to respondent burden, both hospices required to participate in national implementation of the survey, and those exempted from participation, will face a burden.

Per CMS’ final rule in FY 2014 Hospice Wage Index and Payment Rate Update; Hospice Quality Reporting Requirements; and Updates on Payment Reform and in subsequent rules, hospices with 50 decedents or more in a year are required to administer the CAHPS^® Hospice Survey. The burden to these hospices consists of their time and effort to prepare and submit decedent data files to their approved CAHPS^® Hospice Survey vendor. The data files contain data on patients who died in the hospice’s care in the prior month, and are used by the survey vendor to select the sample and field the survey. Hospices use existing databases to generate these files, and are generally able to do so with minimal effort. To keep the burden to hospices as low as possible, the list of required data elements for the file is as parsimonious as possible.

Table 3 shows the estimated annualized cost burden for the provision of the monthly data file by hospices required to participate in national implementation. We estimate that preparation and submission of the monthly file will take 24.0 hours annually for each hospice. We have increased the number of assumed hours because we had reports that some hospices were experiencing difficulties obtaining needed data from their electronic medical records. Although the difficulty may diminish with time, we thought it reasonable to increase the estimated number of hours needed for compliance. Assuming that as in Quarter 2 2015 through Quarter 1 2016, 3,414 hospices conduct the CAHPS^® Hospice Survey, the burden would be 81,936 hours (3,414 hospices * 24 hours). CMS believes that this labor can be conducted by a Medical Records Reviewer. The U.S. Bureau of Labor Statistics estimates that the average hourly wage of Medical Records and Health Information Technicians is $19.44.⁰ Therefore, the annual cost of the wage labor would be $466.56 for each hospice (24 hours * $19.44) for a total of $1,592,835.84 for all hospices participating in national implementation ($466.56 per hospice for 3,414 hospices).

Table 3. Estimated Annualized Cost Burden to Hospices Eligible to Participate in National Implementation

Form Name	Number of Hospices	Total Burden Hours per Hospice	Average Hourly Wage Rate*	Total Cost Burden
Data File for CAHPS® Hospice Survey	3,414	24	$19.44	$1,592,835.84
Total	3,414	24	$19.44	$1,592,835.84

*Based upon. Occupational Outlook Handbook. Retrieved from https://www.bls.gov/ooh/healthcare/medical-recordsand-health-information-technicians.htm on February 16, 2017.

Table 4 shows the estimated annualized cost burden for hospices applying for the size exemption from participation in national implementation. In 2015 and 2016, 548 and 527 hospices applied for this exemption, respectively. We estimate that preparation of the annual decedent count and completion of the form takes 20 minutes (0.333 hours). Assuming that 548 hospices apply for the exemption in a given year, the burden would be 182.67 hours (548 hospices * 0.333 hours). CMS believes that this labor can be conducted by a Medical Records Reviewer. The annual cost of the wage labor would be $6.48 for each hospice (0.333 hours * $19.44) for a total of $3,551.04 for all hospices completing the exemption form ($6.48 per hospice for 548 hospices).

Table 4. Estimated Annualized Cost Burden to Hospices Applying for Exemption from Participation in National Implementation

Form Name	Number of Hospices	Total Burden Hours per Hospice	Average Hourly Wage Rate*	Total Cost Burden
CAHPS® Hospice Survey Exemption for Size Form	548	0.333	$19.44	$3,551.04
Total	548	0.333	$19.44	$3,551.04

Based upon *Based upon. Occupational Outlook Handbook. Retried from https://www.bls.gov/ooh/healthcare/medical-records-and-health-information-technicians.htm on February 16, 2017.

A13. Capital Costs

Survey participants will incur no capital costs as a result of participation. Hospices participating in national implementation will bear an annual cost to secure the services of an approved CAHPS^® Hospice Survey vendor to conduct the survey on their behalf. Table 5 summarizes the estimated annual cost burden to hospices of paying the survey vendor. We estimate that the average annual survey vendor cost will be $4,000 for each of the 3,414 hospices participating in national implementation of the CAHPS^® Hospice Survey, for a total of $13,656,000 (3,414 * $4,000).

Table 5. Estimated Annualized Cost Burden to Hospices for Contracting a Survey Vendor for National Implementation of the CAHPS Hospice Survey

Form Name	Number of Hospices	Average Cost to Contract a Survey Vendor	Total Cost Burden
CAHPS® Hospice Survey	3,414	$4,000	$13,656,000
Total	3,414	$4,000	$13,656,000

A14. Cost to the Federal Government

The annual cost to the Federal Government for sampling, data collection, analysis and reporting of scores is $1,583,796.

A15. Program Changes or Adjustments to Annual Burden

The number of respondents subject to the National Implementation of the CAHPS® Hospice Survey has increase significantly from 561,026 in 2014 to 951,482 for 2017.

The 2017 estimate is based on CMS’ actual experience with the CAHPS® Hospice Survey, as well as experience with surveys of similar length that were fielded with

Medicare beneficiaries. The significant increase in respondents resulted in an overall burden hour increase of 68,329 hours (from 98,179 hours to 166,508 hours).

A16. Tabulation and Publication of Results

Our focus now will be publication of CAHPS Hospice Survey results on the

Medicare.gov website. We will also be providing hospices with preview reports of their data. We anticipate publication will occur in early 2018.

Specifically, CMS is planning to publicly report adjusted “top-box” scores for each of the eight CAHPS Hospice Survey measures endorsed by the National Quality Forum. These include six composite measures (composed of multiple survey questions; Hospice Team Communication, Getting Timely Care, Treating Family Member with Respect, Getting

Emotional and Religious Support, Getting Help for Symptoms, Getting Hospice Care

Training) and two global measures (each composed of one survey question; Rating of Hospice, Willingness to Recommend). Top-box scores reflect the proportion of respondents that selected the most positive response category(ies) for the questions within the measure. Top-box scores are adjusted for both mode of survey administration and case mix.

To adjust responses for the effect of mode of survey administration, which can affect scores but is not related to the quality of hospice care, CMS applies survey mode adjustments derived from a 2015 CAHPS Hospice Survey mode experiment. Survey data collected using Mail Only or Mixed Mode are adjusted according to the difference in mode effects between that mode and the Telephone Only mode, as estimated through linear regression in the CAHPS Hospice Survey mode experiment. For Mixed mode, there is a single adjustment regardless of whether an individual responded by mail or phone (i.e., the adjustment is for the overall administration mode, not the mode in which the individual responds).

To ensure that comparisons between hospices reflect differences in performance rather than differences in patient and/or caregiver characteristics, CMS adjusts responses for case mix (i.e., variations of such characteristics across hospices). The case-mix adjustment model includes the following variables:

• response percentile (calculated by ranking lag time—that is, days between death and survey response—among respondents for each hospice in each month, then dividing by total sample size)

• decedent age

• payer for hospice care

• primary diagnosis

• length of final episode of hospice care

• respondent age

• respondent education

• relationship of decedent to caregiver

• language

Details regarding scoring and adjustment of the CAHPS Hospice Survey measures are available at the official survey website, www.hospicecahpssurvey.org.

In addition, we plan to conduct ad hoc analysis of the survey data already collected. This will include preparation for star ratings, assuming the decision is made to include them in the Hospice Compare site.

A17. Display of OMB Expiration Date

The expiration date and OMB control number will be displayed on the survey (upper right-hand corner).

A18. Exceptions to the Certification Statement

There are no exceptions to the certification statement identified in item 19 of OMB Form 83-I associated with this data collection effort.

0 Retrieved from http://www.bls.gov/oes/current/oes292071.htm on February 16, 2017.

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