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 the 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 experience reports describing MIPS data for all MIPS eligible clinicians.
CMS has requested approval for two additional PRA packages associated with the CY 2018 Quality Payment Program final rule with comment period. The collection of information associated with the CY 2018 Quality Payment Program final 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 has established a policy 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. OMB has approved the information collection associated with the virtual group election process, which was submitted as a separate PRA package (0938-1343).
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.
Data submission requirements for groups
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.
We established several policies related to data submission requirements in CAHPS in the CY 2017 Quality Payment Program final rule. We established that 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 established 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. We also established that groups that elect to use CAHPS for MIPS must elect to submit via one other submission mechanism (that is qualified registry, Qualified Clinical Data Registry (QCDR), EHR, or CMS Web Interface). 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 another 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 will be transmitted to CMS via a CMS-approved survey vendor.
In the CY 2018 proposed rule, we proposed a policy that, starting in the 2018 MIPS performance period, in addition to CAHPS for MIPS, groups may use one or more submission mechanisms (that is, qualified registry, Qualified Clinical Data Registry (QCDR), EHR, CMS Web Interface) to complete their quality data submission. Based on public comments, we are establishing the policy to allow groups to use more than one submission mechanism in addition to CAHPS starting in the 2019 MIPS performance period.
Scoring policies
Although we are not requiring groups or virtual groups to participate in the CAHPS for MIPS survey, we believe patient experience is important. In the CY 2017 final rule, we established 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. In addition, we established a scoring policy that counts the use of a CAHPS survey (including the CAHPS for MIPS survey) as a high-weighted activity under the improvement activities performance category. The quality performance category score and improvement activities performance category score are both part of the final score, which is used to determine whether the MIPS eligible clinician receives a positive, neutral, or negative MIPS payment adjustment.
Virtual Groups
In the CY 2018 Quality Payment Program final rule with comment period, we are also establishing a policy 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.
Revisions to CAHPS for MIPS Survey Instrument
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 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 established retaining the CAHPS for MIPS survey administration period that was utilized for PQRS from November to February. However, this survey administration period has become operationally problematic for the administration of MIPS. In order to compute scores, we must have the CAHPS for MIPS survey data earlier than the current survey administration period deadline allows. Therefore, we finalized for the Quality Payment Program Year 2 and future years that the survey administration period would span over a minimum of 8 weeks to a maximum of 17 weeks and would end no later than February 28th following the applicable performance period (82 FR 53632).1 We will further specify start and end timeframes of the survey administration period through our normal communication channels.
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 are establishing that 8 SSMs be used for measurement and two additional SSMs be used for informational purposes. The revised survey reduces the number of SSMs from twelve to ten. In addition, the number of items in some of the SSMs will be reduced and 1 item will be moved to contribute to a different SSM for scoring. Under the 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 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 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. For consistency with AHRQ’s update, CMS has made wording changes in four items, deleted four items, and made an update to the items that compose the Care Coordination SSM. 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 revised survey reduces the number of SSMs from twelve to ten and the number of questions from 81 to 58. These changes were supported by analyses of CAHPS for PQRS survey data (the predecessor survey under the Physician Quality Reporting System, or PQRS).
To maintain consistency with the CAHPS for ACOs survey, two SSMs (and the ten questions in the SSMs) were removed from the 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 survey, though reduced in length, still provides actionable data from a quality improvement perspective. Table 1 summarizes the 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 G provides the references 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 |
|
3 |
2 wording changes; deleted 2 questions |
To align with AHRQ version 3.0 |
|
4 |
Deleted 1 question; moved 1 question to Care Coordination |
To align with AHRQ version 3.0 |
|
1 |
No change |
- |
|
4 |
Deleted 2 questions |
Improved reliability |
|
2 |
Deleted 6 questions |
Improved reliability |
|
1 |
No change |
- |
|
2 |
No change |
- |
|
3 |
No change in number; removed 1 question and replaced it with 1 question formerly in How Well Providers Communicate |
To align with AHRQ version 3.0 questions |
|
9 |
No change |
- |
|
1 |
Deleted 1 question |
Improved reliability |
|
0 |
Deleted SSM |
Low reliability |
|
0 |
Deleted SSM |
To maintain consistency with CAHPS for ACOs |
We are removing two SSMs from the CAHPS for MIPS survey, which would result in the collection of ten SSMs in the CAHPS for MIPS survey. We are establishing a policy that for the Quality Payment Program Year 2 and future years to remove two SSMs, “Helping You to Take Medication as Directed” and “Between Visit Communication.” We are removing 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 the SSM “Helping You to Take Medication as Directed.” Furthermore, based on analyses of SSMs conducted in an attempt to improve their reliability, removing questions from this SSM did not result in any improvements in reliability (see Appendix A for further detail). 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 those SSMs. However, we are removing this SSM in order to maintain consistency with the Medicare Shared Savings Program that utilizes the CAHPS Survey for 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 ten 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 are establishing a policy not to score the “Health Status and Functional Status” SSM and the “Access to Specialists” SSM beginning with the CY 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 score them.
Pilot Testing
These revisions for the CAHPS for MIPS survey were tested in a CAHPS for ACOs pilot survey using a survey identical to the 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 was only to be used to assess the impact of the revised instrument and is not being 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.
Results from the pilot study suggest that administration of the shortened version of the survey (i.e., the pilot survey) is likely to result in improvements in overall response rates. Findings show that the response rate to the pilot survey was 3.4 percentage points higher than the response rate to the Reporting Year (RY) 2016 CAHPS for ACOs survey among ACOs participating in the pilot study. Increases in response rates tended to be larger among ACOs that had lower response rates in the prior year.
In addition, after accounting for survey questions that were removed from the pilot survey, the average survey responses for ACOs who participated in the pilot study were mostly similar across the two survey versions (pilot and RY 2016). After consideration of the findings of the CAHPS for ACO survey pilot and the public comments we received on the proposed rule, the CY 2018 Quality Payment Program final rule with comment period finalized our proposal to use the revised CAHPS for MIPS survey without any additional revisions beyond the revisions discussed in the proposed rule. (82 FR 53629 through 53632)
Beyond CY 2018, CMS may make additional modifications to the CAHPS for MIPS survey that would be submitted for approval as a revision to this information collection request. In the CY 2018 Quality Payment Program final rule with comment period, we sought 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 sought 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 experience reports that will describe the patient experience measures for all MIPS eligible clinicians who elect to use CAHPS for MIPS as one of their quality measures, and for subgroups of clinicians using CAHPS.
The MIPS annual statistical experience 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 CAHPS for MIPS for the 2018 MIPS performance period will not overlap the performance period for the MIPS 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 finalized 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 (82 FR 53592), a significant hardship exception from the advancing care information performance category for small practices (82 FR 53682 through 53683), and bonus points to the final score of MIPS eligible clinicians that are in small practices and submit data on at least one performance category in the 2018 performance period (82 FR 53778). 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 CY 2018 Quality Payment Program proposed rule which served as the 60-day Federal Register notice was published on June 30, 2017 (82 FR 30010 through 30500, RIN 0938–AT13, CMS-5522-P). The CY 2018 Quality Payment Program final rule with comment period will serve as the 30-day Federal Register notice and was posted for public inspection on November 2, 2017 and published on November 16, 2017 (82 FR 53568 through 54229, RIN 0938–AT13, CMS–5522–FC and IFC).
9. Payments/Gifts to Respondents
We will use this data to assess MIPS eligible clinician performance in the MIPS quality performance category, calculate the final score, and calculate positive and negative payment adjustments based on the final score.
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)
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/.
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 Data Description |
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 |
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 current number of vendors for the CAHPS for MIPS 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 and compiling documentation, including the quality assurance plan, that demonstrates that they comply with Minimum Survey Vendor Business Requirements.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.
Burden Data Description |
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) = (a)*(b) |
150 |
Estimated Total Annual Burden Cost for CAHPS Vendor Application Process (e) = (c)*(d) |
$13,215 |
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.
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 finalizing 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 final 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 required 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 Data Description |
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 |
Capital Costs
Survey participants will not incur capital costs as a result of participation.
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; education and outreach to other stakeholders; 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, and generation of an annual statistical experience report.
Program or Burden Changes
The change in the estimated annual burden for the CAHPS for MIPS survey version 2.0 compared to the CAHPS for MIPS survey in the transition year is 13,771 hours8 lower than the previously approved the burden estimate for the CAHPS for MIPS survey 1.0 burden. The reduced burden is due to the shortened survey length.
The previously approved CAHPS for MIPS survey information collection assumed 461 groups per year for the CAHPS for MIPS survey. The same assumptions were used for the CAHPS for MIPS survey version 2.0 estimates.
There may be slight wording changes made to some questions in the 2018 CAHPS for MIPS survey. The final version of the CAHPS for MIPS survey will be posted to the QPP website or CMS website. Additionally, any forms provided in the appendices are still in the developmental phase. Final products may vary slightly due to technical issues associated with transitioning from the developmental phase to the active/live phase.
Publication and Tabulation Dates
CMS is finalizing to include public reporting of eligible clinician and group Quality Payment Program information on the Physician Compare website, in an easily understandable format. The information includes performance of eligible clinicians or groups under the Quality Payment Program.
With the exception of data that must be mandatorily reported on Physician Compare, for each program year, CMS relies on established public reporting standards to guide the information available for inclusion on Physician Compare. The public reporting standards require data included on Physician Compare to be statistically valid, reliable, and accurate; comparable across submission mechanisms; and meet the reliability threshold. And, to be included on the public facing profile pages, the data must also resonate with website users, as determined by CMS.
Sections 1848(q)(9)(A) and (D) of the Act facilitate the continuation of a phased approach to public reporting by requiring the Secretary to make available on the Physician Compare website, in an easily understandable format, individual MIPS eligible clinician and group performance information, including:
The MIPS eligible clinician’s final score;
The MIPS eligible clinician’s performance under each MIPS performance category (quality, cost, improvement activities, and advancing care information);
Names of eligible clinicians in Advanced APMs and, to the extent feasible, the names of such Advanced APMs and the performance of such models; and,
Aggregate information on the MIPS, posted periodically, including the range of final scores for all MIPS eligible clinicians and the range of the performance of all MIPS eligible clinicians for each performance category.
The final score will include the CAHPS for MIPS survey measure score for MIPS eligible clinicians that elect to participate in the CAHPS for MIPS survey as one of their six required quality measures. CAHPS for MIPS summary survey scores will also be publicly reported. The public reporting is anticipated to start in late 2019 for the 2018 performance period.
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 We are establishing that the survey administration period would span over a minimum of 8 weeks to a maximum of 17 weeks. In past survey cycles the survey administration period has been roughly 12 weeks. While CMS does not anticipate a significantly shorter survey administration period in the future, we are finalizing this flexibility in the event that we would need to shorten the survey cycle to accommodate CMS program/operational needs. We do not anticipate that a shorter survey administration period would result in seasonal differences in the estimates across vendors or survey cycles. For example, if we were to move to an 8 week survey administration period, all CMS approved survey vendors would be required to administer the survey in roughly the same timing, and the 8 week survey administration period would be the same across survey cycles.
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.
8 The total burden in hours for CAHPS for MIPS survey 1.0 (transition year) was estimated to be 43,661 hours. The total burden in hours for CAHPS for MIPS survey version 2.0 was estimated to be 29,950 hours. The total burden reduction from CY 2017 to CY 2018 is 43,661–29,108 = 14,553 hours was due to the reduction in length of the survey.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | CAHPS for MIPS Supporting Statement - Part A |
| File Modified | 0000-00-00 |
| File Created | 2021-01-21 |