CMS-10450 CAHPS for MIPS SS Part A (07-03-18) (rev OSORA PRA)

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

Background

CMS is submitting updates to two ICRs associated with the CAHPS for MIPS survey to OMB for approval under the PRA as a revision of the previously approved CAHPS for MIPS package (0938-1222; CMS-10450). The CAHPS for MIPS survey (version 2.0) is used in the Quality Payment Program (QPP) to collect data on fee-for-service Medicare beneficiaries’ experiences of care with eligible clinicians participating in MIPS 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. 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 survey information is used for quality reporting, the Physician Compare website, and annual statistical experience reports describing MIPS data for all MIPS eligible clinicians.

This PRA package addresses the information collections related to the statutorily required quality measurement. The CAHPS for MIPS survey results in burden to three different types of entities: groups and virtual groups, vendors, and beneficiaries associated with administering the survey. Virtual groups are subject to the same requirements as groups, therefore we will refer only to groups as an inclusive term for both unless otherwise noted.

In the CY 2019 Quality Payment Program proposed rule, we estimate a total of 14,485.5 hours with a total cost of $374,655 for the information collections submitted for approval as a revision of OMB control number 0938-1222 (CMS-10450).

1. Summary and Overview

   1. Data submission requirements for groups

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. 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. Additionally, groups that elect to use CAHPS for MIPS must elect to submit on at least one other collection type (eCQM, MIPS CQMs, QCDR measures, 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 is required to submit at least five additional quality measures. 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 is transmitted directly to CMS via a CMS-approved survey vendor.

2. Scoring policies

Although we are not requiring groups to participate in the CAHPS for MIPS survey, we believe patient experience is important. In the CY 2017 Quality Payment Program 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.

Beginning with the 2021 MIPS payment year, we are proposing to reduce the denominator (that is, the total available measure achievement points) for the quality performance category by 10 points for groups that register for the CAHPS for MIPS survey but do not meet the minimum beneficiary sampling requirements. By reducing the denominator instead of assigning the group a score of zero measure achievement points (because the group would be unable to submit any CAHPS for MIPS survey data), we are effectively removing the impact of the group’s inability to submit the CAHPS for MIPS survey. We believe this reduction in denominator would remove any need for groups to find another measure if they are unable to submit the CAHPS for MIPS survey.

3. Virtual Groups

In the CY 2018 Quality Payment Program final rule, we established 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 would be used for the final score and the associated MIPS payment adjustment and performance feedback using the same methods as for clinician groups.

4. CAHPS for MIPS Survey Administration

The CY 2018 Quality Payment Program final rule provided 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 and that we will further specify start and end timeframes of the survey administration period through our normal communication channels (82 FR 53632).

A. Justification

2. 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 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. The survey contains ten SSMs. Eight of these SSMs will be scored (Getting Timely Care, Appointments, and Information; How Well Providers Communicate; Patient’s Rating of Provider; Health Promotion and Education; Shared Decision Making; Stewardship of Patient Resources; Courteous and Helpful Office Staff; and Care Coordination), while the remaining two (Health Status and Functional Status and Access to Specialists) are included on the survey for informational purposes only. Like other quality measures, each of the eight scored SSMs in the CAHPS for MIPS survey will have an individual benchmark which will be used to establish the number of points. The CAHPS for MIPS survey will be scored based on the average number of points across the eight scored 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 because it requires a significant investment of time and resources. As part of the requirements of this activity, MIPS eligible clinicians must register for the CAHPS for MIPS survey and must select and authorize a CMS-approved survey vendor to collect and report survey data using the survey and specifications provided by us.

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.

2. 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.

2. Duplication of Efforts

The information to be collected will not duplicate similar information currently collected by CMS. 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 multiple surveys.

2. 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. In response to feedback 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 and a significant hardship exception from the Promoting Interoperability performance category for small practices (82 FR 53682 through 53683). In the CY 2019 Quality Payment Program proposed rule, we are proposing a revision to define the low-volume threshold by dollar amount ($90,000), beneficiary count (200), or covered professional services to Part-B enrolled individuals (minimum threshold of 200) as well as to to add a small practice bonus in the quality performance category for MIPS eligible clinicians in small practices if the MIPS eligible clinician submits data to MIPS on at least 1 quality measure. Also, as discussed previously, we are proposing to reduce the denominator (that is, the total available measure achievement points) for the quality performance category by 10 points for groups that register for the CAHPS for MIPS survey but do not meet the minimum beneficiary sampling requirements beginning in the 2021 MIPS payment year.

We believe that these additional flexibilities and reduction in barriers will further reduce the impact on small practices within the Quality Payment Program by reducing participation burden and excluding additional clinicians from mandatory participation.

2. 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.

2. 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.

2. Federal Register/Outside Consultation

The July 27, 2018 (83 FR 35704), proposed rule (CMS-1693-P, RIN 0938-AT31) serves as the 60-day Federal Register notice. The rule was placed on display for public inspection on July 3, 2018. Comments are due no later than 5 p.m. on September 10, 2018.

2. 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.

2. 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.

2. Sensitive Questions

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

2. Burden Estimates (Hours & Wages)

   1. Wage Estimates

To derive average costs, we used data from the U.S. Bureau of Labor Statistics’ May 2017 National Occupational Employment and Wage Estimates for all salary estimates (http://www.bls.gov/oes/current/oes_nat.htm). In this regard, Table 1 presents the mean hourly wage, the cost of fringe benefits and overhead (calculated at 100 percent of salary), and the adjusted hourly wage. The adjusted hourly wage is used to calculate the labor costs associated with our proposed requirements.

As indicated, we are adjusting our employee 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. Therefore, 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 1: National Occupational Employment and Wage Estimates

Occupation Title	Occupational Code	Mean Hourly Wage ($/hr.)	Fringe Benefits and Overhead ($/hr.)	Adjusted Hourly Wage ($/hr.)
All Occupations (for Individuals’ Wages)	Not applicable	$24.34	N/A	$24.34
Computer Systems Analysts	15-1121	$44.59	$44.59	$89.18

Source: Occupational Employment and Wage Estimates May 2017, U.S. Department of Labor, Bureau of Labor Statistics. https://www.bls.gov/oes/.

2. Burden for Group Registration for CAHPS for MIPS Survey

In this CY 2019 Quality Payment Program rule, we are proposing to adjust our currently approved number of respondents based on more recent data and adjust our per respondent time estimate based on our review of the current burden estimates against the existing registration process.

Under MIPS, the CAHPS for MIPS survey counts for 1 measure toward the MIPS quality performance category and, as a patient experience measure, it also fulfills the requirement to submit at least one high priority measure in the absence of an applicable outcome measure. Groups that wish to administer the CAHPS for MIPS survey must register by June of the applicable 12-month performance period, and electronically notify CMS of which vendor they have selected to administer the survey on their behalf. For the 2019 MIPS performance period, we assume that 454 groups will enroll in the MIPS for CAHPS survey based on the number of groups which elected to register during the CY 2017 registration period; a decrease of 7 compared to the number of groups currently approved by OMB under the aforementioned control number (82 FR 53917).

As shown in Table 2, we assume that the staff involved in the group registration for CAHPS for MIPS Survey will mainly be computer systems analysts (or their equivalent) who have an average labor cost of $89.18/hr. We assume the CAHPS for MIPS Survey registration burden consists of 0.25 hours to register for the survey as well as 0.5 hours to select the CAHPS for MIPS Survey vendor that will be used and electronically notify CMS of their selection. In this regard the total time for CAHPS for MIPS registration is 0.75 hours. Although the registration process remains unchanged from the CY 2018 Quality Payment Program final rule, after we reviewed the steps required for registration more thoroughly, we believe that the burden was less than we had originally estimated. In that regard we propose to reduce the estimated burden from 1.5 hours to 0.75 hours per respondent

In aggregate we estimate an annual burden of 340.50 hours (454 groups x 0.75 hr per group) at a cost of $30,366 (340.50 hr x $89.18/hr).

Independent of the change in time per group, the decrease in the number of groups registering results in an adjustment to the total burden of -10.5 hours at -$936 (-7 groups x 1.5 hrs x $89.18/hr). Accounting for the decrease in the number of groups registering, the decrease in time per group to register results in an adjustment to the total burden of -340.5 hours at -$30,366 (454 groups x -0.75 hr x $89.18/hr). When these adjustments are combined, the net adjustment is -351 hours (-10.5 – 340.5) at -$31,302 (-$936 - $30,366).

TABLE 2: Estimated Burden for Group Registration for CAHPS for MIPS Survey

Burden Data Description	Burden Estimate
# of Groups Registering for CAHPS (a)	454
Total Annual Hours for CAHPS Registration (b)	0.75
Total Annual Hours For CAHPS Registration (c) = (a)*(b)	340.5
Labor rate to Register for CAHPS @ computer systems analyst’s labor rate of $89.18/hr.) (d)	$89.18
Total Annual Cost For CAHPS Registration (e) = (a)*(d)	$30,366

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

In this CY 2019 Quality Payment Program rule, we are proposing adjustments to the number of groups electing to report on the CAHPS for MIPS survey as well as the average number of beneficiaries per group based on more recent data.

Under MIPS, groups of 25 or more clinicians can elect to contract with a CMS-approved survey vendor and use the CAHPS for MIPS survey as one of their 6 required quality measures. 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 CAHPS is to assume that respondent time is valued, on average, at civilian wage rates. As explained previsouly, BLS data sets out an average hourly wage for civilians in all occupations to be $24.34/hr. 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 our cost estimate for the beneficiaries’ time.

For the 2019 MIPS performance period, we assume that 241 groups will elect to report on the CAHPS for MIPS survey, which is equal to the number of groups participating in CAHPS for MIPS for the 2017 MIPS performance period and a decrease from the 461 groups currently approved by OMB. Table 3 shows the estimated annual burden for beneficiaries to participate in the CAHPS for MIPS Survey. Based on the number of complete and partially complete surveys for groups participating in CAHPS for MIPS survey administration for the 2017 MIPS performance period, we assume that an average of 273 beneficiaries will respond per group for the 2019 MIPS performance period. Therefore, the CAHPS for MIPS survey will be administered to approximately 65,793 beneficiaries per year (241 groups x an average of 273 beneficiaries per group responding). This is an adjustment to our currently approved 132,307 beneficiary estimate.

The CAHPS for MIPS survey that will be administered in the 2019 MIPS performance period is unchanged from the survey administered in the 2018 MIPS performance period. In that regard we continue to estimate an average administration time of 12.9 minutes (or 0.215 hr) at a pace of 4.5 items per minute for the English version of the survey. For the Spanish version, we estimate an average administration time of 15.5 minutes (assuming 20 percent more words in the Spanish translation). However, since less than 1 percent of surveys were administered in Spanish for reporting year 2016, our burden estimate reflects the time for administering the English version of the survey.

Given that we expect approximately 65,793 respondents, we estimate an annual burden of 14,145 hours (65,793 respondents x 0.215 hr/respondent) at a cost of $344,289 (14,145 hr x $24.34/hr).

The decrease in the number of beneficiaries responding to the CAHPS for MIPS survey results in an adjustment to the total time burden of -14,301 hours and -$348,087 (-66,514 beneficiaries x 0.215 hr x $24.34/hr).

TABLE 3: Estimated Burden for Beneficiary Participation in CAHPS for MIPS Survey

Burden Data Description	Burden Estimate
# of Groups Practices Administering CAHPS for MIPS Survey (a)	241
# of Beneficiaries Per Group Responding to Survey (b)	273
# of Total Beneficiaries Reporting (c)=(a)*(b)	132,307
# of Hours Per Benficiary Respondent (d)	0.215
Cost (@ labor rate of $24.34/hr.) (e)	$24.34
Total Annual Hours (f) = (c)*(d)	14,145
Total Annual Cost for Beneficiaries Responding to CAHPS for MIPS (g)=(c)*(e)	$344,289

2. Capital Costs

Survey participants will not incur capital costs as a result of participation. However, there will be costs for clinicians to hire a vendor to administer the CAHPS for MIPS survey. We do not have systemized information for the cost of CAHPS. Our anecdotal information is that vendor bids with a sample of approximately 860 beneficiaries ranges from $4,000 to $7,000 depending on services requested (e.g., progress reports, other reports); addition of survey administration in other languages may or may not incur additional costs.

2. 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.

2. Program or Burden Changes

Table 4 includes our proposed rule burden estimates for annual recordkeeping associated with the Quality Payment Program. As shown in Tables 4 and 5, the total estimated burden associated with the information collections submitted for approval as a revision of OMB control number 0938-1222 is 14,485.5 hours with a total labor cost of $374,655, reductions of 15,314 hours and $394,855.

TABLE 4: Summary of Proposed Quality Payment Program Burden Estimates and Requirements

Information Collection	Currently Approved Respondents	Proposed Respondents	Change in Respondents	Currently Approved Total Burden Hours	Proposed Total Burden Hours	Change in Total Burden Hours
§414.1325 and 414.1335 (CAHPS for MIPS Survey) Beneficiary Participation	132,307	65,793	66,514	29,108	14,145	-14,963
§414.1325 and 414.1335 (CAHPS for MIPS Survey) Group Registration	461	454	-7	691.5	340.5	-351
Total for OMB 0938-1222 (CMS 10450)	132,768	66,247	66,507	29,800	14,485.5	-15,314

TABLE 5: Summary of Proposed Changes to Quality Payment Program Burden Estimates

Regulation Section(s) Under Title 42 of the CFR	Responses	Burden per Response (hours)	Total Annual Burden (hours)	Labor Cost of Reporting ($/hr)	Total Cost ($)*	Total Cost Adjustments due to Policy Changes ($)*	Total Cost Adjustments due to change in assumptions ($)*
§414.1325 and 414.1335 [(CAHPS for MIPS Survey) Beneficiary Participation]	65,793	0.215	14,145	5.23	344,289	0	-363,553
§414.1325 and 414.1335 [(CAHPS for MIPS Survey) Group Registration]	454	0.75	340.5	66.89	30,366	0	-31,302
Total for OMB 0938-1222 (CMS-10450)	66,247		14,485.5		374,655	0	-394,855

*With respect to the PRA, this rule would not impose any non-labor costs.

Table 6 provides the reasons for changes in the estimated burden for information collections in the CY 2019 Quality Payment Program proposed rule.

TABLE 6: Reasons for Change in Burden Compared to the Currently Approved
CY 2018 Information Collection Burdens

Table in Collection of Information	Changes in burden due to finalized Year 3 policies	Changes to "baseline" of burden continued Year 2 policy (italics are changes in number of respondents’ due to updated data)
Table 2: Beneficiary Responses to CAHPS for MIPS Survey	None	Decrease in the number of respondents as fewer eligible group practices elect to have vendors administer the CAHPS for MIPS survey and fewer beneficiaries per group respond to the survey, on average.
Table 3: Registration for CAHPS for MIPS Survey	None	Decrease in the number of respondents as fewer eligible group practices elect to have vendors administer the CAHPS for MIPS survey and fewer beneficiaries per group respond to the survey, on average.

Table 7 summarizes the annual burden estimates for proposed requirements for all ICRs being submitted for OMB approval under control number 0938-1222 (CMS-10450).

TABLE 7: Annual Requirements and Burden

Regulation Section(s) Under Title 42 of the CFR	Respondents	Responses	Burden per Response (hours)	Total Annual Burden (hours)	Labor Cost of Reporting ($/hr)	Total Cost ($)*
§414.1325 and §414.1335	(66,521)	(66,521)	varies	(15,314)	Varies	(394,855)

* With respect to the PRA, this rule would not impose any non-labor costs.

2. 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 2020 for the 2019 performance period.

2. 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.

2. Certification Statement

There are no exceptions to the certification statement.

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