Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey
for the Merit-Based Incentive Payment System (MIPS)
CMS 10450, OMB Control Number 0938-1222
CMS is submitting updates to two information collection requests associated with the CAHPS for MIPS survey. 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 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 2018 information collection request addresses the requirements 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.
We are also requesting approval for one additional information collection request associated with the CY 2019 Physician Fee Schedule (PFS) final rule. The final rule information collection request (other than virtual group election and CAHPS-related data collection) will be submitted to OMB as a MIPS revision under control number t0938-1314 (CMS-10621). OMB has approved the information collection associated with the virtual group election process under control number 0938-1343 (CMS-10652).
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 CAHPS for MIPS survey would also count as a high-weighted activity under the improvement activities performance category. The data collected on the CAHPS for MIPS survey measures is transmitted directly to CMS via a CMS-approved survey vendor.
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.
In the CY 2019 PFS final rule, we have finalized that beginning with the 2021 MIPS payment year, we will reduce the total available measure achievement points for the quality performance category by 10 points for groups that submit 5 or less measures and 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.
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.
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).
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.
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.
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.
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.
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 finalized in the CY 2018 Quality Payment Program final rule 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 PFS final rule, we have finalized to modify the definition of low-volume threshold to mean for the 2020 MIPS payment year, we will utilize the minimum number (200 patients) of Part B-enrolled individuals who are furnished covered professional services by the eligible clinician or group during the low-volume threshold determination period or the minimum amount ($90,000) of allowed charges for covered professional services to Part B-enrolled individuals by the eligible clinician or group during the low-volume threshold determination period. In addition, we have also finalized moving the small practice bonus to the quality performance category and increasing it to 6 bonus points 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 have finalized to reduce the denominator (that is, the total available measure achievement points) for the quality performance category by 10 points for groups that submit 5 or less measures and 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.
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.
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.
Serving as the 60-day notice, the CY 2019 PFS proposed rule (RIN 0938-AT31, CMS-1693-P) published in the Federal Register on July 27, 2018 (83 FR 35704).
The CY 2019 PFS final rule published on November 23, 2018 (83 FR 59452).
In the proposed rule, we estimated a total burden of 14,485.5 hours at a cost of $374,655. In the final rule, we revised our estimate to 8,604.5 hours at a cost $223,148. The change (-5,881 hours and -$151,507) is due to updated data becoming available from the 2018 MIPS performance period related to the number of groups registering for the CAHPS for MIPS survey and the number of groups with sufficient beneficiary sample size to conduct the CAHPS for MIPS survey.
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.
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.
There are no sensitive questions associated with this survey. Specifically, the collection does not solicit questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private.
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 final 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 |
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 282 groups will enroll in the MIPS for CAHPS survey based on the number of groups which elected to register during the CY 2018 registration period.
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 adjusted 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 notifying CMS of this selection. In this regard, the total time for CAHPS for MIPS registration is 0.75 hours.
In aggregate, we estimate an annual burden of 211.50 hours (282 groups x 0.75 hr per group) at a cost of $18,862 (211.50 hr x $89.18/hr).
Table 2: Estimated Burden for Group Registration for CAHPS for MIPS Survey
Burden Data Description |
Burden Estimate |
# of Groups Registering for CAHPS (a) |
282 |
Total Annual Hours for CAHPS Registration (b) |
0.75 |
Total Annual Hours For CAHPS Registration (c) = (a)*(b) |
211.5 |
Labor rate to Register for CAHPS @ computer systems analyst’s labor rate of $89.18/hr.) (d) |
$89.18/hr |
Total Annual Cost For CAHPS Registration (e) = (a)*(d) |
$18,862 |
Survey Vendor Application
Vendors must 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.
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 Attestation Statement, Vendor Participation Form, and compiling documentation, including the quality assurance plan, that demonstrates that they comply with Minimum Survey Vendor Business Requirements.1 This is comparable to the burden of the QCDR and qualified registry self-nomination process. 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 $89.18/hr. Therefore, the annual burden hours is 150 (15 CAHPS vendors x 10 hr) at a cost of $13,377 (150 hr x $89.18/hr) (see Table 3).
Burden Data Description |
Burden Estimate |
Estimated # of 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) |
$891.80 |
Estimated Total Annual Burden Hours (d) = (a)*(b) |
150 |
Estimated Total Annual Burden Cost for CAHPS Vendor Application Process (e) = (c)*(d) |
$13,377 |
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 in the CY 2019 PFS final rule, the BLS sets out an average hourly wage for civilians in all occupations at $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 143 groups will elect to report on the CAHPS for MIPS survey, which is equal to the number of groups that have registered and have a sufficient beneficiary sample size to conduct the CAHPS for MIPS survey in the 2018 MIPS performance period. Table 4 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 2018 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 39,039 beneficiaries per year (143 groups x an average of 273 beneficiaries per group responding).
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 39,039 respondents, we estimate an annual burden of 8,393 hours (39,039 respondents x 0.215 hr/respondent) at a cost of $204,286 (8,393 hr x $24.34/hr).
Table 4: Estimated Burden for Beneficiary Participation in CAHPS for MIPS Survey
Burden Data Description |
Burden Estimate |
# of Groups Practices Administering CAHPS for MIPS Survey (a) |
143 |
# of Beneficiaries Per Group Responding to Survey (b) |
273 |
# of Total Beneficiaries Reporting (c)=(a)*(b) |
39,039 |
# of Hours Per Beneficiary Respondent (d) |
0.215 |
Cost (@ labor rate of $24.34/hr.) (e) |
$24.34/hr |
Total Annual Hours (f) = (c)*(d) |
8,393 |
Total Annual Cost for Beneficiaries Responding to CAHPS for MIPS (g)=(c)*(e) |
$204,286 |
Burden Summary
Survey Respondents |
Respondents |
Total Responses (per year) |
Time per Response (hr) |
Total Time (hr) |
Labor Rate ($/hr) |
Total Cost ($) |
Group Registration |
282 |
282 |
0.75 |
212 |
89.18 |
18,862 |
Survey Vendor Application |
15 |
15 |
10 |
150 |
89.18 |
13,377 |
Beneficiary Participation |
39,039 |
39,039 |
0.215 |
8,393 |
24.34 |
204,286 |
TOTAL |
39,336
|
39,336
|
varies |
8,755 |
varies |
236,525 |
Information Collection Instruments/Instructions
Appendix B: Mail Survey (No Changes)
Appendix C: Initial Cover Letter (English) (No Changes)
Appendix D: Second Cover Letter (English) (No Changes)
Appendix E: Script (No Changes)
Appendix F: Vendor Application (No Changes)
Appendix H: Attestation Statement (No Changes)
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.
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.
We have adjusted our currently approved number of respondents based on more recent data and adjusted our per respondent time estimate based on our review of the current burden estimates against the existing registration process.
For the 2019 MIPS performance period, we assume that 282 groups will enroll in the MIPS for CAHPS survey based on the number of groups which elected to register during the CY 2018 registration period; a decrease of 179 compared to the number of groups currently approved by OMB under the aforementioned control number (82 FR 53917).
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. Therefore, we have adjusted the estimated burden from 1.5 hours to 0.75 hours per respondent.
Independent of the change in time per group, the decrease in the number of groups registering results is an adjustment to the total burden of -268.5 hours at -$23,945 (-179 groups x 1.5 hr 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 -211.5 hours at -$18,862 (282 groups x -0.75 hr x $89.18/hr). When these adjustments are combined, the net adjustment is -480 hours (-268.5 – 211.5) at -$42,807 (-$23,945 - $18,862).
Survey Vendor Application
No change.
We have adjusted 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.
For the 2019 MIPS performance period, we assume that 143 groups will elect to report on the CAHPS for MIPS survey, which is equal to the number of groups that have registered and have a sufficient beneficiary sample size to conduct the CAHPS for MIPS survey in the 2018 MIPS performance period; a decrease of 318 from the 461 groups currently approved by OMB.
Based on the number of complete and partially complete surveys for groups participating in CAHPS for MIPS survey administration for the 2018 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 39,039 beneficiaries per year (143 groups x an average of 273 beneficiaries per group responding). This is a decrease of 93,268 from our currently approved 132,307 beneficiary estimate.
The decrease in the number of beneficiaries responding to the CAHPS for MIPS survey results in an adjustment to the total time burden of -20,715 hours and -$503,556 (-93,268 beneficiaries x 0.215 hr x $24.34/hr).
Summary of Changes
Information Collection |
Currently Approved Respondents |
Finalized Respondents |
Change in Respondents |
Currently Approved Hours |
Finalized Hours |
Change in Hours |
§414.1325 and 414.1335 (CAHPS for MIPS Survey) Group Registration |
461 |
282 |
-179 |
692 |
212 |
-480 |
§414.1325 and 414.1335 (CAHPS for MIPS Survey) Beneficiary Participation |
132,307 |
39,039 |
-93,268 |
29,108 |
8,393 |
-20,715 |
Total |
n/a |
n/a |
-93,447 |
n/a |
n/a |
-21,195 |
We plan to publicly report MIPS information through the Physician Compare website either on public profile pages or via the Downloadable Database housed on data.medicare.gov for the purpose of promoting more informed health care choices by for people with Medicare. The public reporting is anticipated to start in late 2020 for the 2019 MIPS performance period. We plan public reporting of some measures in a MIPS eligible clinician's MIPS data; in that for each performance period, we will post on a public website (for example, Physician Compare), in an easily understandable format, information regarding the performance of MIPS eligible clinicians or groups under the MIPS. The Physician Compare performance year 2016 measures will be available for preview at the Physician Compare website https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/physician-compare-initiative/
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.
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.
There are no exceptions to the certification statement.
1 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.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | CAHPS for MIPS Supporting Statement - Part A |
| Author | CMS |
| File Modified | 0000-00-00 |
| File Created | 2021-01-16 |