Cms-10102 Supporting Statement A- 11-28-18

November 2018

National Implementation of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey

CMS 10102

OMB Supporting Statement - Part A

Prepared by

Division of Consumer Assessment & Plan Performance Centers for Medicare & Medicaid Services

7500 Security Boulevard

Baltimore, MD 21244

TABLE OF CONTENTS

Section Page

A. Background…………………………………………………………………… 4

B. Justification…………………………………………………………………… 5

1. Need and Legal Basis…………………………………………….……… 5

2. Information Users………………………………………………………... 6

3. Use of Information Technology………………………………………….. 7

4. Duplication of Effort……………………………………………………… 8

5. Small Businesses…………………………………………………………. 8

6. Less Frequent Collection…………………………………………………. 8

7. Special Circumstances……………………………………………………. 9

8. Federal Register/Outside Consultation……………………………………. 9

9. Payments/Gifts to Respondents…………………………………………… 9

10. Confidentiality…………………………………………………………….. 9

11. Sensitive Questions……………………………………………………….. 10

12. Burden Estimates (Hours & Wages)……………………………………... 10

13. Capital Costs……………………………………………………………… 11

14. Cost to the Federal Government………………………………………….. 11

15. Changes to Burden ………………………………………….. 11

16. Publication/Tabulation Dates 12

17. Expiration Date 12

18. Certification Statement 12

EXHIBITS

Exhibit A-1: Annual Hours/Cost Burden of the HCAHPS Survey….…………… 10

LIST OF ATTACHMENTS

Attachment A -- HCAHPS Survey Instrument (Mail) and Supporting Material

Attachment B -- HCAHPS Survey Instrument (Telephone) and Supporting Material

Attachment C -- HCAHPS Survey Instrument (Interactive Voice Response) and Supporting Material

Attachment D -- Sixty Day Federal Register Notice – HCAHPS

OMB SUPPORTING STATEMENT – Part A:

National Implementation of the Hospital CAHPS Survey

CMS-10102

1. Background

The HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) Survey is the first national, standardized, publicly reported survey of patients’ perspectives of their hospital care. HCAHPS is a 29-item survey instrument and data collection methodology for measuring patients’ perceptions of their hospital experience. Since 2008, HCAHPS has allowed valid comparisons to be made across hospitals locally, regionally and nationally.

Three broad goals have shaped HCAHPS. First, the standardized survey and implementation protocol produce data that allow objective and meaningful comparisons of hospitals on topics that are important to consumers. Second, public reporting of HCAHPS results creates new incentives for hospitals to improve quality of care. Third, public reporting enhances accountability in health care by increasing transparency of the quality of hospital care provided in return for the public investment.

The HCAHPS Survey asks recently discharged patients about aspects of their hospital experience that they are uniquely suited to address. The core of the survey contains 19 items that ask “how often” or whether patients experienced a critical aspect of hospital care, rather than whether they were “satisfied” with their care. Also included in the survey are three screener items that direct patients to relevant questions, five items to adjust for the mix of patients across hospitals, and two items that support Congressionally-mandated reports. (See Attachment A: HCAHPS Survey Instrument (Mail) and Supporting Materials.)

Since March of 2008, results from the HCAHPS survey have been publicly reported on the Hospital Compare website which can be found at www.hospitalcompare.hhs.gov or through a link on www.medicare.gov. The HCAHPS Survey and its implementation protocols can be found in the current version of the HCAHPS Quality Assurance Guidelines (Version 13.0, March 2018), located at: www.hcahpsonline.org/en/quality-assurance/.

In the FY 2018 IPPS/LTCH PPS final rule (82 FR 38328 through 38342), out of an abundance of caution, in the face of a nationwide epidemic of opioid over prescription, we finalized a refinement to the HCAHPS Survey measure as used in the Hospital Inpatient Quality Reporting Program by removing the previously adopted Pain Management questions and incorporating new Communication About Pain questions beginning with patients discharged in January 2018. As discussed in the CY 2019 OPPS/ASC proposed rule (83 FR 37218), since finalization of the Communication About Pain questions, we have received feedback that some stakeholders are concerned that, although the revised questions focus on communications with patients about their pain and treatment of that pain, rather than how well their pain was controlled, the questions still could potentially impose pressure on hospital staff to prescribe more opioids in order to achieve higher scores on the HCAHPS Survey. In response to stakeholder feedback, recommendations from the President’s Commission on Combatting Drug Addiction and the Opioid Crisis, to comply with the requirements of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act (P.L. 115-271), and to avoid any potential unintended consequences under the Hospital Inpatient Quality Reporting (IQR) Program, CMS is revising the HCAHPS survey by removing the three recently revised pain communication questions. The removal of these questions is effective with October 2019 discharges. At that point, the HCAHPS Survey will consist of 29 questions.

2. Justification

   1. Need and Legal Basis

Beginning in 2002, CMS partnered with the Agency for Healthcare Research and Quality (AHRQ), another agency in the federal Department of Health and Human Services, to develop and test the HCAHPS Survey. AHRQ and its CAHPS Consortium carried out a rigorous and multi-faceted scientific process, including a public call for measures; literature review; cognitive interviews; consumer focus groups; stakeholder input; a three-state pilot test; extensive psychometric analyses; consumer testing; and numerous small-scale field tests. CMS provided three separate opportunities for the public to comment on HCAHPS and responded to over a thousand comments. The survey, its methodology and the results it produces are in the public domain.

In May 2005, the HCAHPS Survey was endorsed by the National Quality Forum, a national organization that represents the consensus of many healthcare providers, consumer groups, professional associations, purchasers, federal agencies, and research organizations. In December 2005, the federal Office of Management and Budget gave its final approval for the national implementation of HCAHPS for public reporting purposes. CMS implemented the HCAHPS Survey in October 2006 and the first public reporting of HCAHPS results occurred in March 2008.

Enactment of the Deficit Reduction Act of 2005 created an additional incentive for acute care hospitals to participate in HCAHPS. Since July 2007, hospitals subject to the Inpatient Prospective Payment System (IPPS) annual payment update provisions ("subsection (d) hospitals") must collect and submit HCAHPS data in order to receive their full annual payment update.

The incentive for IPPS hospitals to improve patient experience was further strengthened by the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), which specifically included HCAHPS performance in the calculation of the value-based incentive payment in the Hospital Value-Based Purchasing program beginning with October 2012 discharges.

2. Information Users

As noted above, there are three broad goals of the HCAHPS Survey. These goals are of value to consumers and providers of health care services as well as to CMS. First, the standardized survey and implementation protocol produce data that allow objective and meaningful comparisons of hospitals on topics that are important to consumers. Second, public reporting of HCAHPS results creates new incentives for hospitals to improve quality of care. Third, public reporting enhances accountability in health care by increasing transparency of the quality of hospital care provided in return for the public investment. HCAHPS scores have been publicly reported on the Hospital Compare Web site since 2008 and since 2012 have been used in the payment determination for Inpatient Prospective Payment System (IPPS) hospitals that participate in the Hospital Value-Based Purchasing (Hospital VBP) program.

3. Use of Information Technology

The national implementation of HCAHPS is designed to allow third-party CMS-approved survey vendors to administer HCAHPS using mail-only, telephone-only, mixed-mode (mail with telephone follow-up), or active IVR (interactive voice response).

With respect to a telephone-only or mixed-mode survey, the CMS-approved survey vendors use electronic data collection or CATI systems. CATI is also used for telephone follow-up with mail survey non-respondents. With respect to IVR survey administration, the IVR technology gathers information from respondents by prompting respondents to answer questions by pushing the numbers on a touch-tone telephone. Patients selected for IVR mode are able to opt out of the interactive voice response system and return to a “live” interviewer if they wish to do so. There are numerous advantages to administering a telephone interview using a CATI system or IVR technology, including the following:

• costs less than in-person data collection;

• allows for a shorter data collection period;

• allows for less item nonresponse because the system controls the flow of the interview;

• increases data quality by allowing consistency and data range checks on respondent answers;

• creates a centralization of process/quality control; and

• reduces post-interview processing time and costs.

CMS has tested new modes for the HCAPHS Survey, specifically a Speech Enabled-Interactive Voice Response mode and a Web-based mode, but concluded that issues stemming from differences in response rate and mode effects across implementations make such models unsuitable for the HCAHPS Survey at this time. Results of the investigation for using these modes of survey implementation are presented in Elliott, Brown, et al. (2013), “A Randomized Experiment Investigating the Suitability of Speech-Enabled IVR and Web Modes for Publicly Reported Surveys of Patients’ Experience of Hospital Care”, Medical Care Research and Review, 70 (2): 165-184.

The HCAHPS Survey does not require a signature from respondents. In fact, all information obtained through the survey is reported in the aggregate and no individual respondent’s information is ever reported independently or with any identifying information.

4. Duplication of Efforts

HCAPHS collects information that is fundamentally different from other CAHPS or patient experience of care surveys. CMS is not aware of any existing validated survey instrument where the unit of analysis is the acute care hospital and the focus of the survey is patient-reported experience of care. The information collected through this survey will therefore not duplicate any other effort and is not obtainable from any other source.

Many hospitals carry out their own patient experience of care surveys. These diverse, proprietary surveys do not allow for comparisons across hospitals. Making comparative performance information available to the public assists consumers in making informed choices when selecting an acute care hospital and creates incentives for facilities to improve the care they provide.

5. Small Businesses

Hospitals are not generally considered to be small businesses. All hospitals have the option to conduct HCAHPS as a stand-alone survey or to integrate it with their existing survey activities. They can choose to administer HCAHPS by mail, phone, mail with telephone follow-up, or active IVR. Costs associated with collecting HCAHPS will vary depending on:

• The method hospitals currently use to collect patient survey data,

• The number of patients surveyed (target is 300 completed surveys per year), and

• Whether it is possible to incorporate HCAHPS into their existing survey.

Some smaller hospitals that participate in HCAHPS might be unable to reach the target of 300 completed surveys in a 12-month period. In such cases, the hospital should sample all discharges (census) and attempt to obtain as many completes as possible. HCAHPS scores based on fewer than 100 or 50 completed surveys are publicly reported but the lower reliability of these scores is noted by an appropriate footnote.

6. Less Frequent Collection

Great effort was expended considering how often HCAHPS data should be collected. We solicited and received much comment on this issue. Two options for the frequency of data collection were suggested: once during the year or continuous sampling. The majority of hospitals/vendors suggested continuous sampling would be easier to integrate into their current data collection processes. Thus we decided to require sampling of discharges on a continuous basis (i.e., a monthly basis) and cumulate these samples to create rolling estimates based on 12- months of data. We chose to pursue the continuous sampling approach for the following reasons:

• It is more easily integrated with many existing survey processes used for internal improvement,

• Improvements in hospital care can be more quickly reflected in hospital scores (e.g., 12- month estimates could be updated on a quarterly or semi-annual basis),

• Hospital scores are less susceptible to unique events that could affect hospital performance at a specific point in time,

• It is less susceptible to gaming (e.g., hospitals being on their best behavior at the time of an annual survey), and

• There is less variation in time between discharge and data collection.

7. Special Circumstances

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

7. Federal Register/Outside Consultation

The 60 day Federal Register notice was published on December 11, 2018 (83 FR 63648). There were comments received in reference to the timing of the removal of the 3 items from the HCAHPS survey and in reference to making some changes to the survey. The comments have been addressed in the “Response to Comments” document.

The 30-day Federal Register notice published on March 15, 2019 (84 FR 9527).

7. Payments/Gifts to Respondents

There are no provisions for payments or gifts to survey respondents.

7. Confidentiality

All information obtained through the HCAHPS Survey is reported in the aggregate. No individual respondent’s information is reported independently or with identifying information. We have designed the data files so that the hospital/vendor submits a de-identified dataset to CMS through a QIO according to 45 CFR Section § 164.514. No protected health information is submitted to CMS. In all the modes of survey administration, guidelines are included on issues related to confidentiality:

• Cover letters are not to be attached to the survey

• Respondents’ names are not to appear on the survey

• Interviewers are not to leave messages on answering machines or with household members since this could violate a respondent’s privacy

Please see HCAHPS Quality Assurance Guidelines, V13.0, pp. 53-54, for detailed information on patient confidentiality, www.hcahpsonline.org/en/quality-assurance/.

11. Sensitive Questions

There are no questions of a sensitive nature on the HCAHPS Survey.

12. Burden Estimates (Hours & Wages)

To calculate the cost for survey respondents, we use the Average Hourly Earnings of $26.71 as reported by the U.S. Bureau of Labor Statistics, final January 2018 estimates at https://www.bls.gov/eag/eag.us.htm (last modified April 20, 2018). The HCAHPS survey averages approximately 3,104,200 participating survey respondents (completed surveys) a year, as evidenced throughout the 2012 through 2016 reporting periods. On average, it takes respondents 7.25 minutes (0.120833 hours) to complete the survey, for a total 375,090 hours annual burden (3,104,200 respondents by 0.120833 hours). The annual cost burden of the HCAHPS Survey for survey respondents is thus $10,018,653 (375,090 total respondent hours X $26.71 average hourly earnings).

EXHIBIT 1: Annual Hours/Cost Burden of the HCAHPS Survey

HCAHPS Survey	Number of Respondents	Total Burden Hours	Average Hourly Earnings*	Estimated Data Collection Cost to Respondents
Total	3,104,200	375,090	$26.71	$10,018,653

*Average Hourly Earnings of $26.71, based on average hourly earnings of all employees on private nonfarm payrolls, seasonally adjusted, final January 2018 estimates, U.S. Bureau of Labor Statistics.

Over the next three years, we anticipate that about 4,200 hospitals will participate in HCAHPS. Since 2015 the number of hospitals participating in HCAHPS has been fairly stable at approximately 4,200 hospitals for each four quarter period. To derive average costs for hospitals, we estimate an amount of $4,000 per hospital for HCAHPS data collection activities, the annual cost burden totaling $16,800,000. Assuming a one hour per hospital time cost, the annual burden for hospitals is 4,200 hours.

In total, the annual cost burden of the survey is (survey respondents $10,018,653) + (hospitals

$16,800,000) = $26,818,653. The annual hour burden is (survey respondents 375,090) +

(hospitals 4,200 hours) = 379,290 hours.

13. Capital Costs

Hospitals have the option to conduct HCAHPS as a stand-alone survey or to integrate it with an existing survey. Hospitals can choose to administer HCAHPS by mail, phone, mail with telephone follow-up, or active IVR. Costs associated with collecting HCAHPS will vary depending on:

• The method hospitals currently use to collect patient survey data,

• The number of patients surveyed (target is 300 completed surveys per year), and

• Whether it is possible to incorporate HCAHPS into their existing survey.

Over the next three years, we anticipate that about 4,200 hospitals will participate in HCAHPS. Using the estimate of $4,000 per hospital for HCAHPS data collection, the annual cost burden is $16,800,000.

14. Cost to the Federal Government

Costs to the government include: hospital/vendor training and technical assistance; approving hospitals/vendors for conducting surveys; ensuring the integrity of the data; accumulating the data; analyzing the data; making adjustments for patient-mix and mode of administration; and public reporting. The annual cost to the Federal Government is estimated to be $3,325,000.

15. Changes to Burden

Responding to concerns raised by some stakeholders that the HCAHPS pain items create pressure on physicians to overprescribe opioids in hopes of achieving better survey results, CMS announced plans in the FY 2018 IPPS Final Rule to replace the original Pain Management questions (items 12, 13 and 14 on the HCAHPS Survey) with three new questions that focus on communication about pain. The new pain items were required on all surveys administered to patients discharged from January 1, 2018 and forward.

In order bring the HCAHPS Survey into alignment with the SUPPORT Act, Section 6104 (https://www.alexander.senate.gov/public/_cache/files/64a0f95e-e4b6-406e-9340-6a2755e8e34a/930-am-edits-09.26.18-final-opioid-sec-by-sec-bipart-bicam.pdf , the CY 2019 OPPS Final Rule (https://www.federalregister.gov/documents/2018/11/21/2018-24243/medicare-program-changes-to-hospital-outpatient-prospective-payment-and-ambulatory-surgical-center), CMS will remove the three Communication About Pain items (items 12, 13 and 14) from the HCAHPS Survey effective with October 2019 discharges.

Removal of these three items from the HCAHPS Survey reduces burden to patients, as shown above in section 12, but has no effect on hospitals, as shown in section 13. The burden hours have decreased from 417,990 to 379,290.

Since 2015, the number of hospitals participating in HCAHPS has been fairly stable at approximately 4,200 hospitals. We estimate that the number of hospitals will remain fairly stable over the next three years.

16. Publication/Tabulation Dates

Since October 2006, the HCAHPS Survey has been administered on a continuous basis, and since March 2008, HCAHPS results have been publicly reported on the Hospital Compare website four times per year. This pattern will continue into the foreseeable future.

17. Expiration Date

CMS will display the OMB number and expiration date.

18. Certification Statement

The proposed data collection does not involve any exceptions to the certification statement.

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