HHCAHPS Supporting Statement A

Supporting Statement Part A

The Home Health Care CAHPS® Survey (HHCAHPS)

(CMS-10275, OMB 0938-1066)

Background

In 2001, the DHHS Quality Initiative was implemented to ensure the quality of health care for all Americans through accountability and public disclosure. The goals of the initiative are to empower consumers with quality-of-care information so they can make more informed decisions about their health care and to stimulate and support providers and clinicians to improve the quality of health care. The Quality Initiative implemented in November 2002 for nursing homes, and then implemented for home health agencies (the Home Health Quality Initiative) in 2003. From 2003 to mid-2010, home health agencies were required to report clinical quality data to CMS, and beginning in mid-2010, home health agencies were required to report HHCAHPS Survey data. Before the HHCAHPS Survey, there was no national standardized survey of the patients’ experiences in home health care.

CMS implements a survey that measures and publicly reports patients' experiences with home health care they receive from Medicare-certified home health agencies through the data collection effort described in this request: the Consumer Assessment of

Healthcare Providers and Systems Home Health Care Survey (HHCAHPS). The HHCAHPS Survey was developed and tested by the Agency for Healthcare Research and Quality (AHRQ) and is part of the family of CAHPS® surveys. It is a standardized survey for home health patients to assess their home health care providers and the quality of the home health care they receive. HHCAHPS is the only national survey about home health care patients' experiences with their care in Medicare-certified home health agencies. The Centers for Medicare & Medicaid Services (CMS) requests a three-year clearance from the Office of Management and Budget (OMB) under the

Paperwork Reduction Act of 1995 to continue implementation of the HHCAHPS Survey. Implementation is ongoing and there have been no changes to the questionnaire or survey administration procedures since it was approved by OMB in 2017.

A. Justification

1. Circumstances Making the Collection of Information Necessary

The survey is necessary because it fulfills the goal of transparency with the public about home health patient experiences. The survey is used by Medicare-certified home health agencies to improve their internal quality assurance in the care that they provide in home health. The HHCAHPS survey is also used in a Medicare payment program. Medicare-certified home health agencies (HHAs) must contract with CMS-approved survey vendors that conduct the HHCAHPS on behalf of the HHAs to meet their requirements in the Home Health Quality Reporting Program.

2. Purpose and Use of Information

The national implementation of the Home Health Care CAHPS Survey is designed to collect ongoing data from samples of home health care patients who receive skilled services from Medicare-certified home health agencies. The data collected from the national implementation of the Home Health Care CAHPS Survey is used for the following purposes:

• To produce comparable data on the patients’ perspectives of the care they receive from home health agencies (HHCAHPS is the only patient survey that has national data that is reliable and valid for comparisons.) The patient survey results have been publicly reported since April 2012 and they are updated quarterly, and Star Ratings were added in January 2016);

• To create incentives for agencies to improve the quality of care they provide through public reporting of survey results (home health agencies can view their data in comparison to others in their zip code, state, and the nation);

• To enhance public accountability in health care by increasing the transparency of the quality of care provided in return for the public investment (people use Home Health Compare on www.medicare.gov to view, access, and/or download HHCAHPS data for comparing home health agencies);

• HHCAHPS is used in the Home Health Quality Payment Program (HH QRP) and nonparticipation results in a 2% reduction in the annual payment update (APU) (used in the HH QRP for the CY 2012 APU and forward through the CY 2020 APU and continuing); and

• AHRQ uses the data in their annual report on Racial and Ethnic Disparities and in their annual reports about the demographic characteristics of the patient respondents to the HHCAHPS Survey.

3. Technological Collection Techniques

The HHCAHPS Survey is approved for data collection using mail, telephone, or mail with telephone follow-up (also called mixed mode). The average age of the patient respondents over time is 79 years old. In HHCAHPS, about 89% of the home health agencies choose to use mail only mode with their respective survey vendors. Mail only mode is the most affordable survey mode.

3. Efforts to Identify Duplication

This information collection does not duplicate other efforts. The HHCAHPS Survey includes 25 core survey questions about the home health experience. The survey questionnaire is unchanged from prior OMB submissions. The survey is designed to gather only the data that CMS needs for assessing experiences with home health care. Some home health agencies may choose to conduct their own patient experience of care surveys, but those surveys do not allow for comparisons across home health care agencies. The HHCAHPS Survey provides the only comparative performance information for the public and helps consumers make more informed choices when selecting a home health care agency. It also creates incentives for home health care agencies to improve the care they provide.

We allow agencies to add their own questions to the HHCAHPS survey but they must follow the

HHCAHPS questions; and we caution against adding questions that are similar in content to the HHCAHPS questionnaire. We also caution home health agencies and their approved HHCAHPS survey vendors that additional questions may adversely affect the HHCAHPS Survey response rates.

3. Impact on Small Businesses

Survey respondents are patients who receive or who received home health care in Medicare certified home health care agencies. The HHCAHPS Survey does not impact small businesses or other small entities.

3. Consequences if Information is Collected Less Frequently

The primary reason for continuous data collection is to get feedback soon after receiving home health care, or while receiving home health care. Continuous data collection gives everyone the ability to address issues of concern as quickly as possible. We cannot do this if the survey is administered once or twice a year. The data reflect the patient perspective over the whole year rather than introducing potential bias by only collecting data in one period of time.

CMS must additionally have continuous monthly collection of the survey data so that home health agencies can fulfill their requirements for the annual payment update. The reporting requirements for the Home Health Quality Reporting Program were set up to count the months of survey participation. If agencies do not participate fully in HHCAHPS, they receive a 2% reduction in their annual payment update. When CMS publicly reports data it is for a 12-month period of time, but we note if less than 12 months of data are publicly reported. CMS needs to continually provide recent data on Home Health Compare on www.medicare.gov so that CMS can be transparent and provide data on home health care. We reduce survey burden to chronically ill home health patients because the HHCAHPS Survey can only be sent to the same home health patient once every six months. The HHCAHPS Survey was modeled after another continuous CAHPS Survey; HCAHPS or the Hospital CAHPS Survey, CMS 10102, OMB 0938-098.

3. Special Circumstances

There are no special circumstances with the HHCAHPS Survey 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 Notice/Outside Consultations

Federal Register

The 60-day notice was published in the Federal Register on 3/6/2020 (85 FR 13162).

No comments were received.

The 30-day notice was published in the Federal Register on 5/14/2020 (85 FR 28948).

Outside Consultations

NQF has reviewed and re-endorsed HHCAHPS several times since the first endorsement on

March 31, 2009. NQF re-endorsed the HHCAHPS Survey measures in September 2019. The NQF number for the HHCAHPS measures is 0517. CMS annually calls for public comments on the HHCAHPS Survey in the annually-issued HH PPS Rule. In the past five years, we did not receive any comments about the HHCAHPS Survey. There was only one exception that related to a larger policy issue. In the CY 2020 HH PPS proposed rule, CMS proposed to remove all quality measures that concerned pain. One of the many measures was a question on the HHCAHPS Survey about the discussion of pain. CMS received hundreds of comments and in response, CMS reversed its proposal and finalized retaining all pain quality measures in the CY 2020 HH PPS final rule AHRQ was responsible for the development and testing of the Home Health Care CAHPS Survey. As the lead agency, AHRQ worked with three grantee organizations to develop and test the survey instrument: the American Institutes for Research, the Yale/Harvard team, and RAND. An additional contractor, Westat, also participated in a supporting role. During the survey instrument development phase, AHRQ also consulted with a range of outside organizations and individuals representing state and federal government agencies and non-profit and private sector organizations. AHRQ convened technical expert panels on February 8, 2007, and July 15, 2008. Panel members for the instrument development included representatives from the following organizations:

• AARP (American Association of Retired Persons)  Abt Associates Inc.

• American Academy of Home Health Care Physicians

• American Association for Homecare

• American Association of Homes and Services for the Aging

• American Hospital Association

• American Occupational Therapy Association

• American Physical Therapy Association

• American Speech-Language-Hearing Association

• Maryland Health Care Commission

• National Association for Home Care & Hospice

• National Center for Health Statistics, Centers for Disease Control and Prevention (CDC)

• National Quality Forum

• Paraprofessional Healthcare Institute

• Professional Healthcare Resources, Inc.

• Quality Insights of Pennsylvania

• Quality Partners of Rhode Island

• Veterans Health Administration

• Visiting Nurse Associations of America (VNAA)

CMS has worked with RTI International, for the national implementation of the HHCAHPS Survey since 2008. RTI, with CMS, is responsible for developing the protocols and survey guidelines required to ensure the standardized administration of the Home Health Care CAHPS Survey, the review of survey vendor applicants, working with CMS to train multiple independent survey vendors, providing oversight of the approved vendors, and receiving and processing Home Health Care CAHPS Survey data collected and submitted by the approved HHCAHPS survey vendors. RTI was responsible for analyzing data from the mode experiment to determine the mode adjustment and the patient-mix adjustment model. During the national implementation, RTI adjusts the data for patient mix and nonresponse and provides comparative results for public reporting.

In addition, RTI convened a technical expert panel composed of representatives from the home health industry, consumer advocacy organizations, the government, and research organizations. Members of the committee provided guidance to RTI on the development of the design for the mode experiment and the plans for the national implementation. RTI, CMS, and members of the technical expert panel met on February 21, April 15, and June 19, 2008.

The technical expert panel members who provided input and guidance to RTI for the national implementation represented the following organizations:

• AARP (American Association of Retired Persons)  American Association of Homes and Services for the Aged  Center for Medicare Advocacy, Inc.

• Consumer Coalition for Quality Health Care

• Health Services Advisory Group

• Independent Consultant, formerly of AHRQ

• National Association for Home Health Care and Hospice

• RAND

• Service Employees International Union

• Visiting Nurse Service of New York

9. Payments/Gifts to Respondents

This data collection does not include incentive payments or gifts to HHCAHPS survey respondents.

9. Assurance of Confidentiality

Individuals who are contacted as part of this data collection are 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.

9. Questions of a Sensitive Nature

There are no sensitive questions associated with this collection. 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.

9. Estimates of Annualized Burden Hours and Costs

Wage Estimates

Individuals. To derive the average costs for individuals, we used data from the U.S. Bureau of

Labor Statistics’ May 2018 National Occupational Employment and Wage Estimates for our salary estimate (www.bls.gov/oes/current/oes_nat.htm). We believe that the burden will be addressed under All Occupations (occupation code 00-0000) at $24.98/hr since the group of individual respondents varies widely from working and nonworking individuals and by respondent age, location, years of employment, and educational attainment, etc.

Unlike our private sector adjustment to the respondent hourly wage (see below), we are not adjusting this figure for fringe benefits and overhead since the individuals’ activities would occur outside the scope of their employment.

Private Sector. To derive the average costs for HHAs, we used data from the U.S. Bureau of Labor Statistics’ May 2018 National Occupational Employment and Wage Estimates for all salary estimates (www.bls.gov/oes/current/oes_nat.htm). We believe that the burden will be addressed by a Medical Records Reviewer (occupation code 29-2071) at $21.16/hr. As indicated below we are adjusting our employee hourly wage estimate by a factor of 100 percent to $42.32/hr.

The 100 percent adjustments are rough estimates, 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.

Burden Estimates

Home Health Care CAHPS Survey. We estimate it will take 0.20 hours (12 minutes) at $24.98/hr for a home health patient to complete the Home Health Care CAHPS Survey. Our estimate is based on the written length of the survey and CMS’s experience with the national implementation of HHCAHPS, including average times observed by survey vendors currently conducting this survey.

The total number of patients sampled in the time period of April 2018-March 2019, was

4,334,532 patients. Of the 4,334,532 patients, 1,186,240 (28%) returned a completed HHCAHPS survey that was submitted to the HHCAHPS Warehouse. In that same period, these patients were served by 8,990 home health agencies. If we divide 1,186,240 patients by 8,990 agencies, we have an average of 132 patients responding to the HHCAHPS survey by agency.

In aggregate, we estimate a burden of 237,248 hours (1,186,240 patients x 0.20 hr) at a cost of $5,926,455 (237,248 hr x $24.98/hr) or $4.996 per survey ($5,926,455 /1,186,240 patients)

The survey instrument and procedures for completing the instrument are designed to minimize burden on all respondents.

Patient Files. Section 484.250 requires that an HHA submit to CMS, HHCAHPS data in order for CMS to administer the payment rate methodologies described in §§ 484.215, 484.230, and 484.235. The burden associated with this is the time and effort put forth by the HHA to submit the HHCAHPS patient files to their approved HHCAHPS survey vendor.

Section 484.255(i) requires the submission of quality measures as specified by the Secretary.

As part of this requirement, each HHA sponsoring a Home Health Care CAHPS (HHCAHPS) Survey must prepare and submit to its survey vendor a file containing data on patients served the preceding month that will be used by the survey vendor to select the sample and field the survey. This file (essentially the sampling frame) for most home health agencies can be generated from existing databases with minimal effort. For some small HHAs, preparation of a monthly sample frame may require more time. However, data elements needed on the sample frame will be kept at a minimum to reduce the burden on all HHAs. The burden associated with this requirement is the time and effort put forth by the HHA to prepare and submit the file containing patient data on patients.

No significant burden is anticipated for small agencies beyond providing their contracted vendor with a monthly file of patients served. We estimate that the monthly file will take 24 hours at $42.32/hr for a HHA Medical Records Reviewer to complete each file on an annual basis. Of the 8,990 HHAs conducting the HHCAHPS, we estimate a burden of 215,760 hours (8,990 HHAs x 24 hr) at a cost of $9,130,963 (215,760 hr x $42.32/hr).

HHCAHPS Participation Exemption Request Form. For small HHAs serving less than 60 eligible patients in an annual period, CMS requires the completion of an HHCAHPS Participation Exemption Request form (PER form) accessible from https://homehealthcahps and submitted with an agency ID and password under the secure portal on the website. CMS estimates that it takes 20 minutes (0.33) at $42.32/hr for a HHA Medical Records Reviewer to complete the HHCAHPS Participation Exemption Request Form.

HHAs with 59 or fewer patients complete the form to be exempt from HHCAHPS participation period so they will still get their full annual payment update. HHAs must fill out the exemption form annually because patient counts fluctuate from year-to-year.

There is a steady decline in the number of HHCAHPS participation exemption request forms filed since the first APU period of CY 2012. Here are the totals of the number of HHAs submitting exemption forms by the CY APU years:

CY APU Year	Number of HHAs filing PER forms
CY 2012	1,918
CY 2013	1,486
CY 2014	1,138
CY 2015	1,115
CY 2016	1,038
CY 2017	883
CY 2018	815
CY 2019	713
CY2020	696

For the Burden Summary table below, we use “700” as the number of HHAs filing an exemption form given the continuing downward trend.

Burden Summary

Requirements	Respondents	Total Responses per year	Time per Response (hr)	Total Time (hr)	Labor Rate ($/hr)	Total Cost ($)
HHCAHPS Survey	1,186,240	1,186,240	0.20	237,248	24.98	5,926,455
Monthly Patient Files	8,990	107,880	24*	215,760	42.32	9,130,963
HHCAHPS Participation Exemption Request Form	700	700	0.33	231	42.32	9,776
TOTAL	1,195,930	1,294,820	24.53	453,239	varies	15,067,194

*Reflects time per year per respondent for 12 monthly patient files.

Information Collection Instruments and Instruction/Guidance Documents

All of the following documents are currently approved by OMB. We are not changing any of them. Nor are we adding or removing any documents from what is currently approved.

HHCAHPS Survey. We have attached the HHCAHPS survey in English, Spanish, Simplified Chinese, Traditional Chinese, Russian, Vietnamese, and Armenian.

We have attached the Supplemental Questions (there are 10 of them) that are OMB-approved, and we have attached them in the languages of English, Spanish, Simplified Chinese, Traditional Chinese, Russian, Vietnamese, and Armenian.

We have attached the optional question, “Consent to Share Responses”, which becomes Question 35 on the HHCAHPS Survey. It is mandatory that Question 35 be on the survey, and the answer must be checked YES, if the HHCAHPS vendors are sharing the results of the individual surveys with the home health agencies. We have attached the Consent to Share Responses question in the languages of English, Spanish, Simplified Chinese, Traditional Chinese, Russian, Vietnamese, and Armenian.

We have also attached the annually-issues HHCAHPS Protocols and Guidelines Manual for

2020 (Version 12.0) which is the official “how-to” guide for the HHCAHPS survey implementation so that survey implementation is occurring the same way across the nation.

Monthly Patient Files: All home health agencies must give their vendors a list of their patients who are eligible for the HHCAHPS survey. We have attached the Patient Administrative Record file along with a detailed explanation of the patient lists that is from the HHCAHPS Protocols and Guidelines Manual for 2020.

HHCAHPS Participation Exemption Request Form: The HHCAHPS Participation Exemption Request Form for the CY 2020 Annual Payment Update was our ninth version of the exemption form, because we began HHCAHPS requirements for the CY 2012 annual payment period. If home health agencies had 59 or fewer patients eligible for HHCAHPS from April 1, 2017-March 31, 2018, then they did not have to do the required HHCAHPS for the CY 2020 APU payment that occurred in the period of April 1, 2018-March 31, 2019 if they completed the HHCAHPS

Participation Exemption Request form and CMS verified the home health agencies’ counts on the forms. Every year, home health agencies are asked to count their patients in the year prior to the HHCAHPS data collection period, and to file an HHCAHPS Participation Exemption Request form if they have too few patients (59 or fewer patients). Most agencies that are very small do complete the exemption form, and also, CMS does verify that these agencies do in fact have very small home health patient counts. The HHCAHPS Participation Exemption Request form on the HHCAHPS website at this time is for the CY2021 APU. On April 1, 2020, we will post the CY 2022 HHCAHPS Participation Exemption Request Form and remove the CY 2021 form.

13 Capital Costs

While HHCAHPS survey respondents do not incur any capital costs, every HHA has an annual cost to secure the services of an approved HHCAHPS survey vendor that has remained at an average cost of $3,000 per year since the last OMB approval period.

The number of participating HHAs varies from year to year which carries over to the number of completed surveys. In this iteration we are adjusting the number of HHAs based on April 2018 – March 2019 data.

We based the number of agencies on the period of April 2018-March 2019. We think that we will not have more agencies than this in the next couple of years because there are fewer home health agencies now (11,334 based on March 2019 data) than there were in in March 2017 (nearly 12,000 home health agencies). The industry is changeable and there are mergers as well as closures.

Contract with a Survey Vendor

	Number of HHAs	Number of responses	Cost per response ($)	Total cost ($)
Currently Approved (2017)	9,933	9,933	3,000	29,799,000
Proposed (2021)	8,990	8,990	3,000	26,970,000
Change	-943	-943	n/a	-2,829,000

14. Estimates of Annualized Cost to the Government

The annual cost to the federal government for September 15, 2019 - September 14, 2020 is

$1,767,463. This is CMS’ cost for the contract with the federal contractor managing the national implementation of HHCAHPS. RTI International, Inc. is the federal contractor for the national implementation of HHCAHPS.

14. Program Changes or Adjustments to Annual Burden

We are not proposing any program changes.

For this renewal, we are presenting data from the CY 2020 APU data submissions for the period of April 2018-March 2019, which indicates we have a larger number of respondents to HHCAHPS than in 2017.

HHCAHPS Survey

	Number of respondents	Number of responses	Hours per response	Total burden hours
Currently Approved (2017)	1,176,699	1,176,699	0.20	235,340
Proposed (2021)	1,186,240	1,186,240	0.20	237,248
Change	+9,541	+9,541	n/a	+1,908

The number of participating HHAs varies from year to year which carries over to the number of completed surveys. In this iteration we are adjusting the number of HHAs based on April 2018 – March 2019 data.

FOR THE CY 2020 APU PARTICIPATION PERIOD, THE AVERAGE PATIENTS COMPLETING THE HHCAHPS SURVEY WAS 1,186,240 PATIENTS DIVIDED BY 8,990 HOME HEALTH AGENCIES = 132 PATIENTS:

Unique HHAs = 8,990

Files Accepted = 98,394

Patients Sampled = 4,334,532

Completed Surveys = 1,186,240

Response Rate = 28%

Average Patients Sampled/HHA = 482

Since we have not received feedback since our last OMB submission that home health agencies need more time, we are maintaining the same participation completion time estimate for our 2021 OMB submission. Typically, the monthly patient file is done electronically by the home health agencies’ software vendors that run their patient lists for many purposes in the daily operational needs of their agencies.

Monthly Patient Files

Number of Number of Hours per HHAs responses response			Total burden hours
Currently Approved (2017) 9,933 119,196 2			238,392
Proposed (2021) 8,990 107,880 2			215,760
Change -943 -11,316 n/a			-22,632
HHCAHPS Participation Exemption Request Form
Number of HHAs	Number of responses	Hours per response	Total burden hours
Currently Approved (2017) 1,000	1,000	0.33	330
Proposed (2021) 700	700	0.33	231
Change -300	-300	n/a	-99

16. Tabulation and Publication of Results

We implement the HHCAHPS Survey so that we can provide the public with information about home health agencies from the views of home health patients. We have publicly reported HHCAHPS data since April 2012 on Home Health Compare on www.medicare.gov and the survey data is updated quarterly. Before we post new data, we provide HHA provider preview reports to all participating HHAs so that they will see their own survey data before it is publicly reported on www.medicare.gov and they may send comments to us if something looks incorrect in the data. On Home Health Compare, the HHCAHPS data is posted for the HHAs along with the corresponding State and National averages so viewers can assess how the home health agencies’ data compare with the State and National averaged HHCAHPS data. We began to post Star Ratings on www.medicare.gov for HHCAHPS in January 2016 and we update the Star Ratings on a quarterly basis.

16. Display of OMB Expiration Date

The HHCAHPS Survey and the HHCAHPS Participation Exemption Request Form display the OMB Expiration Date and the PRA Disclosure Statement.

18. Exceptions to the Certification Statement

None.

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