SUPPORTING STATEMENT
CAHPS® Hospice survey
(CMS-10537; omb 0938-1257)
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 Consumer Assessment of Healthcare Plans and Systems (CAHPS®) Hospice Survey. Under Contract Number GS-10F-0275P and Task Order number 75FCMC19F0026, the project team will continue to implement and analyze a hospice experience of care survey for primary caregivers (i.e., bereaved family members or close friends) of patients who died while receiving hospice care (“decedents”).
CMS launched the development of the CAHPS® Hospice Survey in 2012. Public reporting of the results on Hospice Compare started in 2018. The goal of the survey is to measure the experiences of patients and their caregivers with hospice care. The survey was developed to:
Provide a source of information from which selected measures could be publicly reported to beneficiaries and their family members as a decision aid for selection of a hospice program;
Aid hospices with their internal quality improvement efforts and external benchmarking with other facilities; and
Provide CMS with information for monitoring the care provided.
CMS announced its intention to implement the CAHPS® Hospice Survey in the FY 2014 Hospice Wage Index and Payment Rate Update; Hospice Quality Reporting Requirements; and Updates on Payment Reform. National implementation of the survey launched on January 1, 2015 with hospices administering the survey for a “dry run” for at least one month in the first quarter of 2015. Starting April 1, 2015 (second quarter), hospices were required to participate on a monthly basis in order to receive the full Annual Payment Update (APU). Implementation is ongoing and there have been no changes to the questionnaire.
The U.S. Department of Health and Human Services (DHHS) developed the National Health Care Quality Strategy (NQS) to create national aims and priorities to guide local, state, and national efforts to improve the delivery of health care services, patient health outcomes, and population health. Since the NQS was developed, CMS has launched quality initiatives that require public reporting of quality measures for a variety of health care delivery settings, including nursing homes, hospitals, home health care, and kidney dialysis centers. Collection and public reporting of health care quality measures:
• provides information that consumers can use to assist them in making health care choices or decisions;
• aids health care systems and providers with internal quality improvement efforts and external benchmarking; and
• provides CMS with information for monitoring health care providers’ performance.
Surveys focusing on patients’ experience of care with their health care providers are an important part of the NQS. In addition to publicly reporting clinical quality measures, CMS is currently reporting measures from patient experience of care surveys in a variety of settings, including in-center hemodialysis (ICH) centers, hospitals, home health agencies, hospices, health and drug plans on the Medicare web site Web site.
Publicly reporting comparative survey results related to patients’ perspectives of the care they receive from providers and plans collected through the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Surveys support CMS’s efforts to put patients first and improve the beneficiary experience.
CAHPS is a standardized family of surveys developed by the Agency for Healthcare Research and Quality (AHRQ) for patients to assess and report the quality of care they receive from their health care providers and health care delivery systems.
For national implementation survey vendors collect the data from primary informal caregivers (i.e., bereaved family members or close friends) of patients who died while receiving hospice care in any of the following settings: (1) at home or in an assisted living facility, (2) in a nursing home, and (3) in an inpatient setting (i.e., freestanding inpatient unit or acute care hospital). Three modes of survey administration are allowed: mail-only (up to two mailed surveys), telephone-only (up to 5 telephone attempts), and mixed mode (mailed survey followed by up to 5 telephone attempts beginning 21 days later). Mailed questionnaires are formatted for data scanning, and data from all returned surveys are scanned into an electronic data file. Computer Assisted Telephone Interviewing (CATI) is used for the telephone mode. Currently we have no web-based option as a mode of data collection for the CAHPS Hospice Survey. We are in the process of testing other CAHPS surveys in order to determine if a web-based option is feasible and what form it should take. We are hoping to test a web-based option of the CAHPS Hospice Survey, probably next year, and will make application to OMB for that test through the Generic OMB package available for web surveys.
The CAHPS® Hospice Survey includes items addressing communication, timely care, respect, spiritual and emotional support, symptom management, the training of family members to care for the patient, and overall care ratings. The survey questionnaire is unchanged from our prior submission. The survey is designed to gather only the data that CMS needs for assessing experiences with hospice care.
Though some hospices and vendors may voluntarily use the Family Evaluation of Hospice Care, the Veterans Health Administration Bereaved Family Survey, or other site-specific surveys to collect data on experiences with hospice care, the CAHPS® Hospice Survey is the only standardized instrument used to collect such data from all hospices across the country for the purposes of comparability and accountability.
Survey respondents are primary caregivers of patients who died while receiving hospice care. The survey should not impact small business or other small entities.
The survey will be administered once to each primary informal caregiver following the death of his or her family member or friend. The consequences of not collecting these data are that we would not have CAHPS Hospice Survey data to report publicly on Hospice Compare or successor CMS websites. This would reduce the information about hospice providers that available to the public. Currently, hospices are required to collect these data to meet the requirements of the Hospice Quality Reporting Program (HQRP). Compliance with the HQRP impacts their annual payment updates. The consequence of not collecting the data would be that hospices would not meet the quality reporting requirements and may be subject to lower annual payment updates.
There are no special circumstances associated with this information collection request.
The 60-day Federal Register Notice was published in the Federal Register 02/26/2020
[85 FR 11087].
One comment was received during the comment period. However, the comment was unrelated to the CAHPS Surveys.
The 30-day Federal Register Notice was published in the Federal Register 05/29/2020
[85 FR 32399].
No comments were received.
This data collection will not include respondent incentive payments or gifts.
Survey vendors are required to take steps to assure respondent confidentiality. These include preventing access to confidential data sets, restricting access to systems or rooms in which CAHPS® Hospice Survey data is kept, and requiring that vendor staff sign confidentiality agreements. Survey results are identified by an ID number that is not associated with an individual’s name or other identifying information. CMS does not publish results for hospices that had fewer than 30 responses over the previous eight quarters. It is permissible for vendors to share unofficial identifiable survey results with individual hospices. However, the information must s used only for quality improvement and should be confined to managers and quality improvement personnel. They cannot to be shared with direct care staff.
As this survey requests information from bereaved family members or close friends of a deceased patient, the potential for distress is possible; however, CMS’ experience with the CAHPS Hospice Survey thus far indicates that this is a very rare event. The cover letter that vendors send accompanying mailed surveys is required to include a toll-free number which respondents may use for questions or concerns. Should a respondent experience distress significant enough for him or her to request additional support, we recommend that survey vendors’ telephone staff put the respondent in contact with the appropriate local resource (generally a bereavement counselor or social worker on the hospice team that provided care to their family member or friend). This visit and support groups for bereavement are part of the services covered under the Medicare Hospice Benefit.
Estimated annualized burden hours and costs to respondents for the national implementation of the CAHPS® Hospice Survey are shown in Tables 1 and 2. Based on participation in national implementation in the CAHPS® Hospice Survey from Quarter 3 2016 through Quarter 2 2018, we assume that 3,670 hospices will administer the survey to an average of 281.2 cases per year. Thus, we estimate that the CAHPS® Hospice Survey will be administered to a maximum of 1,032,004 individuals each year for the duration of the collection period covered by this application for the purposes of national implementation. As not all sampled cases will complete the survey, this estimate reflects the maximum burden possible. The estimated number of responses is based on actual hospice participation in national implementation of the CAHPS® Hospice Survey.
Our burden estimates do not include any estimates for the Mode Experiment. The reason for this is that the Mode Experiment was a one-time study conducted in 2015. We have not conducted any subsequent mode experiments. The goal of the original Mode Experiment was to determine whether or not we needed to adjust our data by the mode of data collection (mail, telephone, or mail with telephone follow-up). The experiment also produced coefficients for adjusting our survey data. The coefficients are in use, but they pose no burden to the hospices.
Table 1 shows the estimated annualized burden for the respondents' time to participate in the national implementation data collection. The survey contains 47 items and is estimated to require an average administration time of 10.4 minutes in English (at a pace of 4.5 items per minute) and 12.5 minutes in Spanish (assuming 20 percent more words in the Spanish translation), for an average response time of 10.47 minutes or 0.174 hours (assuming that 1% of survey respondents complete the survey in Spanish). These burden and pace estimates are based on CMS’ experience with the CAHPS® Hospice Survey and surveys of similar length that were fielded with Medicare beneficiaries. As indicated below, the annual total burden hours for survey participants are estimated to be 180,004.43 for the continued national implementation of the survey.
Table 1. Estimated Annualized Burden Hours for Respondents: National Implementation of the CAHPS® Hospice Survey
Survey Version |
Number of Respondents |
Number of Responses per Respondent |
Hours per Response |
Total Burden Hours |
CAHPS® Hospice Survey |
1,032,004 |
1 |
0.174 |
180,004.43 |
Total |
1,032,004 |
1 |
0.174 |
180,004.43 |
Table 2 shows the cost burden to respondents associated with their time to complete a survey as part of national implementation. The annual total cost burden is estimated to be $10,145,049.73. This estimate is higher than the $7,710,481.60estimated in the prior OMB filing, due to the increased number of hospices participating (and correspondingly, the increased number of respondents), as well as an increase in the average hourly rate.
Table 2. Estimated Annualized Cost Burden for Respondents: National Implementation
Form Name |
Number of Respondents |
Total Burden Hours |
Average Hourly Wage Rate* |
Total Cost Burden |
CAHPS® Hospice Survey |
1,032,004 |
180,004.43 |
$56.36* |
$10,145,049.73 |
Total |
1,032,004 |
180,004.43 |
$56.36* |
$10,145,049.73 |
* Source: Data from the U.S. Bureau of Labor Statistics’ November 2019 National Occupational Employment and Wage Estimates for all salary estimates. This figure includes a 100% fringe benefit on an average wage of $28.18.
Retrieved from https://www.bls.gov/news.release/empsit.t19.htm on November 1, 2019
In addition to respondent burden, both hospices required to participate in national implementation of the survey, and those exempted from participation, will face a burden.
Per CMS’ final rule in FY 2014 Hospice Wage Index and Payment Rate Update; Hospice Quality Reporting Requirements; and Updates on Payment Reform and in subsequent rules, hospices with 50 decedents or more in a year are required to administer the CAHPS® Hospice Survey. The burden to these hospices consists of their time and effort to prepare and submit decedent data files to their approved CAHPS® Hospice Survey vendor. The data files contain data on patients who died in the hospice’s care in the prior month, and are used by the survey vendor to select the sample and field the survey. Hospices use existing databases to generate these files, and are generally able to do so with minimal effort. To keep the burden to hospices as low as possible, the list of required data elements for the file is as parsimonious as possible.
Table 3 shows the estimated annualized cost burden for the provision of the monthly data file by hospices required to participate in national implementation. We estimate that preparation and submission of the monthly file will take 24.0 hours annually for each hospice. Assuming that as in Quarter 3 2016 through Quarter 2 2018, 3,670 hospices conduct the CAHPS® Hospice Survey, the burden would be 88,080 hours (3,670 hospices * 24 hours). CMS believes that this labor can be conducted by a Medical Records Reviewer. The U.S. Bureau of Labor Statistics estimates that the 2018 median hourly wage of Medical Records and Health Information Technicians is $19.40.1 Therefore, the annual cost of the wage labor would be $465.60 for each hospice (24 hours * $19.40) for a total of $1,708,752 for all hospices participating in national implementation ($465.60 per hospice for 3,670 hospices).
Table 3. Estimated Annualized Cost Burden to Hospices Eligible to Participate in National Implementation |
||||
Form Name |
Number of Hospices |
Total Burden Hours per Hospice |
Average Hourly Wage Rate* |
Total Cost Burden |
Data File for CAHPS® Hospice Survey |
3,670 |
24 |
$19.40 |
$1,708,752.00 |
Total |
3,670 |
24 |
$19.40 |
$1,708,752.00 |
*Retrieved from https://www.bls.gov/ooh/healthcare/medical-records-and-health-information-technicians.htm on November 1, 2019. |
||||
Table 4 shows the estimated annualized cost burden for hospices applying for the size exemption from participation in national implementation. In 2017 and 2018, 623 and 627 hospices applied for this exemption, respectively. We estimate that preparation of the annual decedent count and completion of the form takes 20 minutes (0.333 hours). Assuming that 627 hospices apply for the exemption in a given year, the burden would be 208.79 hours (627 hospices * 0.333 hours). CMS believes that this labor can be conducted by a Medical Records Reviewer. The annual cost of the wage labor would be $6.46 for each hospice (0.333 hours * $19.40) for a total of $4,050.55 for all hospices completing the exemption form ($6.46 per hospice for 627 hospices).
Table 4. Estimated Annualized Cost Burden to Hospices Applying for Exemption from Participation in National Implementation
Form Name |
Number of Hospices |
Total Burden Hours per Hospice |
Average Hourly Wage Rate* |
Total Cost Burden |
CAHPS® Hospice Survey Exemption for Size Form |
627 |
0.333 |
$19.40 |
$4,050.55 |
Total |
627 |
0.333 |
$19.40 |
$4,050.55 |
*Retrieved from https://www.bls.gov/ooh/healthcare/medical-records-and-health-information-technicians.htm on November 1, 2019.
A13. Capital Costs
Survey participants will incur no capital costs as a result of participation. Hospices participating in national implementation will bear an annual cost to secure the services of an approved CAHPS® Hospice Survey vendor to conduct the survey on their behalf. Table 5 summarizes the estimated annual cost burden to hospices of paying the survey vendor. We estimate that the average annual survey vendor cost will be $4,000 for each of the 3,670 hospices participating in national implementation of the CAHPS® Hospice Survey, for a total of $14,680,000 (3,670 * $4,000).
Table 5. Estimated Annualized Cost Burden to Hospices for Contracting a Survey Vendor for National Implementation of the CAHPS Hospice Survey
Form Name |
Number of Hospices |
Average Cost to Contract a Survey Vendor |
Total Cost Burden |
CAHPS® Hospice Survey |
3,670 |
$4,000 |
$14,680,000 |
Total |
3,670 |
$4,000 |
$14,680,000 |
The annual cost to the Federal Government for sampling, data collection, analysis and reporting of scores is $1,757,306.
No program changes. We do, however, note a 7.5% increase in the number of hospices participating in the survey from 2017 through 2019 (from 3,414 to 3,670), We believe this increase is due to more hospices becoming aware of the requirement as well as some hospices growing in size to the point that they must participate in the survey. Burden estimates do not include any estimates for the Mode Experiment, which was previously included in the packages last iteration. The reason for this is that the Mode Experiment was a one-time study conducted in 2015. We have not conducted any subsequent mode experiments.
In February 2018, CMS started publicly reporting patient-mix adjusted “top-box” scores for each of the eight CAHPS Hospice Survey measures endorsed by the National Quality Forum. These include six composite measures (composed of multiple survey questions; Communication with family; Getting timely help; Treating patient with respect; Emotional and spiritual support; Help for pain and symptoms; Training family to care for patient and two global measures (each composed of one survey question; Rating of this hospice Willing to recommend this hospice). ) Top-box scores reflect the proportion of respondents that selected the most positive response category(ies) for the questions within the measure. Top-box scores are adjusted for both mode of survey administration and case mix.
To adjust responses for the effect of mode of survey administration, which can affect scores but is not related to the quality of hospice care, CMS applies survey mode adjustments derived from a 2015 CAHPS Hospice Survey mode experiment. Survey data collected using Mail Only or Mixed Mode are adjusted according to the difference in mode effects between that mode and the Telephone Only mode, as estimated through linear regression in the CAHPS Hospice Survey mode experiment. For Mixed mode, there is a single adjustment regardless of whether an individual responded by mail or phone (i.e., the adjustment is for the overall administration mode, not the mode in which the individual responds).
We solicited feedback on patient mix adjustment and mode adjustment in the Federal Register (82 FR 36675). Updated information on the coefficients we use to make these adjustments can be found at the CAHPS Hospice Survey technical website.
To ensure that comparisons between hospices reflect differences in performance rather than differences in patient and/or caregiver characteristics, CMS adjusts responses for case mix (i.e., variations of such characteristics across hospices). The case-mix adjustment model includes the following variables:
response percentile (calculated by ranking lag time—that is, days between death and survey response—among respondents for each hospice in each quarter, then dividing by total sample size)
decedent age
payer for hospice care
primary diagnosis
length of final episode of hospice care
respondent age
respondent education
relationship of decedent to caregiver
language
Details regarding scoring and adjustment of the CAHPS Hospice Survey measures are available at the official survey website, www.hospicecahpssurvey.org.
We are currently conducting ad hoc analysis of the survey data already collected to begin preparation for star ratings. We expect that star ratings will be included in future public reporting, but we do not have a timeframe.
We also solicited comments regarding suggested changes, additions or deletions to the questionnaire that would improve its value to hospices. (84 FR 38525) for quality improvement and consumers for selecting a hospice.
The OMB number and required language will be displayed on the survey.
There are no exceptions to the certification statement identified in item 19 of OMB Form 83-I associated with this data collection effort.
1 Retrieved from https://www.bls.gov/ooh/healthcare/medical-records-and-health-information-technicians.htm. Retrieved November 1, 2019
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | DRAFT Supporting Statement A for Hospice Experience of Care Survey |
| Subject | Supporting Statement A for Hospice Experience of Care Survey |
| Author | The RAND Corporation |
| File Modified | 0000-00-00 |
| File Created | 2021-01-14 |