Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey for the Merit-Based Incentive Payment System (MIPS) (CMS-10450)

Forms and Documents

Document Name	Status
Form CMS-10450 CAHPS for MIPS Survey Vendor Application Form and Instruction	Unchanged
Form CMS-10450 CAHPS for MIPS Survey Beneficiary Participation Form	Modified
CAHPS for MIPS PRA Emergency Justification 2-23-21 SIGNED.pdf Supplementary Document	2021-02-25
CMS-10450 Supporting Statement B (12-22-20).docx Supporting Statement B	2021-02-26
CMS-10450 - Supporting Statement A_ 1-22-21.docx Supporting Statement A	2021-02-26
Appendix G Technical References.docx Supplementary Document	2018-12-13

IC Document Collections

IC ID	Document Title	Status
227777	CAHPS for MIPS Group Registration	Unchanged
227776	CAHPS for MIPS Survey Vendor Application Form and Instruction	Unchanged
206234	CAHPS for MIPS Survey Beneficiary Participation Form	Modified

ICR Details

OMB Control No: 0938-1222	ICR Reference No: 202102-0938-018
Status: Received in OIRA	Previous ICR Reference No: 201812-0938-014
Agency/Subagency: HHS/CMS	Agency Tracking No: CCSQ
Title: Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey for the Merit-Based Incentive Payment System (MIPS) (CMS-10450)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 04/20/2021
Date Submitted to OIRA: 02/26/2021

	Requested	Previously Approved
Expiration Date	6 Months From Approved	01/31/2022
Responses	30,249	39,336
Time Burden (Hours)	6,902	8,755
Cost Burden (Dollars)	0	0

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Abstract: Section 1848(q) of the Social Security Act, as amended by section 101 of the Medicare Access and CHIP Reauthorization Act of 2015, authorizes the establishment of a Merit-based Incentive Payment System (MIPS) for eligible clinicians. Beginning in CY 2017, eligible clinicians are required to collect and submit data on four performance categories to CMS (quality, cost, advancing care information and improvement activities). This program replaces and consolidates portions of the PQRS, Value-based Modifier, and the Medicare EHR Incentive Program. The Act also establishes a second track, Advanced Alternative Payment Models (APMs) for clinicians to participate in instead of MIPS. The CAHPS survey information is used for quality reporting to collect data on fee-for-service Medicare beneficiaries’ experiences of care with eligible clinicians participating in MIPS, the Physician Compare website, and annual statistical reports describing MIPS data for all MIPS eligible clinicians.

Emergency Justfication: The Centers for Medicare & Medicaid Services (CMS) requests that an information collection request to support the implementation of the CAHPS for MIPS survey to add an item on telehealth to address the Public Health Emergency (PHE) be processed under the emergency clearance process associated with Paperwork Reduction Act of 1995 (PRA), specifically 5 CFR 1320.13(a)(2)(i). In order to address our stakeholders and the increased use of telehealth care due to the PHE for COVID-19, a question is being added to the CAHPS for MIPS survey (85 FR 84873). The question is being added to integrate one telehealth item to assess the patient-reported usage of telehealth services (for example, phone or video visit). The addition of this new item resulted in additional burden to respond, as indicated below. The additional question collects self-reported information from CAHPS for MIPS Survey respondents on the modalities of care (in-person, telephone or video visit) received during the last 6 months. This survey item would be utilized for informational purposes only and would not be used for quality scoring or payment purposes. In addition, the cover page of the CAHPS for MIPS Survey is revised to include a reference to care in telehealth settings. This question would integrated into the CAHPS for MIPS survey. The CAHPS for MIPS survey 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 survey 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 generally used for quality reporting, the Care Compare website, and annual statistical experience reports describing MIPS data for all MIPS eligible clinicians. More specifically, without PRA emergency approval, CMS would need to delay the CY 2021 implementation of the telehealth survey item, which would be in opposition to what stakeholders have requested from CMS to make this telehealth item part of the survey starting in CY 2021. CMS data indicates that the use of telehealth has increased since CY 2020 and the telehealth survey item and additional instructional text are needed ensure consistent interpretation of survey item across the pool of patients responding to the survey, and to provide CMS with valuable information on modalities of patient care. We were unable to submit this new survey item for comment along with the CY 2021 PFS proposed rule due to the testing that was needed before the updated survey instrument was ready. Therefore, in the CY 2021 PFS final rule (85 FR 84982), we stated we would make the updated survey instrument and burden available for public review through a stand-alone non-rule Federal Register notice that is expected to publish in early CY 2021. We intend to implement the CY 2021 survey with the new telehealth item. Due to the work needed to prepare for the implementation of the CY 2021 survey we are requesting emergency PRA OMB approval by April 30, 2021. PRA approval is needed so necessary tasks can be completed by late spring such as vendor training, preparing letters and Computer Assisted Telephone Interviewing (CATI) scripts.

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Authorizing Statute(s): US Code: 42 USC 1395w-4 Name of Law: MACRA of 2015
   PL: Pub.L. 111 - 148 10331 Name of Law: Affordable Care Act
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 10331 Name of Law: Affordable Care Act
US Code: 42 USC 1395w-4 Name of Law: MACRA of 2015

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 11780	02/26/2021
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
CAHPS for MIPS Survey Vendor Application	CMS-10450, CMS-10450	Appendix F: Vendor Form ,   Appendix H: Vendor Attestation
CAHPS for MIPS Survey Beneficiary Participation	CMS-10450, CMS-10450	Mail Survey ,   CAHPS for MIPS CATI Script
CAHPS for MIPS Group Registration

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ICR Summary of Burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	30,249	39,336	0	0	-9,087	0
Annual Time Burden (Hours)	6,902	8,755	0	0	-1,853	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The CAHPS for MIPS survey will be administered to approximately 29,952 beneficiaries per year (117 groups x an average of 256 beneficiaries per group responding). This is a decrease of 9,087 from our currently approved 39,039 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 -1,853 hours and -$50,950 (-9,087 beneficiaries x 0.218 hr x $25.72/hr).

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Annual Cost to Federal Government: $2,177,573

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Yes

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 02/26/2021

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