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

ICR 202102-0938-018

OMB: 0938-1222

Federal Form Document

Forms and Documents
IC Document Collections
ICR Details
0938-1222 202102-0938-018
Received in OIRA 201812-0938-014
HHS/CMS CCSQ
Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey for the Merit-Based Incentive Payment System (MIPS) (CMS-10450)
Revision of a currently approved collection   No
Emergency 04/20/2021
02/26/2021
  Requested Previously Approved
6 Months From Approved 01/31/2022
30,249 39,336
6,902 8,755
0 0

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.
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.

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

Not associated with rulemaking

  86 FR 11780 02/26/2021
No

  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
No
No
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).

$2,177,573
Yes Part B of Supporting Statement
    Yes
    Yes
Yes
No
No
Yes
Denise King 410 786-1013 [email protected]

  No

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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
02/26/2021


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