Justification memo

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
7500 Security Boulevard, Mail Stop 00-00-00
Baltimore, Maryland 21244-1850

DATE:

February 23, 2021

TO:

Dominic Mancini
Acting Administrator, OIRA

FROM:

Elizabeth Richter
Acting Administrator, CMS

SUBJECT:

Request for Emergency Clearance of the Paperwork Reduction Act Package for
the Consumer Assessment of Healthcare Providers and Systems (CAHPS)
Survey for the Merit-Based Incentive Payment System (MIPS)

Emergency Justification
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.
The CAHPS for MIPS survey results in burden to three different types of entities: groups, virtual
groups, Alternative Payment Model (APM) Entities, vendors, and beneficiaries associated with
administering the survey. Virtual groups are subject to the same requirements as groups;
therefore, we will refer only to groups as an inclusive term for both unless otherwise noted.
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
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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. PRA approval is also needed so we will be able to move
forward with advance distribution of the survey to vendors that is necessary to inform the business
arrangements vendors make during summer 2021 with the groups and virtual groups that register
for CAHPS during April to June 2021. Additionally, distribution of the CY 2021 survey is a
deliverable within a CMS contract that ends in June. OMB approval is needed by April 30, 2021
to assure the obligation for delivery can be met before the contract closes.
The burden associated with this collection is low. In order to respond to the additional item
included in the CAHPS for MIPS survey, we estimated that an additional 0.2 minutes is needed
for beneficiaries to respond to the telehealth related question in the survey. We adjusted
the estimated time for beneficiaries to administer the 2021 CAHPS for
MIPS survey from 12.9 minutes to 13.1 minutes at an estimated annual cost of $168,209. We
expect approximately 29,952 respondents (a total of 117 groups and 256 respondents per group)
would administer the survey. We estimate an annual burden of 6,540 hours (29,952 respondents x
0.2183 hr/respondent) at a cost of $168,209 (6,540 hr x $25.72/hr). (85 FR 84982 through 84983)
Background
CMS established several policies related to data submission requirements in CAHPS in the CY
2017 Quality Payment Program final rule (81 FR 77116). We established that the CAHPS for
MIPS survey counts for one measure towards the MIPS quality performance category, and
groups of two or more MIPS eligible clinicians can voluntarily elect to participate in the CAHPS
for MIPS survey as one of their six required quality measures. We also established the following
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criteria for the submission of data on the CAHPS for MIPS survey by registered groups via a
CMS-approved survey vendor: for the applicable 12-month performance period, the group must
have the CAHPS for MIPS survey reported on its behalf by a CMS-approved survey vendor.
Additionally, groups that elect to use CAHPS for MIPS must elect to submit on at least one other
collection type (eCQMs, MIPS CQMs, QCDR measures, or CMS Web Interface (until sunset).
The CAHPS for MIPS survey counts for one measure toward the MIPS quality performance
category and, as a patient experience measure, also fulfills the requirement to report at least one
high priority measure in the absence of an applicable outcome measure. If a group elects to use
the CAHPS for MIPS survey, which would count as a patient experience measure, that group is
required to submit at least five additional quality measures. In other words, a group may report
any five measures within MIPS plus the CAHPS for MIPS survey to achieve the six measures
threshold. The CAHPS for MIPS survey would also count as a high-weighted activity under the
improvement activities performance category. The data collected on the CAHPS for MIPS
survey measures is transmitted directly to CMS via a CMS-approved survey vendor.
The CY 2018 Quality Payment Program final rule provided that the survey administration period
would span over a minimum of 8 weeks to a maximum of 17 weeks and would end no later than
February 28th following the applicable performance period and that we will further specify start
and end timeframes of the survey administration period through our normal communication
channels (82 FR 53632).
We do not anticipate concerns from CAHPS for MIPS survey vendors or stakeholders.
Timeline
February 26, 2021
 Target publication date for 42-day FR notice to initiate standard OMB process.
 Start of 42-day public comment period.
 PRA package posted for public review on the CMS PRA web site.
April 9, 2021
 End of 42-day comment period
 CMS reviews and responds to comments, as needed.
 PRA package revised as needed.
April 20, 2021
 OMB approval received.

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