Cms-10102 Supporting Statement A

Survey is the first national, standardized, publicly reported survey of patients’ perspectives of their hospital care. HCAHPS is a 29-item survey instrument and data collection methodology for measuring patients’ perceptions of their hospital experience. Since 2008, HCAHPS has allowed valid comparisons to be made across hospitals locally, regionally and nationally.

Three broad goals have shaped HCAHPS. First, the standardized survey and implementation protocol produce data that allow objective and meaningful comparisons of hospitals on topics that are important to consumers. Second, public reporting of HCAHPS results creates new incentives for hospitals to improve quality of care. Third, public reporting enhances accountability in health care by increasing transparency of the quality of hospital care provided in return for the public investment.

The HCAHPS Survey asks recently discharged patients about aspects of their hospital experience that they are uniquely suited to address. The core of the survey contains 19 items that ask “how often” or whether patients experienced a critical aspect of hospital care, rather than whether they were “satisfied” with their care. Also included in the survey are three screener items that direct patients to relevant questions, five items to adjust for the mix of patients across hospitals, and two items that support Congressionally mandated reports. (See Attachment A: HCAHPS Survey Instrument (Mail) and Supporting Materials.) Currently, the HCAHPS Survey instruments and materials are translated into nine languages: Spanish, Chinese, Russian, Vietnamese, Portuguese, German, Tagalog, and Arabic. CMS regularly asks for feedback on the need for additional languages and will continue to create additional language translations as needs arise.

Since March of 2008, results from the HCAHPS survey have been publicly reported. Currently HCAHPS results are publicly reported on the Care Compare Web site, https://www.medicare.gov/ca r e -compare/?providerType=Hospital&redirect=tr u e, and in the Provider Data Catalog, https://data.cms.gov/provid e r -data/dataset/dg c k -sy fz

The HCAHPS Survey and its implementation protocols can be found in the current version of the HCAHPS Quality Assurance Guidelines (Version 18.0, March 2023), located at:

www.hcahpsonline.org/en/quali t y -assuranc e /.

In 2021, we conducted a large-scale mode experiment to test the addition web-based modes of data collection and other updates to the HCAHPS Survey. We have not made any changes to data collection for this Paperwork Reduction Act package. A future OMB Paperwork Reduction Act

package will include future updates to the survey administration protocols and content for the HCAHPS Survey pending rulemaking. The final Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals rule (CMS-1785-F) describes future survey administration updates; see https://www.federalregister.gov/public -inspection/2023 -16252/medicare -program -hospital -inpatient - prospective -payment -systems -for -acute -care -hospitals -and -the. We have submitted potential HCAHPS measure updates to the 2023 Measures Under Consideration process for review by the Measures Application Partnership, which is a multi-stakeholder partnership that provides recommendations to HHS on the selection of quality and efficiency measures for CMS programs. Updates to HCAHPS measures will be submitted in a future OMB Paperwork Reduction Act package. The present update does not impact any of the supplemental documents in this PRA package.

During this PRA iteration, CMS is requesting an extension approval with no changes to the collection’s instruments. The amount of time needed to complete the HCAHPS Survey has not changed, but the number of respondents has decreased since the previous PRA approval in 2021. CMS has also included the various translation versions of the survey that have been mentioned within the package in the past but are now apart of the PRA package.

B. Justification

Need and Legal Basis

Beginning in 2002, CMS partnered with the Agency for Healthcare Research and Quality (AHRQ), another agency in the federal Department of Health and Human Services, to develop and test the HCAHPS Survey. AHRQ and its CAHPS Consortium carried out a rigorous and multi-faceted scientific process, including a public call for measures; literature review; cognitive interviews; consumer focus groups; stakeholder input; a three-state pilot test; extensive psychometric analyses; consumer testing; and numerous small-scale field tests. CMS provided three separate opportunities for the public to comment on HCAHPS and responded to over a thousand comments. The survey, its methodology and the results it produces are in the public domain.

In May 2005, the HCAHPS Survey was endorsed by the consensus-based entity, National Quality Forum, a national organization that represents the consensus of many healthcare providers, consumer groups, professional associations, purchasers, federal agencies, and research organizations. In December 2005, the federal Office of Management and Budget gave its final approval for the national implementation of HCAHPS for public reporting purposes. CMS implemented the HCAHPS Survey in October 2006 and the first public reporting of HCAHPS results occurred in March 2008.

Enactment of the Deficit Reduction Act of 2005 created an additional incentive for acute care hospitals to participate in HCAHPS. Since July 2007, hospitals subject to the Inpatient Prospective Payment System (IPPS) annual payment update provisions ("subsection (d) hospitals") must collect and submit HCAHPS data in order to receive their full annual payment update.

The incentive for IPPS hospitals to improve patient experience was further strengthened by the

Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), which specifically included

HCAHPS performance in the calculation of the value-based incentive payment in the Hospital Value-Based Purchasing program beginning with October 2012 discharges.

Information Users

As noted above, there are three broad goals of the HCAHPS Survey. These goals are of value to consumers and providers of health care services as well as to CMS. First, the standardized survey and implementation protocol produce data that allow objective and meaningful comparisons of hospitals on topics that are important to consumers. Second, public reporting of HCAHPS results creates new incentives for hospitals to improve quality of care. Third, public reporting enhances accountability in health care by increasing transparency of the quality of hospital care provided in return for the public investment. As part of the Hospital Inpatient Quality Reporting program, HCAHPS scores have been publicly reported on the Hospital Compare Web site since 2008; currently HCAHPS scores are publicly reported on the CMS Care Compare Web site and in the

Provider Data Catalog. Since 2012 have been used in the payment determination for Inpatient

Prospective Payment System (IPPS) hospitals that participate in the Hospital Value-Based

Purchasing (Hospital VBP) program. HCAHPS scores are also used in the CMS PPS-Exempt Cancer Hospital program, in other federal and state government programs, in hospital rating services such as Consumer Reports and U.S. News & World Report, in hospital quality improvement projects, and in scholarly research and publications.

Use of Information Technology

The national implementation of HCAHPS is designed to allow third-party CMS-approved survey vendors to administer HCAHPS using mail-only, telephone-only, mixed-mode (mail with telephone follow-up), or active IVR (interactive voice response).

In recent years, CMS has received feedback from hospitals, hospital associations, survey vendors, and other stakeholders requesting the option to administer the survey using a web mode as an alternative to the existing approved modes. Separate from this OMB PRA package, under the

“Application to Use Burden/Hours from Generic PRA Clearance: Testing of Web Survey Design and Administration for CMS Experience of Care Surveys (CMS-10694, OMB 0938-1370), CMS tested an e-mail HCAHPS survey as the first mode in three novel mixed mode designs: Web-Mail mode, Web-Phone mode, and Web-Mail-Phone mode.

In the FY 2024 IPPS/LTCH PPS proposed rule (88 FR 27113), we proposed to add three new modes of survey administration (Web-Mail mode, Web-Phone mode, and Web-Mail-Phone mode) in addition to the current Mail Only, Phone Only, and Mail-Phone modes, beginning with January 2025 discharges. These changes in HCAHPS survey administration were finalized in the final Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals rule (CMS-1785-F); see https://www.federalregister.gov/public -inspection/2023 -16252/medicare -program -hospital -inpatient - prospective -payment -systems -for -acute -care -hospitals -and -the. We will note these changes in a subsequent OMB package that will also include revisions to the HCAHPS Survey content.

Duplication of Efforts

HCAHPS collects information that is fundamentally different from other CAHPS or patient experience of care surveys. CMS is not aware of any existing validated survey instrument where the unit of analysis is the acute care hospital, and the focus of the survey is patient reported experience of care. The information collected through this survey will therefore not duplicate any other effort and is not obtainable from any other source.

Many hospitals carry out their own patient experience of care surveys. These diverse, proprietary surveys do not allow for comparisons across hospitals. Making comparative performance information available to the public assists consumers in making informed choices when selecting an acute care hospital and creates incentives for facilities to improve the care they provide.

Small Businesses

Hospitals are not generally considered to be small businesses. All hospitals have the option to conduct HCAHPS as a stand-alone survey or to integrate it with their existing survey activities. They can choose to administer HCAHPS by mail, phone, mail with telephone follow-up, or active IVR.

Costs associated with collecting HCAHPS will vary depending on:

The method hospitals currently use to collect patient survey data,
The number of patients surveyed (target is 300 completed surveys per year)
Whether it is possible to incorporate HCAHPS into their existing survey

Some smaller hospitals that participate in HCAHPS might be unable to reach the target of 300 completed surveys in a 12-month period. In such cases, the hospital should sample all discharges (census) and attempt to obtain as many completes as possible. HCAHPS scores based on fewer than 100 or 50 completed surveys are publicly reported but the lower reliability of these scores is noted by an appropriate footnote. CMS does not publicly report HCAHPS scores based on 25 or fewer completed surveys.

Less Frequent Collection

Great effort was expended considering how often HCAHPS data should be collected. We solicited and received much comment on this issue when HCAHPS was being developed. Two options for the frequency of data collection were suggested: once during the year, or continuous sampling. The majority of hospitals/vendors suggested continuous sampling would be easier to integrate into their current data collection processes. Thus, we decided to require sampling of discharges on a continuous basis (i.e., a monthly basis) and cumulate these samples to create rolling estimates based on 12- months of data. We chose to pursue the continuous sampling approach for the following reasons:

It is more easily integrated with many existing survey processes used for internal improvement.
Improvements in hospital care can be more quickly reflected in hospital scores (e.g.,

12- month estimates could be updated on a quarterly or semi-annual basis)

Hospital scores are less susceptible to unique events that could affect hospital performance at a specific point in time.
It is less susceptible to gaming (e.g., hospitals being on their best behavior at the time of an annual survey)
There is less time between discharge and data collection.

Less frequent data collection would result in a longer gap between when survey respondents experienced hospital care, and when their survey results were publicly reported, which would diminish the value of HCAHPS data in public reporting and hospital quality improvement efforts.

Special Circumstances

There are no special circumstances associated with this information collection request.

Federal Register/Outside Consultation

The 60-day Federal Register notice published in the Federal Register (88 FR 57461) on 08/23/2023.

Two comments were received. Please see attachment, “Response to Comments, HCAHPS OMB 60 days, CMS 10102,” for response to comments. No changes were made to our data collection methodology based on these comments.

The 30-day Federal Register Notice published in the Federal Register (88 FR 82379) on 11/24/2023.

Payments/Gifts to Respondents

There are no provisions for payments or gifts to survey respondents.

Confidentiality

All information obtained through the HCAHPS Survey is reported in the aggregate. No individual respondent’s information is reported independently or with identifying information. We have designed the data files so that the hospital/vendor submits a de-identified dataset to CMS. No protected health information is submitted to CMS. In all the modes of survey administration, guidelines are included on issues related to confidentiality:

Cover letters are not to be attached to the survey.
Respondents’ names do not appear on the survey.
Interviewers are not to leave messages on answering machines or with household members since this could violate a respondent’s privacy.

Please see HCAHPS Quality Assurance Guidelines, V18.0, pp. 57-58, for detailed information on safeguarding patient confidentiality, www.hcahpsonline.org/en/quali t y -assuranc e /.

Sensitive Questions

There are no questions of a sensitive nature on the HCAHPS Survey.

Burden Estimates (Hours & Wages)

To calculate the cost for survey respondents, we use the Average Hourly Earnings of $33.44 as reported by the U.S. Bureau of Labor Statistics, preliminary May 2023 estimates at https://www.bls.gov/eag/eag.us.h tm (last modified June 26, 2022). The HCAHPS survey averages approximately 2,300,000 participating survey respondents (completed surveys) a year, as evidenced throughout the 2022 reporting period. This includes respondents at PPS- Exempt Cancer hospitals that participate in HCAHPS. We utilize HCAHPS data from CY 2022 because it is the most recent complete year of HCAHPS data.

On average, it takes respondents 7.25 minutes (0.120833 hours) to complete the survey, for a total 277,916-hour annual burden (2,300,000 respondents by 0.120833 hours). The annual cost burden of the HCAHPS Survey for survey respondents is thus $9,293,511 (277,916 total respondent hours X $33.44 average hourly earnings).

EXHIBIT A-1: Annual Hours/Cost Burden of the HCAHPS Survey

Number of Total Average Hourly Estimated Data Collection

HCAHPS Survey Respondents Burden Hours Earnings* Cost to Respondents

Total 2,300,000 277,916 $33.44 $9,293,511

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*Average Hourly Earnings of $33.44, based on average hourly earnings of all employees on private nonfarm payrolls, seasonally adjusted, preliminary May 2023 estimates, U.S. Bureau of Labor Statistics.

Since 2018 the number of hospitals participating in HCAHPS has been fairly stable at approximately

4,500 hospitals for each four-quarter period through December 2019, which includes PPS-Exempt

Cancer hospitals that participate in HCAHPS. Over the next three years, we anticipate that about 4,450 hospitals will participate in HCAHPS. To derive average costs for hospitals, we estimate an average amount of approximately $4,200 per hospital for HCAHPS data collection activities, the annual cost burden totaling $18,690,000. Assuming a one hour per hospital time cost, the annual burden for hospitals is 4,450 hours.

In total, the annual cost burden of the survey is:

(Survey respondents $9,293,511) + (hospitals $18,690,000) = $27,983,511.

The annual hour burden is:

(Survey respondents 277,916) + (hospitals 4,450 hours) = 282,366 hours.

Capital Costs

Hospitals have the option to conduct HCAHPS as a stand-alone survey or to integrate it with an existing survey. Hospitals can choose to administer HCAHPS by mail, phone, mail with telephone follow-up, or active IVR. Costs associated with collecting HCAHPS will vary depending on:

The method hospitals currently use to collect patient survey data.
The number of patients surveyed (target is 300 completed surveys per year)
Whether it is possible to incorporate HCAHPS into their existing survey

Over the next three years, we anticipate that about 4,450 hospitals will participate in HCAHPS. Using the estimate of $4,200 per hospital for HCAHPS data collection, the annual cost burden is $18,690,000.

Cost to the Federal Government

Costs to the government include hospital/vendor training and technical assistance; approving hospitals/vendors for conducting surveys; ensuring the integrity of the data; accumulating the data; analyzing the data; making adjustments for patient-mix and mode of administration; and public reporting. The annual cost to the Federal Government is estimated to be $3,475,000.

Changes to Burden

Since 2018, the number of hospitals participating in HCAHPS has been fairly stable at approximately 4,500 hospitals. We estimate that the number of hospitals will decrease to about 4,450 over the next three years. Using the estimate of $4,200 per hospital for HCAHPS data collection, the annual cost burden has increased to $18,690,000.

The amount of time needed to complete the HCAHPS Survey has not changed, but the number of respondents has decreased since the previous PRA approval in 2021, resulting in a lower annual hour burden. However, the increase in the average hourly wage has resulted in a higher annual cost burden for respondents.

Publication/Tabulation Dates

Since October 2006, the HCAHPS Survey has been administered on a continuous basis. From

March 2008 to December 2020, HCAHPS results were publicly reported on the CMS Hospital Compare website four times per year. Since 2021, HCAHPS results have been publicly reported on the CMS Care Compare Web site,

https://www.medicare.gov/ca recompare/?providerType=Hospital&redirect=tr u e, and in the Provider Data Catalog, https://data.cms.gov/provid e r -data/dataset/dg c k -sy fz four times per year. This pattern will continue into the foreseeable future.

Expiration Date

CMS will display the OMB number and expiration date. This information appears inside a box at the beginning of the mail survey and in the OMB Paperwork Reduction Act language, which is placed either in the survey cover letter, or in the survey instrument.

Certification Statement

The proposed data collection does not involve any exceptions to the certification statement.

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title	National Implementation of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey
Author	Christine Payne
File Modified	0000-00-00
File Created	2023-12-11