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, including administration and analysis of 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”).
The CAHPS Hospice Survey is currently available in eight languages including English, Spanish, Chinese (traditional and simplified), Russian, Portuguese, Vietnamese, Polish, and Korean. The CAHPS Hospice Survey is administered between approximately 2 and 4.5 months following the death of the hospice patient. Hospice patients and the primary caregivers noted in their hospice’s administrative records are eligible for inclusion in the sampling universe if:
Patients were over the age of 18
Patients died at least 48 hours following last admission to hospice care
Patients had a caregiver listed or available and caregiver contact information is known
Patients had a primary caregiver who is someone other than a non-familial legal guardian
Patients had a primary caregiver who has a U.S. or U.S. Territory home address
Patients or caregivers of patients who voluntarily request that they not be contacted (those who sign “no publicity” requests while under the care of hospice or otherwise directly request not to be contacted) are excluded.
Implementation is ongoing and to date there have been no changes to the questionnaire and only minor changes to survey administration procedures. However, in recent years, CMS has received feedback from hospice stakeholders requesting the option to administer the survey using a web-based mode as an alternative to the existing approved modes of mail only, telephone only, and mixed mode (mail with telephone follow-up) and that CMS shorten the survey instrument. These suggestions are aimed at reducing burden and improving the survey’s response rate.
In 2021, CMS conducted a large-scale OMB-approved mode experiment (OMB 09381370) to test revisions to the CAHPS Hospice Survey. This OMB package is seeking approval for implementation of a revised, shorter CAHPS Hospice Survey instrument (Attachment A). The revised survey is eight items shorter than the current survey and uses simpler language. Specifically, changes to the survey and the quality measures derived from it include:
Removal of three nursing home items and an item about moving the family member that are not included in scored measures.
Removal of one survey item regarding confusing or contradictory information from the Communication with family measure.
Replacement of the multi-item Training family to care for patient measure with a new, one-item summary measure.
Simplified wording to component items in the Communication with family, Getting timely help, and Treating patient with respect measures, updated pronouns to be gender neutral (i.e., they instead of he or she), and added “cultural” to the item regarding religious and spiritual support in the Emotional and spiritual support measure.
All nine quality measures derived from the revised CAHPS Hospice Survey received endorsement through the Consensus Standards Approval Committee (CSAC) Fall 2022 endorsement and maintenance cycle. Survey changes are documented in the crosswalk submitted with this package (Attachment B). Taken together, these changes to the survey instrument reduce the average amount of time for respondents to complete the CAHPS Hospice Survey from 10.42 minutes to 8.68 minutes. The mode experiment showed a 0.9 percentage point increase in response rates when implementing the revised survey in the mail-only mode. The revised instrument has been translated into all languages currently available for national implementation of the survey (noted above). CMS will consider additional language translations if requested by hospices.
A. Justification
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). CMS began publicly reporting hospices’ CAHPS Hospice Survey measure scores in 2018, and CAHPS Hospice Survey Star Ratings in 2022.
Proposed changes to the CAHPS Hospice Survey instrument, addition of a new approved mode of survey administration, and changes to survey administration procedures are currently going through the Federal rulemaking process for FY 2025 Hospice Wage Index and Payment Rate Update.
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, and hospices on the Medicare Care Compare web site (https://www.medicare.gov/care-compare).
Publicly reporting comparative survey results related to patients’ perspectives of the care they receive from providers and plans collected through the CAHPS Surveys support CMS’s efforts to promote person-centered care 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).
CMS’ CAHPS Hospice Survey Quality Assurance Guidelines manual provides information to survey vendors and hospices on the Program Requirements, including the purpose of the CAHPS Hospice Survey, communication with patients and/or their caregivers, the Roles and Responsibilities for participating organizations (i.e., CMS, hospices, and survey vendors), survey vendor analysis of CAHPS Hospice Survey data, the Minimum Business Requirements to administer the CAHPS Hospice Survey, and the Rules of Participation.
Three modes of survey administration are currently 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.
In recent years, CMS has received feedback from many stakeholders, including survey vendors, hospices, and hospice associations, requesting a web-based mode as an alternative to the existing approved modes. In a separate OMB PRA package,
“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 the feasibility of a web-based survey as the first mode in a web-mail mixed mode design.
CMS is planning to introduce a web-mail mixed mode that includes web with mail follow-up to non-respondents beginning with January 2025 decedents. For hospices that choose this mode, caregivers of decedents will be surveyed using a web-first protocol in which web is the initial mode of survey administration. Sampled enrollees with an available email address will receive an email invitation to complete the survey. Sampled enrollees without an available email address, and those that do, but do not respond by web, will receive up to two mailings of a paper survey.
The CAHPS Hospice Survey includes items addressing communication, timely care, respect, spiritual and emotional support, symptom management, training of family members to care for the patient, care preferences, and overall care ratings. 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 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 informal caregivers (i.e., family members or friends) of patients who died while receiving hospice care. The survey should not impact small business or other small entities.
A6. Consequences of Less Frequent Data Collection
The survey will be administered once following the death of the hospice patient.
There are no special circumstances that would require an information collection to be conducted in a manner that requires respondents to:
Report information to the agency more often than quarterly;
Prepare a written response to a collection of information in fewer than 30 days after
receipt of it;
Submit more than an original and two copies of any document;
Retain records, other than health, medical, government contract, grant-in-aid, or tax records for more than three years;
Collect data in connection with a statistical survey that is not designed to produce valid and reliable results that can be generalized to the universe of study,
Use a statistical data classification that has not been reviewed and approved by
OMB;
Include a pledge of confidentiality that is not supported by authority established in statute or regulation that is not supported by disclosure and data security policies that are consistent with the pledge, or which unnecessarily impedes sharing of data with other agencies for compatible confidential use; or
Submit proprietary trade secret, or other confidential information unless the agency can demonstrate that it has instituted procedures to protect the information's
confidentiality to the extent permitted by law.
The 60-day Federal Register (89 FR 23598) notice was published on 04/04/2024. One comment was received for the 60-day comment period and responses were provided within the attached Response to Comments document. The commenter expressed support for the addition of a web-mail mode, the survey revisions, and the addition of a prenotification letter. The commenter made suggestions for one of the survey questions and encouraged adoption of the new guidance for collecting race and ethnicity.
The 30-day Federal Register (89 FR 56383) notice was published on 07/09/2024.
A9. Respondent Payments or Gifts
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 be used only for quality improvement and may only be shared with managers and quality improvement personnel. Survey responses 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 1 2022 through Quarter 4 2022, we assume that 3,987 hospices will administer the survey to an average of 290.8 cases per year. Thus, we estimate that the CAHPS Hospice Survey will be administered to a maximum of 1,159,420 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.
Table 1 shows the estimated annualized burden for the respondents' time to participate in the national implementation data collection. The revised survey contains 39 items and is estimated to require an average administration time of 8.67 minutes in English (at a pace of 4.5 items per minute) and 10.4 minutes in Spanish (assuming 20 percent more words in the Spanish translation), for an average response time of 8.68 minutes or 0.145 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 168,115.90 for the continued national implementation of the survey.
Survey Version |
Number of Respondents |
Number of Responses per Respondent |
Hours per Response |
Total Burden Hours |
CAHPS Hospice Survey |
1,159,420 |
1 |
0.145 |
168,115.90 |
Total |
1,159,420 |
1 |
0.145 |
168,115.90 |
Table 2 shows the cost burden to respondents associated with their time to complete a survey as part of national implementation. To derive average costs for individuals we used data from the U.S. Bureau of Labor Statistics’ May 2023 National Occupational
Employment and Wage Estimates for our salary estimate
(www.bls.gov/oes/current/oes_nat.htm). We believe that the burden will be addressed under All Occupations (occupation code 00-0000) at $23.11/hour since the group of individual respondents varies widely from working and nonworking individuals and by respondent age, location, years of employment, educational attainment, etc. No percentage for fringe benefit is included in this rate, as surveys are completed outside of the respondent’s employment.
Form Name |
Number of Respondents |
Total Burden Hours |
Median Hourly Wage Rate* |
Total Cost Burden |
CAHPS Hospice Survey |
1,159,420 |
168,115.90 |
$23.11* |
$3,885,158.45 |
Total |
1,159,420 |
168,115.90 |
$23.11* |
$3,885,158.45 |
* Source: Data from the U.S. Bureau of Labor Statistics’ May 2023 National Occupational Employment and Wage Estimates for all salary estimates. Retrieved from www.bls.gov/oes/current/oes_nat.htm on June 13, 2024, .
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 1 2022 through Quarter 4 2022, 3,987 hospices conduct the CAHPS Hospice Survey, the burden would be 95,688 hours (3,987 hospices * 24 hours). CMS believes that this labor can be conducted by a Medical Records
Specialist. The U.S. Bureau of Labor Statistics estimates that the 2023 median hourly
wage of Medical Records Specialists is $23.45.1 We have assumed a 100% fringe benefit on a median wage of $23.45, making the median hourly wage rate $46.90. Therefore, the annual cost of the wage labor would be $1,125.60 for each hospice (24 hours * $46.90) for a total of $4,487,767.20 for all hospices participating in national implementation ($1,125.60 per hospice for 3,987 hospices).
Form Name |
Number of Hospices |
Total Burden Hours per Hospice |
Median Hourly Wage Rate* |
Total Cost Burden |
Data File for CAHPS Hospice Survey |
3,987 |
24 |
$46.90* |
$4,487,767.20 |
Total |
3,987 |
24 |
$46.90* |
$4,487,767.20 |
* Data from the U.S. Bureau of Labor Statistics’ May 2023 National Occupational Employment and Wage Estimates for all salary estimates. Retrieved from www.bls.gov/oes/current/oes_nat.htm on June 13, 2024. This figure includes a 100% fringe benefit on a median wage of $23.45.
Table 4 shows the estimated annualized cost burden for hospices applying for the size exemption from participation in national implementation. In 2022, 920 hospices applied for this exemption. We estimate that preparation of the annual decedent count and completion of the form takes 20 minutes (0.333 hours). Assuming that 920 hospices apply for the exemption in a given year, the burden would be 306.67 hours (920 hospices * 0.333 hours). CMS believes that this labor can be conducted by a Medical Records Specialist. The U.S. Bureau of Labor Statistics estimates that the 2023 median hourly wage of Medical Records Specialists is $23.45.2 We have assumed a 100% fringe benefit on a median wage of $23.45, making the median hourly wage rate $46.90. The annual cost of the wage labor would be $15.62 for each hospice (0.333 hours * $46.90) for a total of $14,368.28 for all hospices completing the exemption form ($15.62 per hospice for 920 hospices).
1
Data from the U.S. Bureau of Labor Statistics’ May 2023 National Occupational Employment and Wage Estimates
for all salary estimates. Retrieved from www.bls.gov/oes/current/oes_nat.htm on June 13, 2024.
2
Data from the U.S. Bureau of Labor Statistics’ May 2023 National Occupational Employment and Wage Estimates
for all salary estimates. Retrieved from www.bls.gov/oes/current/oes_nat.htm on June 13, 2024.
Form Name |
Number of Hospices |
Total Burden Hours per Hospice |
Median Hourly Wage Rate* |
Total Cost Burden |
CAHPS Hospice Survey Exemption for Size Form |
920 |
0.333 |
$46.90* |
$14,370.40 |
Total |
920 |
0.333 |
$46.90* |
$14,370.40 |
*Retrieved from the U.S. Bureau of Labor Statistics’ May 2023 National Occupational Employment and Wage Estimates for all salary estimates. Retrieved from www.bls.gov/oes/current/oes_nat.htm on June 13, 2024. This figure includes a 100% fringe benefit on a median wage of $23.45.
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 3,987 hospices participating in national implementation of the CAHPS Hospice Survey, for a total of $15,948,000 (3,987 * $4,000).
Form Name |
Number of Hospices |
Average Cost to Contract a Survey Vendor |
Total Cost Burden |
CAHPS Hospice Survey |
3,987 |
$4,000 |
$15,948,000 |
Total |
3,987 |
$4,000 |
$15,948,000 |
The approximate annual cost to the Federal Government for sampling, data collection, analysis and reporting of scores is $2,000,000.
Changes to the CAHPS Hospice Survey are documented in the crosswalk submitted with this package. These survey changes and updates to the mode of administration allow CMS to be responsive to stakeholder feedback and serve to increase response rates. Specifically, stakeholder feedback and CMS priorities will be addressed through the following changes:
Implementation of the revised, shorter CAHPS Hospice Survey instrument. The revised survey simplifies wording, removes several items, and also incorporates new topics on care preferences, unfair treatment, and cultural beliefs requested by stakeholders. The average estimated amount of time for respondents to complete the revised CAHPS Hospice survey is 8.68 minutes, a reduction of 1.74 minutes from completion time for the original survey.
Addition of the web-mail mixed mode as an approved mode of administration. During the mode experiment (OMB 0938-1370), CMS responded to stakeholder requests by testing a web-mail mode of CAHPS Hospice Survey data collection. The tested web-mail protocol included an initial email, email reminder, and up to two survey packet mailings. In the mode experiment, the web-mail mode resulted in a markedly improved response rate over the mail only mode (which includes only the two survey mailings) among caregivers with email addresses.
Addition of a prenotification letter to all approved modes of CAHPS Hospice survey administration. This letter would be sent one week prior to the start of survey data collection in all modes. The use of a prenotification letter was tested during the mode experiment; response rates were significantly higher for caregivers who received a prenotification letter relative to those who did not.
Extension of the survey field period by one week. Analysis during the mode experiment showed increases in response rates associated with sending a prenotification one week prior to the beginning of survey data collection and with extending data collection activities by one week. For example, by accepting mailed surveys for one additional week.
In February 2018, CMS started publicly reporting case-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. More information about case-mix adjustment can be found at 82 FR 36675 and 84 FR 38525.
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 currently applies survey mode adjustments derived from a 2015 CAHPS Hospice Survey mode experiment. With the introduction of a new mode of survey administration and new survey items, and availability of data from the 2021 mode experiment, CMS proposes to update the mode adjustments to those derived from the 2021 mode experiment.
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). Case-mix adjustment is performed within each quarter of data after data cleaning and mode adjustment. The current case-mix adjustment model includes the following variables: response percentile (the lag time between patient death and survey response), decedent’s age, payer for hospice care, decedent’s primary diagnosis, decedent’s length of final episode of hospice care, caregiver’s education, decedent’s relationship to caregiver, caregiver’s preferred language and language in which the survey was completed, and caregiver’s age. CMS reviewed the variables included in the current case-mix adjustment model to determine if any changes needed to be introduced along with the revised survey and new mode, and found that no variables need to be added or removed.
Details regarding scoring and adjustment of the CAHPS Hospice Survey measures are available at the official survey website, www.hospicecahpssurvey.org, and will be updated to reflect modifications prior to implementation of the revised survey and survey administration protocol.
Since August 2022, CMS has published CAHPS Hospice Star Ratings on its Care Compare website and the Provider Data Catalog (PDC). Star Ratings make it easier for consumers to use the quality information on the Compare websites and spotlight excellence in healthcare quality. CMS currently calculates nine CAHPS Hospice Star Ratings: one for each of the eight publicly reported CAHPS Hospice measures and a Family Caregiver Survey Rating, which is a summary star rating that combines the star ratings of the eight family caregiver experience measures. Only the CAHPS Hospice Summary Star Rating is publicly reported on Care Compare and available on PDC. CMS updates the CAHPS Hospice Star Ratings every other quarter (i.e., every 6 months). CAHPS Hospice Star Ratings are based on the same data that are used to create the CAHPS Hospice Survey measures reported on the Care Compare website, although the reporting periods may differ. CMS will update Star Ratings calculations to include new and revised measures as data become available.
A17. Display of OMB Expiration Date
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.
| 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 | 2024-07-21 |