July 2024
National Implementation of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey
(CMS 10102, OMB 0938-0981)
OMB Supporting Statement - Part A
Prepared by
Division of Consumer Assessment & Plan Performance
Centers for Medicare & Medicaid Services 7500 Security Boulevard
Baltimore, MD 21244
3. Use of Information Technology 8
8. Federal Register/Outside Consultation 10
9. Payments/Gifts to Respondents 10
12. Burden Estimates (Hours & Wages) 11
14. Cost to the Federal Government 15
16. Publication/Tabulation Dates 16
18. Certification Statement 17
EXHIBITS
Exhibit A-1: Annual Hours/Cost Burden of the HCAHPS Survey, Exclusive of PPS-Exempt Cancer Hospitals ………………………………………………………..…………….............…………… 12
Exhibit A-2: Annual Hours/Cost Burden of the HCAHPS Survey for PPS-Exempt Cancer Hospitals
………………………………………………………………………………….............…………… 12
LIST OF ATTACHMENTS
Attachment A -- HCAHPS Survey Instrument (English)
Attachment B -- HCAHPS Survey Instrument (Spanish)
Attachment C – HCAHPS CATI Script (English)
Attachment D -- Crosswalk of HCAHPS Survey to Updated HCAHPS Survey
Attachment E -- Sixty Day Federal Register Notice – HCAHPS (inserted later)
OMB SUPPORTING STATEMENT – Part A:
National Implementation of the Hospital CAHPS Survey
(CMS-10102, OMB-0938-0981)
The HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems)
Survey is the first national, standardized, publicly reported survey of patients’ perspectives of their hospital care. HCAHPS (pronounced "H-caps"), also known as the CAHPS Hospital Survey, is a survey instrument and data collection methodology for measuring patients' perceptions of their hospital experience. This PRA package includes an updated version of HCAHPS as a 32-item survey instrument and the addition of the web mode of data collection for measuring patients’ perceptions of their hospital experience.
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. Since 2008, HCAHPS has allowed valid comparisons to be made across hospitals locally, regionally, and nationally.
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/care-compare/?providerType=Hospital&redirect=true, and in the Provider Data Catalog, https://data.cms.gov/provider-data/dataset/dgck-syfz 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/quality-assurance/.
2021 Mode Experiment
In 2021, CMS and its HCAHPS Project Team conducted a large-scale mode experiment to test web-based modes of data collection, new and revised survey items, and other updates to the HCAHPS Survey. Based on the results of the mode experiment, CMS proposed an updated version of the HCAHPS Survey instrument with 32 items. (See Attachment D for a crosswalk between the current and updated HCAHPS Survey).
The following is an overview of changes to the updated HCAHPS Survey that have been finalized in the FY 2025 Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals rule (CMS-1808-F):
Adds two new composite measures: Care Coordination, and Restfulness of Hospital
Environment
Moves one individual item (quiet at night) into a new composite measure and adds a new
individual item (give your family or caregiver enough information about symptoms or
health problems)
Updates the “About You” section of the survey by replacing one patient characteristic
item (admitted through the ER for this hospital stay) with a new item (hospital stay
planned in advance)
Moves the item on language mainly spoken at home to appear earlier in the “About You”
Section.
Alphabetizes the response options to the ethnicity and race questions in the English language survey (note survey translations will present the response options in the same order as the English language survey)
The new and revised measures on the updated HCAHPS Survey have undergone the Pre-rulemaking Measure Review process in the 2023 cycle. In the FY 2025 Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals rule (CMS-1808-F) finalized changes to the survey content that will begin with patients discharged January 1, 2025.
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; 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 at that time, National Quality Forum. 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.
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 they 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 the Comprehensive Care for Joint Replacement 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.
In recent years, CMS has received feedback from hospitals, hospital associations, survey vendors, and other stakeholders requesting the option to administer the HCAHPS 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 final rule (88 FR 27113), we added 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; we also removed the IVR mode which is currently not used for any hospitals. 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.
Beginning with January 2025 discharges, 6 modes of survey administration will be available for hospitals to choose: Mail Only, Phone Only, Mail-Phone, Web-Mail, Web-Phone, and Web-Mail-Phone mode.
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 all 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.
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 the modes listed in Section 3 above. 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 sampling) and attempt to obtain as many completes as possible. HCAHPS scores based on fewer than 100 and fewer than 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.
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 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.
There are no special circumstances associated with this information collection request.
A 60-day Federal Register notice of the FY 2025 IPPS/LTCH PPS proposed rule (RIN 0938- AV34, CMS-1808-P) published on May 2, 2024 (89 FR 35934).
During the public comment period for the FY 2025 IPPS proposed rule CMS received 54 submissions that contained 195 comments about the proposed updates to the HCAHPS Survey. Approximately 47% of the comments were classified as ‘support’ the HCAHPS proposals, 25% as ‘do not support,’ and 29% as ‘other.’
Many commenters have largely been supportive of the updates to the HCAHPS Survey and supported adopting the updates to the HCAHPS Survey measure as proposed because they believe the updates modernize the survey, promote person-centered care, reflect new technology and best practices for patient care, better align with CMS's quality strategies, and make the questions more relevant to patients and families while also being useful to hospitals. Several commenters expressed concern that the additional questions being added to the Restfulness sub-measure would have negative impacts including resulting in providers prioritizing a quiet environment over conducting patient rounds and adversely affecting hospitals with dual occupancy rooms.
After consideration of the public comments received, CMS is finalizing adoption of the updates to the HCAHPS Survey measure in the Hospital IQR, PCHQR, and Hospital VBP programs as proposed and without any changes. The comments were addressed in the final rule.
The FY 2025 IPPS/LTCH PPS Final Rule published on August 28 (89 FR 68986).
There are no provisions for payments or gifts to survey respondents.
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/quality-assurance/.
There are no questions of a sensitive nature on the HCAHPS Survey.
We believe that cost for beneficiaries undertaking administrative and other tasks on their own time is a post-tax wage of $24.04/hr. The Valuing Time in U.S. Department of Health and Human Services Regulatory Impact Analyses: Conceptual Framework and Best Practices identifies the approach for valuing time when individuals undertake activities on their own time.0 To determine the costs for respondents, the usual weekly earnings of wage and salary workers of $1,118 was divided by 40 hours to calculate an hourly pre-tax wage rate of $27.95/hr. 0 This rate is adjusted downwards by an estimate of the effective tax rate for median income households of about 14 percent calculated by comparing pre- and post-tax income.0
Exclusive of PPS-Exempt Cancer Hospitals, the HCAHPS survey has approximately 2,309,985 participating survey respondents (completed surveys) a year based upon recent survey completions and accounting for expected use of the new web-first modes of survey administration0 and change in the number of survey items starting with January 2025 hospital discharges.
Among the PPS-Exempt Cancer Hospitals, the HCAHPS survey has approximately 13,105 participating survey respondents (completed surveys) a year, based upon recent survey completions and accounting for expected use of the new web-first modes of survey administration starting with January 2025 hospital discharges and change in the number of survey items.
On average, it will take respondents 8.0 minutes (0.133333 hours) to complete the updated HCAHPS survey.
Exclusive of PPS-Exempt Cancer Hospitals, the total annual burden for participating hospitals is 307,998 hours (2,309,985 respondents by 0.133333 hours). The annual cost burden of the HCAHPS Survey for these survey respondents is $7,404,272 (307,998 total respondent hours X $24.04 median hourly earnings), as shown in EXHIBIT A-1.
EXHIBIT A-1: Annual Hours/Cost Burden of the HCAHPS Survey, Exclusive of PPS-Exempt Cancer Hospitals
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Number of Total Post-Tax Median Estimated Data Collection
HCAHPS Survey Respondents Burden Hours Hourly Wage Rate1 Cost to Respondents
Total 2,309,985 307,998 $24.04 $7,404,272
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Among PPS-Exempt Cancer Hospitals, the total annual burden for participating hospitals is1,747 hours (13,105 respondents by 0.133333 hours). The annual cost burden of the HCAHPS Survey for these survey respondents is $41,998 (1,747 total respondent hours X $24.04 median hourly earnings), as shown in EXHIBIT A-2.
EXHIBIT A-2: Annual Hours/Cost Burden of the HCAHPS Survey for PPS-Exempt Cancer Hospitals
-------------------------------------------------------------------------------------------------------------------------------------------
Number of Total Post-Tax Median Estimated Data Collection
HCAHPS Survey Respondents Burden Hours Hourly Wage Rate1 Cost to Respondents
Total 13,105 1,747 $24.04 $41,998
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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, exclusive of 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, thus the annual cost burden is $18,690,000. Assuming a one hour per hospital time cost, the annual burden for hospitals is 4,450 hours.
Exclusive of PPS-Exempt Cancer hospitals that participate in HCAHPS, the annual cost burden of the survey is:
(Survey respondents $7,404,272 ) + (Hospitals $18,690,000) = $26,094,272.
Exclusive of PPS-Exempt Cancer hospitals that participate in HCAHPS, the annual hour burden is:
(Survey respondents 307,998 hours) + (Hospitals 4,450 hours) = 312,448 hours.
Since 2018 the number of PPS-Exempt Cancer Hospitals participating in HCAHPS has been fairly stable at approximately 11 hospitals for each four-quarter period through December 2019. Over the next three years, we anticipate that about 11 PPS-Exempt Cancer Hospitals will participate in HCAHPS. To derive average costs for PPS-Exempt Cancer Hospitals, we estimate an average amount of approximately $4,200 per hospital for HCAHPS data collection activities, thus the annual cost burden is $46,200. Assuming a one hour per hospital time cost, the annual burden for hospitals is 11 hours.
For the PPS-Exempt Cancer hospitals that participate in HCAHPS, the annual cost burden of the survey is:
(Survey respondents $41,998) + (Hospitals $46,200) = $88,198.
For the PPS-Exempt Cancer hospitals that participate in HCAHPS, the annual hour burden of the survey is:
(Survey respondents 1,747 hours) + (Hospitals 11 hours) = 1,758 hours.
In total, the cost burden for this PRA package is $26,094,272 + $88,198 = $26,182,470.
Hospitals that participate in HCAHPS exclusive of PPS-Exempt Cancer Hospitals:
(Survey respondents $7,404,272 ) + (Hospitals $18,690,000) = $26,094,272
PPS-Exempt Cancer hospitals that participate in HCAHPS:
(Survey respondent $41,998) + (Hospitals $46,200) = $88,198
In total, the hour burden for this PRA package is 312,448 hours + 1,758 hours = 314,206 hours.
Hospitals that participate in HCAHPS exclusive of PPS-Exempt Cancer Hospitals:
(Survey respondents 307,998 hours) + (Hospitals 4,450 hours) = 312,448 hours
PPS-Exempt Cancer hospitals that participate in HCAHPS:
(Survey respondents 1,747 hours) + (Hospitals 11 hours) = 1,758 hours.
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, web with mail follow-up, web with telephone follow-up, or web with mail follow-up and telephone follow-up. 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, exclusive of PPS-Exempt Cancer Hospitals, 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.
Over the next three years, we anticipate that about 11 PPS-Exempt Cancer Hospitals will participate in HCAHPS. Using the estimate of $4,200 per hospital for HCAHPS data collection, the annual cost burden is $46,200.
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; adjusting for patient-mix and mode of administration; and public reporting. The annual cost to the Federal Government is estimated to be $3,977,921.
Changes to the HCAHPS Survey are documented in the crosswalk with this package. These survey changes and updates to the mode of administration adding the web mode allow CMS to be responsive to stakeholder feedback and serve to increase response rates. The change in burden from earlier OMB PRA packages is based upon the increase in survey questions (from 29 to 32) and the expected use of the new web-first modes of survey administration. Furthermore, we employ the post-tax median hourly wage rate ($24.04) to align with the Collection of Information Requirements section of the FY 2025 IPPS/LTCH PPS final rule, which is lower than the previous rate of $33.04. The burden hours increased from 277,916 to 314,206 hours.
The cumulative change in burden (in dollars) is $26,182,470 ($26,094,272 for non PCH hospitals + $88,198 for PCH hospitals) compared to $27,983,511 from the prior OMB PRA package approved on January 2, 2024.
At this time only the Spanish translation of the survey is available. CMS is also preparing Chinese, Russian, Vietnamese, Portuguese, German, Tagalog, and Arabic translations of the survey and will make them publicly available once they are completed. Other than the language, there is no difference between the English and non-English versions of the HCAHPS survey.
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/carecompare/?providerType=Hospital&redirect=true, and in the Provider Data Catalog, https://data.cms.gov/provider-data/dataset/dgck-syfz four times per year. This pattern will continue into the foreseeable future. Beginning with the October 2026 public reporting refresh, results from the updated HCAHPS Survey will be reported in the same manner.
CMS will display the OMB number and expiration date. This information appears in the OMB Paperwork Reduction Act language, which must be placed either in the survey cover letter, or on the survey instrument (mail and web modes).
The data collection does not involve any exceptions to the certification statement.
0 Valuing Time in U.S. Department of Health and Human Services Regulatory Impact Analyses: Conceptual Framework and Best Practices. https://aspe.hhs.gov/reports/valuing-time-us-department-health-human-services-regulatory-impact-analyses-conceptual-framework
0 https://www.bls.gov/news.release/pdf/wkyeng.pdf. Accessed January 1, 2024.
0 https://www.census.gov/library/stories/2023/09/median-household-income.html. Accessed January 2, 2024.
0 The survey administration updates (i.e., the introduction of the web mode of survey administration) was described in the FY 2024 IPPS rule found at 2023-16252.pdf (govinfo.gov).
| 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 | 2024-09-06 |