CAHPS for MIPS FAQs as Registration Deadline Approaches

The June 30th deadline to register with CMS for the 2017 CAHPS for MIPS Survey is quickly approaching. As provider groups make their final decision about whether to conduct the survey in 2017, SPH Analytics thought it might be helpful to post our responses to the Frequently Asked Questions we’ve received regarding the CAHPS for MIPS Survey.

CAHPS for MIPS FAQs

Can you provide an overview of MACRA, MIPS, and the Quality Payment Program?

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) has replaced a collection of several CMS quality programs with a single system where Medicare physicians and clinicians have a chance to be rewarded for quality care.

Healthcare providers will continue to provide healthcare services and business practices as usual. However, eligible clinicians may now qualify to receive a higher Medicare payments based on the practice performance. There are two paths in this Quality Payment Program (QPP):

1. Merit-based Incentive Payment System (MIPS)
   Eligible clinicians may choose to participate in MIPS as individuals or as
   part of a group
2. Advanced Alternative Payment Models (APMs)

The Merit-based Incentive Payment System (MIPS) is one track of the Quality Payment Program, where clinicians earn a performance-based payment adjustment to their Medicare payment. Clinicians participating in MIPS have the flexibility to choose the measures and activities that are most meaningful to their practice to demonstrate performance.

What is the relevance of the CAHPS for MIPS Survey?

Clinicians participating in MIPS have the flexibility to choose the quality measures and activities that are most meaningful to their practice to demonstrate performance.

• The CAHPS for MIPS Survey is an optional quality measure that groups (with 2 or more eligible clinicians) participating in MIPS can elect to administer.
• The CAHPS for MIPS Survey would count in the quality performance category as a patient experience measure. Additionally, a MIPS-eligible clinician may also be awarded points under the improvement activities performance category for administering the survey; however, it cannot be used for both performance categories.
• The CAHPS for MIPS Survey measures the patient’s experience and care received within a primary care practice group. The CAHPS for MIPS Survey is not appropriate for practices that do not include or provide primary care services (for example, a group of surgeons).
• The data collected on these surveys will be submitted to CMS on behalf of the group by a CMS-approved survey vendor (like SPH Analytics).
• Groups must report at least five (5) additional quality measures using another data submission method.

How does the group practice notify CMS of its 2017 participation in CAHPS for MIPS Survey?

The group practices must register by June 30, 2017, to elect participation in the 2017 CAHPS for MIPS Survey. Registration must be completed online through the CMS MIPS Registration System.

• Groups must indicate if they are selecting the CMS Web Interface reporting mechanism as well as elect to administer the CAHPS for MIPS Survey.

What topics are included in the 2017 CAHPS for MIPS Survey?

Similar to the CAHPS for ACO Survey, the CAHPS for MIPS Survey was developed to collect information about the patient’s experience and care received within the group practice setting. The survey measures patient experience with, and ratings of, health care providers.

The core survey includes 80 questions broken out by the following 12 “summary survey measures:”

1. Getting Timely Care, Appointments, and Information
2. How Well Providers Communicate
3. Patient’s Rating of Provider
4. Access to Specialists
5. Health Promotion and Education
6. Shared Decision Making
7. Health Status and Functional Status
8. Courteous and Helpful Office Staff
9. Care Coordination
10. Between Visit Communication
11. Helping You to Take Medications as Directed
12. Stewardship of Patient Resources

To help orient the beneficiary’s point of reference, the survey tool will state the name of the specific clinician/provider who delivered primary care to the eligible beneficiary over multiple visits in the performance year.

The named or eligible provider can be a physician, specialist, nurse practitioner, physician assistant, or clinical nurse specialist.

Are groups required to contract with a CMS-approved survey vendor to conduct the CAHPS for MIPS Survey?

Yes. Group practices are required to contract with a CMS-approved survey vendor to administer the CAHPS for MIPS Survey in accordance with the sample, survey administration, data collection, and reporting specifications provided by CMS.

SPH Analytics is a CMS-approved survey vendor for the 2017 CAHPS for MIPS survey.  

What is the timeframe for survey distribution?

For the program year 2017, the CAHPS for MIPS Survey will be administered during a November 2017 to February 2018 timeline.

Data collected will be submitted by SPH Analytics to CMS on behalf of the group.

What is the CMS methodology for administration/distribution of the CAHPS for MIPS Survey? 

CMS requires the survey be administered through a mixed-mode of data collection that includes:

• CMS pre-notification letter
• Initial survey and cover letter
• Second survey and cover letter to non-respondents
• Up to six follow-up phone calls to beneficiaries who do not return a survey by mail

Are other modes, like web-based or IVR modes of administration, acceptable?

No. The mixed-mode specified by CMS for the CAHPS for MIPS Survey administration requires mail survey administration followed by survey administration via Computer Assisted Telephone Interviewing (CATI) to non-respondents.

IVR or web-based survey administration would not meet the mixed-mode requirements of CMS.

What actions are required of groups opting to administer the survey?

If your group selects the CAHPS for MIPS Survey as one of the quality measures to report to CMS, the group will be responsible for the following:

• Group practice contracts with a CMS-approved survey vendor (like SPH Analytics)
• Select and authorize a CMS-approved survey vendor (like SPH Analytics) to collect and report your survey data to CMS
• Monitor the status of survey timeline, data collection, and CMS data submission
• Receive your CAHPS for MIPS Survey scores from CMS
• Have your CAHPS for MIPS Survey scores available for public reporting on Physician Compare

How often is the CAHPS for MIPS Survey administered?

The survey is conducted on an annual basis. The 2017 survey timeframe for administration and data collection is November 2017 to February 2018.

Who will draw the sample of patients eligible to participate in the survey?

CMS will draw the survey sample of patients eligible to participate in the survey sample and provide to the group’s survey vendor (such as SPH Analytics).

CMS will identify beneficiaries eligible for the survey from the pool of Medicare fee-for-service (FFS) beneficiaries assigned to the group.

What is the CAHPS for MIPS Survey patient sample criteria applied by CMS?

CMS assigns eligible Medicare FFS beneficiaries to the associated group and then randomly pulls the sample (860) from those assigned beneficiaries to create the sample for the CAHPS for MIPS Survey.

• Criteria for Medicare FFS beneficiaries:
  • 18 years of age or older
  • Are not known to be institutionalized or deceased
  • Have had at least two visits for care to the group practice
• The sample will be drawn at the group level, not at the individual clinician level
• The number of patients sampled will vary based on the size of the group
  • For large groups of 100 or more eligible clinicians: CMS will draw a sample of 860 beneficiaries. If there are fewer than 860 beneficiaries but more than 415 beneficiaries, all eligible beneficiaries will be surveyed in 2017. If there are fewer than 416 beneficiaries, the survey cannot be conducted.
  • For groups with 25 to 99 eligible clinicians: CMS will draw a sample of 860 beneficiaries. If there are fewer than 860 beneficiaries but more than 254 beneficiaries, all eligible beneficiaries will be surveyed in 2017. If the group has fewer than 255 beneficiaries, the survey cannot be conducted.
  • For groups with 2 to 24 eligible clinicians: CMS will draw from a sample of 860 beneficiaries. If there are fewer than 860 beneficiaries but more than 124 beneficiaries, all eligible beneficiaries will be surveyed in 2017. If the group has fewer than 125 beneficiaries, the survey cannot be conducted.

Note:  Groups that do not meet the minimum sample sizes noted above cannot administer the CAHPS for MIPS Survey.

Can the group supplement the sample selected by CMS in an effort to generate clinician-level/provider-level results?

No. Oversampling is not allowed in 2017. However, it may be considered by CMS as an option in the future.

Are supplemental questions allowed for the CAHPS for MIPS Survey administration?

No. CMS does not allow groups to add supplemental questions to the CAHPS for MIPS Survey.

What languages are required for CAHPS for MIPS Survey administration?

The CAHPS for MIPS Survey must be administered in English. Groups in Puerto Rico must administer the survey in Spanish and offer English if requested. Additional translations are available for groups to use on an optional basis.

What translations are available from CMS for the CAHPS for MIPS Survey?

CMS has translated the CAHPS for MIPS Survey into Cantonese, Korean, Mandarin, Russian, Spanish, and Vietnamese. Groups have the option of administering the survey in one or more of the available languages.

Are survey vendors allowed to conduct analysis of the CAHPS for MIPS Survey data?

CMS will provide the final and official survey results to groups participating in survey administration. However, survey vendors (such as SPH Analytics) may provide groups with preliminary survey results. Since CMS does not provide the data weighting formulas being applied, all reports provided to groups (whether paper or electronic format) by SPH Analytics are therefore “unofficial” and provided for the purpose of the group’s internal quality improvement efforts.

SPH Analytics is required to maintain respondent confidentiality. Identification, intervention, or any type of follow-up with low scoring individuals/patients is not permitted.

Where can I find the CAHPS for MIPS benchmark scores?

These will be available on the physician compare website (https://www.medicare.gov/physiciancompare/)

What is the difference between CAHPS for ACOs, CAHPS for MIPS and CG CAHPS?

While all three surveys, and other patient experience surveys, can count towards either a high-priority patient experience measure in the MIPS Quality performance category or a high-weighted activity in the MIPS Improvement Activities performance category (but not both), these surveys differ in the type of survey recipients and the information that is measured. The CAHPS Survey for ACOs collects data from Accountable Care Organizations to measure the required patient experience-of-care measures in Next Generation and Pioneer ACO models and the Shared Savings Program. The CAHPS Clinician and Group (CG CAHPS) Survey measures patient satisfaction and general experience with their primary care physician and/or physician practice. The CAHPS for MIPS Survey measures a patient’s experience and care within a physician group.

Are there any restrictions on fielding other surveys at the same time as CAHPS for MIPS Survey?

CMS strongly encourages groups and survey vendors NOT to ask Medicare beneficiaries any CAHPS for MIPS Survey questions four weeks prior to and four weeks after the CAHPS for MIPS Survey administration period. This recommendation does not apply to other CMS surveys.    

Groups should take respondent burden and response rates into account when considering the timing of any additional data collection efforts.

Are group-level results being publicly reported on the Medicare website?

Yes. The CAHPS for MIPS scores are reported by CMS on the Physician Compare website annually.  Public reporting of CAHPS for MIPS Survey scores will serve to assist Medicare consumers in making objective and meaningful health care decisions.

How can I get more information or a proposal from SPH Analytics?

For more information about SPH Analytics or the CAHPS for MIPS Survey, please contact us at info@sphanalytics.com or visit our website at SPHAnalytics.com.

Maximizing MIPS Revenue

As a CMS-Approved QCDR and CAHPS for MIPS Vendor, SPH Analytics is committed to helping our clients meet MIPS reporting requirements and to excel in quality measurement for maximum reimbursement for delivering high-quality care. Contact us for a free MIPS consultation to learn more about our complete MIPS Max Suite of Solutions and how we can help you maximize MIPS revenue.

Additional Resources

• Register for the CMS Web Interface and CAHPS for MIPS Survey
• CMS Quality Payment Program Website (https://qpp.cms.gov)
• MACRA Final Rule Executive Summary
• Request a Free MIPS Consultation

CAHPS^® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).