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May 3 -- The Centers for Medicare & Medicaid Services (CMS) invites review and comment by July 2, 2021 of its proposed 2021 Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey for Merit-based Incentive Payment Systems (MIPS).
 
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 data that CMS needs for assessing physician quality 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 used for quality reporting, the Care Compare website, and annual statistical experience reports describing MIPS data for all MIPS eligible clinicians.

This 2021 information collection request addresses changes to the CAHPS for MIPS Survey associated with the CY 2021 Physician Fee Schedule (PFS) final rule. In order to address the increased use of telehealth care due to the Public Health Emergency (PHE) for COVID-19, an additional question is added to the CAHPS for MIPS survey to integrate one telehealth item to assess the patient-reported usage of telehealth services. In addition, the cover page of the CAHPS for MIPS Survey is revised to include a reference to care in telehealth settings.  
 
We will continue to use the CAHPS for MIPS survey to assess groups containing MIPS eligible clinicians’ performance in the quality performance category. For groups of clinicians electing to report CAHPS for MIPS in the quality performance category, CAHPS for MIPS will be included in the calculation of the final score as a quality measure and thus applied to calculate payment adjustments.  
 
The survey contains ten summary survey measures (SSMs). Eight of these SSMs will be scored (Getting Timely Care, Appointments, and Information; How Well Providers Communicate; Patient’s Rating of Provider; Health Promotion and Education; Shared Decision Making; Stewardship of Patient Resources; Courteous and Helpful Office Staff; and Care Coordination), while the remaining two (Health Status and Functional Status and Access to Specialists) are included on the survey for informational purposes only. Like other quality measures, each of the eight scored SSMs in the CAHPS for MIPS survey will have an individual benchmark which will be used to establish the number of points. The CAHPS for MIPS survey will be scored based on the average number of points across the eight scored SSMs, up to 10 points. This is similar to how other quality measures are scored against a benchmark, which is to assign up to 10 points per measure. The CAHPS for MIPS survey is considered a patient experience measure for the quality performance category and therefore contributes 2 additional bonus points to the quality performance category score. It is also counted as a high weighted activity under the improvement activities performance category because it requires a significant investment of time and resources. As part of the requirements of this activity, MIPS groups must register for the CAHPS for MIPS survey and must select and authorize a CMS-approved survey vendor to collect and report survey data using the survey and specifications provided by us.
 
Seven CAHPS for MIPS SSMs are reported through the Care Compare website on public-facing group profile pages and via the Downloadable Database housed on data.medicare.gov for the purpose of promoting more informed health care choices by people with Medicare. The SSMs are reported as top box percent performance scores.
 
CMS CAHPS for MIPS Survey webpage: https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/CAHPS/MIPS
Draft 2021 CAHPS for MIPS proposal: https://www.cms.gov/Regulations-and-Guidance/Legislation/PaperworkReductionActof1995/PRA-Listing-Items/CMS-10450 See Supporting Statement Parts A and B for technical documentation
FR notice inviting public review and comment: https://www.federalregister.gov/documents/2021/05/03/2021-09256/agency-information-collection-activities-proposed-collection-comment-request
 
Point of contact: mipscahps@hsag.com

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