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Oct 17 -- The Centers for Medicare & Medicaid Services (CMS) is announcing an opportunity for the public to comment on CMS' intention to collect information through CMS–10450: Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey for Merit-based Incentive Payment Systems (MIPS). Comments must be received by December 18, 2023.

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 only the necessary 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 compare tool on the Medicare.gov website, and annual statistical experience reports describing MIPS data for all MIPS eligible clinicians.

This 2024 information collection request addresses the requirements related to the statutorily required quality measurement. The CAHPS for MIPS survey results in burden to three different types of entities: groups, virtual groups, and subgroups; vendors; and beneficiaries associated with administering the survey. Virtual groups are subject to the same requirements as groups and subgroups; therefore, we will refer only to “groups” as an inclusive term for all entities unless otherwise noted.

The CY 2017 Quality Payment Program final rule established the data submission requirements for CAHPS for groups of two or more MIPS eligible clinicians and the requirement that data for each 12-month performance period be reported by a CMS-approved survey vendor on behalf of the group. The CY 2018 Quality Payment Program final rule established a policy to allow virtual groups to submit quality data via all data submission mechanisms available to groups, including the CAHPS for MIPS survey. The CY 2021 Quality Payment Program final rule aligned the Shared Savings Program (SSP) quality performance standard with the MIPS quality performance category via the APM Performance Pathway (APP); specifically, to have SSP Accountable Care Organizations (ACOs) field the CAHPS for MIPS Survey under the APP scoring standard.

The CY 2022 Quality Payment Program final rule established subgroup reporting of CAHPS under the MIPS Value Pathways (MVP). The CY 2022 final rule also established that, clinicians participating in subgroups or groups reporting on the CAHPS for MIPS survey measure within an MVP would be unable to make any changes to their participation in the CAHPS for MIPS survey beginning July 1 of the applicable performance period. The CY 2022 final rule established “subgroup reporting for clinicians” for multispecialty groups participating in MIPS Value Pathway (MVP). Subgroup reporting of CAHPS is currently voluntary.

At this time, CMS requires participation in the CAHPS for MIPS Survey by SSP ACOs, and allows groups, subgroups, virtual groups, and APM entities (other than SSP ACOs) to participate in CAHPS on a voluntary basis.

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 SSMs. Nine of these SSMs will be scored (Getting Timely Care, Appointments, and Information; How Well Providers Communicate; Patient’s Rating of Provider; Access to Specialists; Health Promotion and Education; Shared Decision Making; Stewardship of Patient Resources; Courteous and Helpful Office Staff; and Care Coordination), while the remaining SSM (Health Status and Functional Status) is included on the survey for informational purposes only. Like other quality measures, each of the nine 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 nine 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.

We also will use the CAHPS for MIPS survey data as part of performance feedback to MIPS groups. Selected performance data is made available to beneficiaries, as well as to the public, on the compare tool on the Medicare.gov website. This performance data is intended to help beneficiaries and their caregivers to choose clinicians that provide services that meet their needs and preferences, thus encouraging clinicians to improve the quality of care that Medicare beneficiaries receive. CMS plans to also use the data to produce annual statistical experience reports that will describe the patient experience measures for all MIPS eligible clinicians who elect to use CAHPS for MIPS as one of their quality measures, and for subgroups of clinicians using CAHPS.

Additionally, this survey will provide patient experience of care data that is an essential component of assessing the quality of services delivered to Medicare beneficiaries.

CAHPS for MIPS Survey https://www.cms.gov/data-research/research/consumer-assessment-healthcare-providers-systems/cahps-mips
Draft data collection materials: https://www.cms.gov/regulations-and-guidance/legislation/paperworkreductionactof1995/pra-listing-items/cms-10450
FRN: https://www.federalregister.gov/d/2023-22897 #1

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