1. (CAHPS) Experience of Care Surveys From Design to Implementation
Liz Goldstein, Ph.D.
AHRQ Annual Conference
September 9, 2012

2. The Triple Aim
Better care
Healthier people & communities
Lower cost

3. Patient Experience Surveys
Patient Experience Surveys Support the Triple Aim Through Public Reporting, Pay for Performance, and Quality Improvement
Triple Aim
Public Reporting
Pay for Performance
Quality Improvement
Patient Experience Surveys

4. CAHPS Surveys Measure Patient Experience, Not Patient Satisfaction
CAHPS asks patients whether key things happened in their health care.
Provides actionable information to improve the quality of care.
Focus is on important aspects of care such as communication, access, coordination of care, and patient involvement.
Less subjective than asking about satisfaction.

5. CAHPS Surveys Currently Implemented by CMS
Hospital (HCAHPS)
Home Health Care (HHCAHPS)
Health Plan
Prescription Drug Plan
Fee-for-Service

6. Public Reporting

7. Public Reporting on www.medicare.gov
“Compare” web sites help users gain information and make decisions
Links to “Compare” web sites

8. Home Health Compare Provides Information About Home Health Agencies

9. Compare up to 3 Agencies Simultaneously
Criteria Include
Services Provided
Nursing Care
Physical Therapy
Occupational Therapy
Speech Therapy
Medical Social Services
Home Health Aide
Quality of Patient Care
Managing Daily Activities
Managing Pain and Treating Symptoms
Treating Wounds and Preventing Pressure Sores
Preventing Harm
Preventing Unplanned Hospital Care
And Patient Experience Survey Results…

10. Patient Experience Survey Results Home Health CAHPS (HHCAHPS)
Percent of patients who…
Reported that their home health team gave care in a professional way.
Reported that their home health team communicated well with them.
Reported that their home health team discussed medicines, pain, and home safety with them.
Gave their home health agency a rating of 9 or 10 on a scale from 0 (lowest) to 10 (highest).
Reported YES, they would definitely recommend the home health agency to friends and family.
Composite Measures
Global Scores

11. Incentive for Home Health Agencies to Participate and Report the Data
Reporting HHCAHPS Results
Home Health Annual Payment update
No Report = Less Money

12. Home Page for Hospital Compare

13. Data Available on Hospital Compare
General Information about Hospitals
Patient Experience Data
Clinical Data
Administrative Data

14. Example of Patient Experience Data Presented on Hospital Compare
CAHPS Measures
Hospital 1
Hospital 2
Hospital 3
Patients who reported that their nurses “Always” communicated well.
66%
73%
68%
Patients who reported that their doctors “Always” communicated well.
75%
80%
72%
Dimensions based on patient responses to HCAHPS Surveys.
Data used in Hospital Value Based Purchasing.
Allows the public to see specific, detailed comparisons among providers.

15. Home Page for Medicare Health Plan Comparisons

16. Number of Plans by Type in Your Area
Summary:
Number of Plans by Type in Your Area

17. Individual Plan Entry
Overall Star Ratings

18. CMS Plan Ratings System
CMS created the Five-Star Plan Rating System to help consumers, their families, and caregivers compare health plans. And in the case of Medicate Advantage plans to reward high-performing plans with bonuses.
Excellent
Above average
Average
Below average
Poor
Plan Ratings

19. Adjustments to Patient Experience Data to Ensure Comparable Information
Mix of patients.
Mode of survey administration (if applicable).

20. Pay for Performance

21. Hospital Value Based Purchasing
Hospital Value Based Purchasing links a portion of CMS payment to providers based on performance on a set of quality measures
Hospital Value Based Purchasing established by the Patient Protection and Affordable Care Act of 2010 (Public Law )
Affects payment for patients discharged October 1, 2012 (FY 2013) and forward

22. Here is How it Works:
Hospital VBP Incorporates Patient Experiences into Providers’ Total Performance Score
Clinical Process Domain Score
Patient Experience Domain Score
Total Performance Score + =
Patient Experience Surveys (CAHPS)
70%
30%
Payment

23. HCAHPS and Hospital VBP Scoring
Eight HCAHPS Dimensions in Hospital VBP
Communication with Nurses
Communication with Doctors
Staff Responsiveness
Pain Management
Communication about Medicines
Discharge Information
Cleanliness & Quietness of Hospital Environment (combined)
Overall Rating of Hospital
Percent of patients who chose “Top-box” response

24. Most Dimensions Are Composed of Individual Survey Items
Communications With Nurses
(Items 1, 2, 3 )
1. During this hospital stay, how often did nurses treat you with courtesy and respect?
2. During this hospital stay, how often did nurses listen carefully to you?
3. During this hospital stay, how often did nurses explain things in a way you could understand?
Dimension:
Communications with Doctors
(Items 5, 6, 7)
5. During this hospital stay, how often did doctors treat you with courtesy and respect?
6. During this hospital stay, how often did doctors listen carefully to you?
7. During this hospital stay, how often did doctors explain things in a way you could understand?

25. Patient Experience Domain Score Calculation
HCAHPS Base Score
For each of the Eight HCAHPS Dimensions:
Achievement Points (0-10) and Improvement Points (0-9) are calculated
The larger of the Improvement Points or Achievement Points for each Dimension is used
Dimension scores are summed to create the HCAHPS Base Score : 0 to 80 points
Consistency Points
0 to 20 points
Target hospital’s lowest performing HCAHPS Dimension during the Performance Period
If the lowest scoring Dimension is below the national median,
then the hospital earns between 0 and 19 Consistency Points
Max Patient Experience Domain Total Score = 100 points

26. Patient Responses to Survey Items Patient Experience Domain Score
Patient Experience Central Role in Hospital VBP
Patient Responses to Survey Items
8 Dimensions
Patient Experience Domain Score
30 % of Total Score
Payment

27. Medicare Advantage Quality Ratings
Quality bonuses are required as part of the Affordable Care Act for MA contracts
CMS is conducting a demonstration to determine whether additional quality-based payments lead to more rapid and larger year-to-year quality improvements
Quality bonuses are based on the MA Plan Ratings.

28. Plan Ratings – Multiple Levels
Example Measures
Example Domains
Overall and Summary Rating (1/2 stars)
Overall (MA-PD) or
Summary (Part C and Part D)
Staying Healthy
Breast Cancer Screening
Annual Flu Vaccine
Patient Safety
High Risk Med Use
75% screened
75% vaccinated
10% members receive HRM

29. 9 Domains of Plan Ratings
Ratings of Health Plans (Part C)
Staying healthy: screenings, tests, vaccines
Managing chronic (long-term) conditions
Member experiences with their health plan
Member complaints, problems getting services, and choosing to leave the plan
Health plan customer service
Ratings of Drug Plans (Part D)
Drug plan customer service
Member complaints, problems getting services, and choosing to leave the plan
Member experience with plan’s drug services
Drug pricing and patient safety

30. Sources of Data for Plan Ratings
Surveys (CAHPS Surveys and Health Outcomes Survey)
Clinical Data (Healthcare Effectiveness Data and Information Set, HEDIS)
CMS administrative data
Data collected by CMS contractors

31. Quality Bonus Payments Under Current Law and CMS Demonstration

32. Quality Improvement

33. Quality Improvement
Plan/provider quality improvement (QI) strategies should focus on improving overall care that enrollees/patients are receiving across the full spectrum of services.
QI strategies should not be limited to only the measures included in the public reporting and VBP initiatives.

34. Incentives for Quality Improvement
Public Reporting
Value-based Purchasing

35. High Performer Icon for Plans
CMS highlights contracts receiving a rating of 5 stars with this icon:
Information on Medicare.gov notes that beneficiaries can enroll in 5-star contracts at any time during the year.
This plan got
Medicare’s highest
rating (5 stars) 5

36. Low Performer Icon for Plans
Since 2011, CMS has marked contracts rated less than 3 stars with a low performer icon:
Beginning this fall, beneficiaries will be unable to use MPF to enroll in these contracts.
MPF messaging and Medicare representatives will also discourage enrollment into these contracts.

37. Examples of Tools for Quality Improvement
Medicare Plan Reports
CAHPS Quality Improvement Guide

38. Excerpt from Health Plan Report to use for Quality Improvement

39. Plan Report Points out Strengths and Opportunities for Improvement

40. Recent Updates

41. Recent Enhancements to CMS Patient Experience Surveys
Care Transitions measures added to Hospital CAHPS starting July 2012 on a voluntary basis and January 2013 nationally.
Care Coordination items added to Medicare health plan survey in early 2012.

42. Future Directions In-Center Hemodialysis CAHPS
Accountable Care Organizations
Health Insurance Exchanges
Medicaid Home and Community-Based Services
Hospice
Emergency Room
Outpatient Surgical