(CAHPS) Experience of Care Surveys

From Design to Implementation

Liz Goldstein, Ph.D.AHRQ Annual Conference

September 9, 2012

The Triple Aim

Better care

Better care

Healthier people & communities

Lower cost

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

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.

Hospital (HCAHPS)

Home Health Care (HHCAHPS)

Health Plan

Fee-for-Service

Prescription Drug Plan

CAHPS Surveys Currently Implemented by CMS

Public Reporting

Public Reporting on www.medicare.gov

Links to “Compare” web sites

“Compare” web sites help users gain information and make decisions

Home Health Compare Provides Information About Home Health Agencies

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

Compare up to 3 Agencies SimultaneouslyCriteria Include

And Patient Experience Survey Results…

Patient Experience Survey ResultsHome 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.

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Reporting HHCAHPS Results

Home Health Annual Payment update

Incentive for Home Health Agencies to Participate and Report the Data

No Report = Less Money

Home Page for Hospital Compare

Data Available on Hospital Compare

General Information about HospitalsPatient Experience Data

Clinical Data Administrative Data

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%

Example of Patient Experience Data Presented on Hospital Compare

•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.

Home Page for Medicare Health Plan Comparisons

Summary:Number of Plans by Type in Your Area

Individual Plan Entry

Overall Star Ratings

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

Adjustments to Patient Experience Data to Ensure Comparable

Information

• Mix of patients. • Mode of survey administration (if applicable).

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 111-148)

– Affects payment for patients discharged October 1, 2012 (FY 2013) and forward

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

• 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

HCAHPS and Hospital VBP Scoring

Most Dimensions Are Composed of Individual Survey Items

Dimension: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?

Patient Experience Domain Score Calculation

HCAHPS Base ScoreFor each of the Eight HCAHPS Dimensions:

1. Achievement Points (0-10) and Improvement Points (0-9) are calculated

2. The larger of the Improvement Points or Achievement Points for each Dimension is used

3. 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 PointsMax Patient Experience Domain Total Score = 100 points

Patient Experience Central Role in Hospital VBP

Patient Responses to Survey Items

8 Dimensions

Patient Experience Domain Score

30 % of Total Score

Payment

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.

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

9 Domains of Plan Ratings

Ratings of Health Plans (Part C)

Staying healthy: screenings, tests, vaccinesManaging chronic (long-term) conditions

Member experiences with their health planMember complaints, problems getting services, and choosing to leave the planHealth plan customer service

Ratings of Drug Plans (Part D)

Drug plan customer service

Member complaints, problems getting services, and choosing to leave the planMember experience with plan’s drug servicesDrug pricing and patient safety

Sources of Data for Plan Ratings

1. Surveys (CAHPS Surveys and Health Outcomes Survey)

2. Clinical Data (Healthcare Effectiveness Data and Information Set, HEDIS)

3. CMS administrative data

4. Data collected by CMS contractors

Quality Bonus Payments Under Current Law and CMS Demonstration

Quality Bonus % Less than 3 stars

3 stars 3.5 stars 4/4.5 stars

5 stars

Current law none none none 1.5-5% 1.5-5%2012/2013 demonstration none 3% 3.5% 4% 5%2014 demonstration none 3% 3.5% 5% 5%

Quality Improvement

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.

Incentives for Quality Improvement

• Public Reporting• Value-based Purchasing

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.

5This plan got Medicare’s highest rating (5 stars)

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 1-800 Medicare representatives will also discourage enrollment into these contracts.

Examples of Tools for Quality Improvement

• Medicare Plan Reports• CAHPS Quality Improvement Guide

Excerpt from Health Plan Report to use for Quality Improvement

Plan Report Points out Strengths and Opportunities for Improvement

Recent Updates

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.

Future Directions

• In-Center Hemodialysis CAHPS• Accountable Care Organizations • Health Insurance Exchanges• Medicaid Home and Community-Based

Services• Hospice• Emergency Room• Outpatient Surgical