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

The Triple Aim Better care Healthier people & communities Lower cost

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

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.

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

Public Reporting

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

Home Health Compare Provides Information About Home Health Agencies

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…

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

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

Home Page for Hospital Compare

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

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.

Home Page for Medicare Health Plan Comparisons

Number of Plans by Type in Your Area 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

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

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

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?

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

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

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, 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

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

Quality Bonus Payments Under Current Law and CMS Demonstration

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

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