Participation Basics

What is my REACH ACO required to do?

On an annual basis, REACH ACOs are responsible for contracting with a CMS-approved survey vendor, authorizing their vendor on the ACO REACH CAHPS website, and ensuring the contract and authorization remain in effect for the survey. For a summary of requirements, deadlines, and guidance, see “ACO REACH CAHPS Survey Guidance for Direct Contracting Entities” in the 4i Knowledge Library or under Quick Links For ACOs on the CAHPS website on https://acoreachcahps.org.

What do I have to do on the CAHPS website (https://acoreachcahps.org)?

REACH ACO’s designate a staff member in your ACO to serve as your Survey Administrator. This person needs to go to the website to authorize a vendor. This activity is done annually during the June to August window. Watch the ACO REACH Newsletter for information on when the ACO REACH CAHPS website will open in June for ACOs’ registration and authorization. For assistance with changing or registering a new survey administrator, please see the resources under “Quick Links for ACOs” on the https://acoreachcahps.org website, or contact acoreachcahps@rti.org.

Working with a Survey Vendor

Where and when can I find the list of approved survey vendors?

Each April CMS will provide a list of vendors who have successfully completed ACO REACH CAHPS training. CMS considers these vendors “conditionally approved” and encourages REACH ACOs to contact vendors for cost and service information before contracting with vendors, as there may be differences among vendors.

CMS will post the final list of approved survey vendors for the upcoming performance year each June. It is important to ensure your chosen vendor appears on the June list. Please refer to the ACO REACH newsletter for announcements about the final list and updates.

We already have a vendor Do we need to do anything else? What if I want to switch vendors?

If you wish to continue with your current vendor, simply ensure your contract and BAA are up to date, and (in the June to August window) authorize your vendor on the CAHPS website for the coming performance year. If you wish to change to a new vendor, execute a contract and BAA with that vendor, delete the authorization for the old vendor (see instructions “How To Delete a Vendor Authorization in the CAHPS website’s” “Quick Links for ACOs” menu) and authorize the new vendor during the June to August window.

Do I need Business Associate Agreement (BAA) or Data Usage Agreement (DUA)?

REACH ACOs need to have a BAA with their survey vendor. A previous BAA from another project can be used provided the BAA is accurate, current, and contains the name of the vendor and REACH ACO. Please discuss with your selected survey vendor.

We already conduct a patient survey for another program. Can ACO REACH use that data instead?

No. You are required to conduct the ACO REACH CAHPS. To avoid imposing on beneficiaries, CMS strongly encourages REACH ACOs to refrain from conducting other beneficiary surveys or census surveys from 4 weeks prior to and during the period when the ACO REACH CAHPS is actively surveying.

How do I change a vendor authorization?

Delete the vendor authorization you wish to change by following the directions in “How To Delete A Survey Vendor Authorization” in the “Quick Links for ACOs” menu on the CAHPS website https://acoreachcahps.org. Then, authorize the new vendor. Vendor authorizations should not be changed after authorization deadline. In the event of extenuating circumstances, contact the CAHPS Survey Coordination Team at acoreachcahps@rti.org.

The ACO REACH CAHPS Survey

Why is CMS including a CAHPS/Patient Experience Survey in ACO REACH?

Patient experience indicates high quality care has been provided, according to the patient’s own perspective. Since patient experience is an important component of quality, ACOs’ CAHPS scores impact their Quality Score. Additionally, positive patient experience is associated with higher levels of patient adherence, improved clinical outcomes, and lower utilization of inpatient and emergency department services.

Which official CAHPS survey needs to be fielded for ACO REACH?

CMS requires REACH ACOs to use the ACO REACH questionnaires for quality measurement purposes. This CAHPS survey is very similar to the Next Gen ACO and MIPS CAHPS surveys. There is one ACO REACH CAHPS survey for Standards/New Entrants ACOs and one for High Needs ACOs. CAHPS survey includes questions about health care experiences from the patient’s perspective. Example questions include how hard or easy it is to get appointments, obtain answers to medical questions between visits, and if the patient’s health care team listens and explains things in a way that is easy to understand.

The ACO REACH CAHPS surveys can be found on the CAHPS website under the “Surveys and Protocols” menu.

What are the measures in the ACO REACH survey and how do they map to the survey questions?

The mapping of each CAHPS survey question to a Summary Survey Measure (SSM) is located in Appendices C-2 and C-3 of the PY 2024 Quality Measurement Methodology Report, available on 4i: https://4innovation.cms.gov/secure/knowledge-management/view/850

Below are the SSMs in the Standards/New Entrant questionnaire and the survey questions which map to them:

Getting Timely Care, Appointments, and Information

• In the last 6 months, when you contacted this provider’s office to get an appointment for care you needed right away, how often did you get an appointment as soon as you needed?
• In the last 6 months, when you made an appointment for a check-up or routine care with this provider, how often did you get an appointment as soon as you needed?
• In the last 6 months, when you contacted this provider’s office during regular office hours, how often did you get an answer to your medical question that same day?
• In the last 6 months, when you contacted this provider’s office after regular hours, how often did you get an answer to your medical question as soon as you needed?

How Well Providers Communicate

• In the last 6 months, how often did this provider explain things in a way that was easy to understand?
• In the last 6 months, how often did this provider listen carefully to you?
• In the last 6 months, how often did this provider show respect for what you had to say?
• In the last 6 months, how often did this provider spend enough time with you?

Shared Decision making

• When you and this provider talked about starting or stopping a prescription medicine, did this provider ask what you thought was best for you?
• In the last 6 months, did you and this provider talk about how much of your personal health information you wanted shared with your family or friends?

Patient’s Rating of Provider

• Using any number from 0 to 10, where 0 is the worst number and 10 is the best provider possible, what number would you use to rate this provider?

Care Coordination

• In the last 6 months, how often did this provider seem to know the important information about your medical history?
• In the last 6 months, when this provider ordered a blood test, x-ray, or other test for you, how often did someone from this provider's office follow-up to give you those results?
• In the last 6 months, how often did you and someone from this provider's office talk about all the prescription medicines you were taking?

Courteous and Helpful Office Staff

• In the last 6 months, how often were clerks and receptionists at this provider's office as helpful as you thought they should be?
• In the last 6 months, how often did the clerks and receptionists at this provider's office treat you with courtesy and respect?

Health Promotion and Education

• Your health care team includes all the doctors, nurses and other people you see for health care. In the last 6 months, did you and anyone on your health care team talk about a healthy diet and healthy eating habits?
• In the last 6 months, did you and anyone on your health care team talk about the exercise or physical activity you get?
• In the last 6 months, did anyone on your health care team ask you if there was a period of time when you felt sad, empty, or depressed?
• In the last 6 months, did you and anyone on your health care team talk about things in your life that worry you or cause you stress?

Stewardship of Beneficiary Resources

• In the last 6 months, did you and anyone on your health care team talk about how much your prescription medicines cost?

Health Status and Functional Status (this SSM does not contribute to the ACO’s PY 2024 CAHPS Score)

• In general, how would you rate your overall health?
• In general, how would you rate your overall mental or emotional health?
• Is this a condition or problem that has lasted for at least 3 months?
• Is this medicine to treat a condition that has lasted for at least 3 months?

Access to Specialist (this SSM does not contribute to the ACO’s CAHPS PY 2024 Score)

• In the last 6 months, how often was it easy to get appointments with specialists?

Activities of Daily Living (this SSM does not contribute to the ACO’s PY 2024 CAHPS Score)

• Because of a health or physical problem, are you unable to do or have any difficulty bathing?
• Because of a health or physical problem, are you unable to do or have any difficulty dressing?
• Because of a health or physical problem, are you unable to do or have any difficulty eating?
• Because of a health or physical problem, are you unable to do or have any difficulty getting in or out of chairs?
• Because of a health or physical problem, are you unable to do or have any difficulty walking?
• Because of a health or physical problem, are you unable to do or have any difficulty using the toilet?

For High Needs Questionnaires, the questions are the same except for those differences listed below:

Heath Promotion and Education – omits two questions (sad/empty/depressed and worry/cause stress) from Standards/New Entrants

Emotional Support

• In the last 3 months, did you get as much help as you wanted for your feelings of anxiety or sadness?

Family Support

• In the last 6 months, did this provider involve your family or friends in discussions about your health care as much as you wanted?
• In the last 6 months, did your family members or friends get as much emotional support as they wanted from this provider?

Pain

• In the last 6 months, did this provider give you as much help as you wanted for your pain?

Health Emergency

• Did someone from this provider’s office ever talk with you about what you should do during a health emergency?

Can REACH ACOs add their own questions to the ACO REACH CAHPS?

No.

Does the PY 2024 ACO REACH CAHPS have any changes compared to prior years?

Minor revisions were made after PY 2023. These changes shortened the instrument, discontinued the pre-notification postcard, and lengthened the duration of the survey period. CAHPS will be Pay for Performance in PY 2024 all ACO types. The scores attained, as compared to benchmarks set by CMS, will impact these ACO’s PY 2024 Total Quality Score for ACO REACH. CMS establishes separate benchmarks for High Needs ACOs and for Standards and New Entrant ACOs. For more information see the PY 2024 Quality Measurement Methodology Report.

How is the ACO REACH CAHPS survey conducted?

The survey begins with mail data collection and then follows up by calling non-responders by telephone. Sampled beneficiaries will receive up to 2 mail surveys and 6 telephone calls over the 13-week data collection period.

When will data collection for the Performance Year 2024 ACO REACH CAHPS Survey begin and end?

Data collection begins in September and ends December, approximately 13 weeks. The survey will be conducted annually.

In what languages is the survey available?

The survey is available in English and Spanish for PY 2024.

How long does the survey take?

The ACO REACH CAHPS takes about 10 minutes using hardcopy or 15 to 20 minutes in a telephone interview.

What about patients incapable of doing a survey?

Although providers and staff may not assist patients with completing their surveys, caregivers, family members or friends can help a patient who requires assistance — by recording answers, reading the survey aloud, or translating it into the patients’ language. If a patient cannot respond due to poor health or cognitive or physical limitation, a caregiver, family member or friend knowledgeable about their care can take the survey on their behalf.

Who can REACH ACOs contact if they have questions about the ACO REACH CAHPS Survey?

Please contact the ACO REACH Model Helpdesk at ACOREACH@cms.hhs.gov, or call 1-888-734-6433 (Option 1 (Accountable Care Model), Option 3) from 8:30 AM to 7:30 PM ET. If REACH ACOs have questions related to survey administration, please contact your CAHPS survey vendor directly.

Sampling

Are all REACH ACOs required to conduct the ACO REACH CAHPS?

In general, yes, all REACH ACOs are required to conduct the ACO REACH CAHPS. However, if CMS determines a REACH ACO has an inadequate number of aligned beneficiaries to conduct a survey, CMS will notify the REACH ACO they are exempt from conducting the survey for that performance year.

Which patients are surveyed?

Among Standard/New Entrant REACH ACOs, Medicare beneficiaries who had a primary care visit – either in person or telehealth – with a REACH ACO provider, at least twice in the past 12 months, are eligible to be surveyed. Among High Needs Population REACH ACOs, the beneficiary must have had at least one visit in the past 12 months to be eligible to be surveyed. The 12-months typically reflects the most recent July 1 – June 30 period. CMS draws a random sample of eligible beneficiaries within REACH ACOs. Beneficiaries who receive hospice care, are deceased, or who reside in nursing homes/skilled nursing facilities, are ineligible. More detail about sample specifications can be found in Chapter 4 of the Quality Assurance Guide, found in the CAHPS website’s Surveys and Protocols menu.

How many patients are surveyed per ACO?

In each REACH ACO, 860 beneficiaries are surveyed per ACO. Should there be fewer than 860 survey-eligible beneficiaries, CMS may survey a smaller number based on the number of providers. If the number of beneficiaries is too small to achieve an acceptable level of reliability (i.e., ability to find statistically significant differences between REACH ACOs), the REACH ACO is exempt from conducting the CAHPS survey.

The sample sizes which will be drawn based on the number of beneficiaries per REACH ACO are shown below.

ACO REACH CAHPS Survey Results

How will REACH ACOs receive the results of the ACO REACH CAHPS?

CMS provides each REACH ACO with a personalized Annual Quality Performance Report. This will include CAHPS results and benchmarks. Vendors may also provide results, yet vendor results are not considered official CMS CAHPS results for the program.

Does CMS publicly report the results of ACO REACH CAHPS anywhere?

The results of the ACO REACH CAHPS will be posted to the ACO REACH website (https://innovation.cms.gov/innovation-models/acoreach-model).

How do CAHPS results impact Standard, New Entrant and High Needs Population ACOs PY 2024 Total Quality score?

Among Standard and new Entrant ACOs, the CAHPS composite score accounts for 10 points out of the total 40 possible points awarded based on quality measure performance.

How are the 10 points attained?

A REACH ACO can earn up to 10 Summary Survey Measure (SSM) points for each SSM for a total possible count of 80 SSM points. The SSM points are allocated for each SSM based on a comparison of the REACH ACO’s SSM performance against a benchmark distribution. The table below displays the SSM points out of 10 awarded at each benchmark threshold. A REACH ACO that earned the maximum amount of SSM points for each SSM will receive 8 x 10 SSM points, and this REACH ACO will receive 80/80 or 100% of the 10 CAHPS composite score points. CMS will disseminate the PY 2024 CAHPS Benchmarks for Standard and New Entrant ACOs in March 2024, and for High Needs ACOs in May of 2024.

SSM points awarded by quality performance for CAHPS SSMs

Percentile Threshold Met	<30%	30%	40%	50%	60%	70%	80%	90%
Points Awarded	0	5.5	6.25	7	7.75	8.5	9.25	10

What happens if there are not enough survey respondents for an SSM?

For a given Standard/New Entrant or High Needs Population ACO, CMMI will not assign SSM points if an SSM is based on data from 19 or fewer survey respondents. If this occurs, we will reduce the number of possible SSM points (the denominator of the CAHPS Composite Score) by 10. For example, if an ACO has 1 SSM out of 8 SSMs that has 19 or fewer respondents, the ACO will only be scored on the 7 SSMs that do have sufficient respondents and the maximum number of SSM points that ACO can earn is 70. The denominator for the calculation of the CAHPS Composite Score for this ACO will therefore be 70 instead of 80. An ACO must have SSM points assigned for 50%, or 4 out of the 8 SSMs, to receive a CAHPS Composite Score. The SSM results for SSMs with 19 or fewer survey respondents will not be reported in the Annual Quality Report due to case minimum requirements. For patient confidentiality, percentages and numbers at the question level will not be reported if fewer than 11 respondents answered in any category. If an ACO does not receive a CAHPS Composite Score, that ACO’s total quality points possible used in the calculation of the Initial Quality Score will be reduced by 10. In other words, the ACO’s Initial Quality Score will be based on points earned out of a total possible of 30 points instead of 40.

Responding to Questions from Patients

My patient has questions. Who should they call?

CMS will require your survey vendor to operate a Toll-Free Help Desk for patients. Obtain that phone number, and email address if applicable, from your vendor, to provide to patients. Vendors must also print this number and email address on all survey materials.

Our beneficiaries are wary of surveys. What should we tell them about the survey?

Medicare beneficiaries may doubt the legitimacy of the survey and frequently turn to providers for assurance. When providers respond to patient questions with confidence and support, this puts patients at ease and encourages them to answer the survey.

CMS recommends providers and staff at REACH ACOs use the following resources:

1) FAQ document appropriate to place in Waiting Rooms for patient perusal. This conveys the survey is legitimately related to their health care provider. The Waiting Room FAQs are available in the 4i Knowledge Library under Quality Resources, or on the CAHPS website in the Quick Link Box.

2) Talking Points for providers to use with patients. See the section "Follow CMS’ communication guidance when speaking with patients about the survey” in “Guidance for Direct Contracting Entities” available in the 4i Knowledge Library under Quality Resources or on the CAHPS website under the Quick Link for ACOs.