What is my REACH ACO required to do?
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 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://acoreachcahpsdev.rti.org.
What do I have to do on the CAHPS website (https://acoreachcahpsdev.rti.org)?
REACH ACO’s must go on the CAHPS website to designate a staff member in your ACO to serve as your Survey Administrator. This person needs to do the following by August deadline to be announced by CMS: 1) register as a user on the CAHPS website, 2) register their ACO, and 3) authorize their CAHPS vendor. Once someone is registered as a Survey Administrator for their ACO, they do not need to re-register year after year, but they do need to authorize a vendor 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.
Working with a Survey Vendor
Where and when can I find the list of approved survey vendors?
In April 2023 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 PY2023 ACO REACH CAHPS Survey in June 2023. It is important to ensure your chosen vendor appears on the June 2023 list. Please refer to the ACO REACH newsletter for announcements about the final list and updates.
We already have a vendor from PY2022. 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 PY2023. 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://acoreachcahpsdev.rti.org. Then, authorize the new vendor. Vendor authorizations for PY2023 should not be changed after authorization deadline. In the event of extenuating circumstances, contact the CAHPS Survey Coordination Team at firstname.lastname@example.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”. (That website is currently https://gpdccahpsdev.rti.org and starting February 2023 will be https://acoreachcahpsdev.rti.org.)
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 domain is located in Appendices C-2 and C-3 of the PY2023 Quality Measurement Methodology Report, available on 4i: https://4innovation.cms.gov/secure/knowledge-management/view/850
Below are the domains 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?
- 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 domain does not contribute to the ACO’s PY2023 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 domain does not contribute to the ACO’s CAHPS PY2023 Score)
- In the last 6 months, how often was it easy to get appointments with specialists?
Activities of Daily Living (this domain does not contribute to the ACO’s PY2023 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
- In the last 3 months, did you get as much help as you wanted for your feelings of anxiety or sadness?
- 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?
- In the last 6 months, did this provider give you as much help as you wanted for your pain?
- 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?
Does the PY2023 ACO REACH CAHPS have any changes compared to PY2022 ACO REACH CAHPS?
All survey instruments and protocols are unchanged. Note that PY2022 was Pay-for-Reporting for all ACO types. PY2023 is Pay-for-Performance for Standard and New Entrant ACOs, so these ACO CAHPS results will be scored. The scores attained, as compared to benchmarks set by CMS, will impact these ACO’s PY2023 Total Quality Score for ACO REACH.
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 12-week data collection period.
When will data collection for the Performance Year 2023 ACO REACH CAHPS Survey begin and end?
Data collection for PY 2023 begins in September 2023 and ends December 2023, approximately 12 weeks. The survey will be conducted annually.
In what languages is the survey available?
The survey is available in English and Spanish for PY2023.
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.
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. (The CAHPS website is https://gpdccahpsdev.rti.org through January 2023 and https://acoreachcahpsdev.rti.org beginning February 2023.)
How many patients are surveyed?
Among the High Needs Population REACH ACOs, all eligible beneficiaries are surveyed. Among Standards and New Entrant REACH ACOs, 860 beneficiaries are surveyed. 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.
Standard and New Entrant REACH ACOs
REACH ACOs with 100 or more Participant Providers
· CMS will draw a random sample of 860 survey-eligible aligned beneficiaries.
· If there are fewer than 860 survey-eligible aligned beneficiaries, but at least 416, all eligible beneficiaries will be surveyed.
· If there are fewer than 416 survey-eligible aligned beneficiaries, the survey cannot be conducted.
REACH ACOs with 25 to 99 Participant Providers
· CMS will draw a random sample of 860 survey-eligible aligned beneficiaries.
· If there are fewer than 860 survey-eligible aligned beneficiaries, but at least 255, all eligible beneficiaries will be surveyed.
· If there are fewer than 255 survey-eligible aligned beneficiaries, the survey cannot be conducted.
REACH ACOs with two to 24 Participant Providers
· CMS will draw a random sample of 860 survey-eligible aligned beneficiaries.
· If there are fewer than 860 survey-eligible aligned beneficiaries, but at least 125, all eligible beneficiaries will be surveyed.
· If there are fewer than a minimum of 125 survey-eligible aligned beneficiaries, the survey cannot be conducted.
High Needs REACH ACOs
All REACH ACOs
· All survey-eligible beneficiaries will be selected for the survey. In ACOs with more than 860 survey-eligible beneficiaries, a random sample of 860 beneficiaries will be selected for the survey.
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 PY2023 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. High Needs Population ACOs will be P4R in PY2023 and will receive 10 CAHPS composite score points regardless of their actual CAHPS results.
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 PY2023 CAHPS Benchmarks in March 2023.
SSM points awarded by quality performance for CAHPS SSMs
Percentile Threshold Met
What is a benchmark? How are they established?
A quality performance benchmark is the performance rate an ACO must achieve to earn the corresponding quality points for each measure.
For Standard and New Entrant REACH ACOs in PY2023, CMS will create a pool of patient-mix adjusted CAHPS performance scores from participating entities in MIPS, the Shared Savings Program and NGACO, in 2019 and 2021 as well as from DCEs who participated in Direct Contracting in 2022. CMS then computes this pool’s percentile distribution for each Summary Survey Measure. These distributions become the Quality Performance Benchmarks (QPBs) against which PY2023 REACH ACO performance scores are compared.
What are the measures (SSMs) in the CAHPS survey? Are they the same as MIPS or ACOIn PY2023?
The following are collected for all REACH ACOs. Standard and New Entrant ACOs are scored on these measures.
- Getting Timely Care, Appointments and Information
- How Well Providers Communicate
- Patient’s Rating
- Shared Decision Making
- Care Coordination
- Courteous and Helpful Office Staff
- Health Promotion and Education
- Stewardship of Patient Resources
In PY2023, the following measures are collected for all REACH ACOs, but ACOs are not scored on them in PY2023:
- Health Status and Functional Status
- Access to Specialist
- Activities of Daily Living
4 additional measures are collected from High Needs Population REACH ACOs. As High Needs Population REACH ACOs are Pay-for-Reporting for PY2023, results on these measures do not impact PY2023 Performance Scores.
- Family support
- Emotional Support
- Health Emergency
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.