Author: Zeev N. Kain, M.D., M.B.A., FAAP
ASA Monitor 10 2017, Vol.81, 18-20.
Zeev N. Kain, M.D., M.B.A., FAAP, is Chancellor’s Professor of Anesthesiology and Medicine, Director, Stress and Health, University of California, Irvine, Adjutant Professor, Yale University, New Haven.
The American medical environment is currently experiencing a dramatic transformation, and much of that relies on the Patient Protection and Affordable Care Act (ACA) and Triple Aim initiative. The Triple Aim was developed by Don Berwick of the Institute for Healthcare Improvement (IHI) in 2008 and focuses on revolutionizing U.S. health care through three main tenets: 1) improving individuals’ experience of health care, 2) improving the health of an aging U.S. population and 3) reducing the ever-rising per capita costs of health care. The ACA of 2010 has significantly altered the American health care system, shifting priorities to emphasize the greater importance of patient-centered outcomes. In that context, the ACA mandated public reporting programs that incorporate information collected using the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) surveys.
Anesthesiologists should be knowledgeable about the CAHPS surveys for a number of reasons, such as the Merit-based Incentive Payment System (MIPS) and the fact many anesthesia groups receive various medical directorships from hospitals and as such have an incentive to improve the hospital bottom line. Recently, the Centers for Medicare & Medicaid Services (CMS) has introduced the Outpatient and Ambulatory Surgery (OAS)-CAHPS Survey, which aims to improve quality of health care in the perioperative space and to measure patient experiences with their surgeries performed at hospital outpatient surgery departments or ambulatory surgery centers. The OAS-CAHPS includes a number of questions that directly evaluate anesthesiologists in ambulatory surgical care settings. In addition, a study that was published recently in Pediatric Anesthesia indicated that, contrary to common belief, anesthesiologists are a major determinant in the decision of parents to receive care in a particular center. As such, this article is devoted to review the OAS-CAHPS and ensure that the ASA membership is educated and ready for its launch.
The history of the CAHPS dates back to 1995, when the first survey was created by the Agency for Healthcare Research and Quality (AHRQ) in conjunction with CMS. According to the CMS and AHRQ, the CAHPS survey goals are: 1) “To develop standardized surveys that organizations can use to collect comparable information on patients’ experience of care” and 2) “To generate tools and resources to support the dissemination and use of comparative survey results to inform the public and improve health care quality.”* While numerous studies have reported the high reliability and validity of the CAHPS surveys, many clinicians criticize these surveys and indicate that the questions presented in the surveys are not clear, and attribution to individual specialty or physician is very difficult. That said, it is important to the reader of the Monitor to appreciate that these surveys have been used since 1995, and it is highly unlikely that “they will go away.”
OAS-CAHPS Survey (oascahps.org)
Development: The OAS-CAHPS survey is aimed to measure the experiences of care for patients who received care in Medicare-certified hospital outpatient departments and ambulatory surgery centers. Specifically, the aim of the survey is to measure patients’ perspectives on constructs that are important (for patients) when choosing a facility for their care. The development of the OAS-CAHPS has been under way since 2012, and an initial test was conducted in 2014 (24 facilities) to assess validity, reliability and implementation procedures. Following the initial testing, OAS-CAHPS was revised, and in 2015 a second process of testing was conducted. The survey received accreditation as a CAHPS survey in February 2015. The second process of testing was particularly important as its aims were to assess data collection and develop models to adjust for patient characteristics prior to public reporting. This later aim is highly important since it is well known that certain social characteristics bias the responses to CAHPS surveys and as such a process of “statistical adjustment” has to be done prior to comparing an individual center to national benchmarks. Many more details regarding the development and implementation can be found at oascahps.org. It is important to note that currently there is not a specific timeline for linking OAS-CAHPS performance to reimbursement.
The OAS-CAHPS measures patients’ perception of the quality of care in five domains, comprising 37 questions (13 of which are focused on demographics). There are four questions that specifically mention the term “anesthesia.” These questions relate to information provision and nausea and vomiting. When examining the other questions, however, three more questions are related to “doctors in the facility.”
The OAS-CAHPS survey will be given to adult patients who had specific procedures or surgeries (based on a list of CMS-approved CPT codes and G codes). These procedures have to be performed in a Medicare-certified hospital out-patient department (HOPD) or a Medicare-certified free-standing ambulatory surgery center (ASC), and overnight-stay patients are included. Patients are only eligible to receive the OAS-CAHPS survey once every six months. HOPDs or ASCs can apply for exemption from mandatory OAS-CAHPS, if they have 59 or fewer OAS-CAHPS-eligible patients annually. The OAS-CAHPS survey must be administered by an independent CMS-approved vendor and can be admini-stered by mail, telephone or a combination of mail with a telephone follow-up.
Timeline: In January 2016, CMS began voluntary monthly data collection using the OAS-CAHPS survey tool, and the initial plan was for CMS to begin public reporting in January 2018 based on the OAS-CAHPS data collected between July 2016 and June 2017 of the voluntary partici-pation period. CMS did indicate that facilities will be able to request their voluntarily collected OAS-CAHPS data be suppressed from public reporting during the preview report period.
On July 20, 2017, however, the Federal Register published a new proposed rule for the OAS-CAHPS. In this latest Proposed Rule, CMS proposes to delay the implementation of OAS-CAHPS to 2020 payment determination (2018 data voluntary data collection). If approved, this means that OAS-CAHPS would continue with the voluntary reporting throughout 2018. The rationale provided for the delay is to enable CMS “to analyze the national implementation data and consider any necessary modifications to the survey tool and/or CMS systems and review the regulatory burden for providers and investigate strategies to reduce the burden before making a determination of timing for future implemen-tation.” Also “the delay will allow additional time for participating facilities to identify a survey vendor and work through.” For those of us who hope this CAHPS measure will simply go away, the CMS indicates that “CMS continues to believe that the OAS CAHPS Survey addresses an area of care that is not adequately addressed in the current measure set and will be useful to assess aspects of care where the patient is the best or only source of information. These measures will enable objective and meaningful comparisons between hospital outpatient departments and ambulatory surgery centers.”
The conclusion of this author (ZNK) is that the OAS-CAHPS will be implemented and anesthesiologists should be ready for this event. The rationale for this conclusion is multifactorial, but mainly because no CAHPS survey ever developed by CMS was unimplemented. And while the final outcome of the ACA repeals is not clear, value-based care is currently being widely adopted in the private insurance sector, and patient experience continues to increase as a major outcome for this form of economic model.
*Agency for Healthcare Research and Quality, “CAHPS Glossary” cahps.ahrq.gov/about-cahps/glossary/index.html.
US Department of Health and Human Services. Hospital Value-Based Purchasing. ICN 907664. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Hospital_VBPurchasing_Fact_Sheet_ICN907664.pdf. Published September 2015. Last accessed August 10, 2017.
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