Frequently Asked Questions About CGCAHPS

Added on Jul 25, 2015

Have questions about CGCAHPS? You're not alone. There is a lot to understand when it comes to participating in the public reporting initiative. Here are the answers to some of the most frequently asked CGCAHPS questions.

Q: WHAT IS CAHPS?

A: CAHPS stands for Consumer Assessment of Healthcare Providers and Systems. A series of patient experience survey tools have been developed by the Agency for Healthcare Research and Quality (AHRQ) and are used by health plans, hospitals, and home health agencies to understand their patients’ perceptions of their quality of health care.

Q: WHO DEVELOPED CGCAHPS?

A: The Clinician and Group CAHPS set of instruments was developed by AHRQ.

Q: WHAT CONCEPT AREAS ARE INCLUDED IN CGCAHPS?

A: Items within the CGCAHPS survey instruments can be used to create measures of patients' perceptions of care, including getting appointments and health care when needed, how well doctors communicate, courtesy and helpfulness of office staff and overall rating of the doctor.

Q: WHAT IS THE STATUS OF THE CGCAHPS IMPLEMENTATION?

A: There are state and regional initiatives that use variations of the publicly available CGCAHPS instrument.

  • Medical practices with more than 100 providers under one tax identification number and participate in Physician Quality Reporting System through the GPRO web-interface are required to participate in CGCAHPS; reporting will impact their value modifier (VM) payment in 2016.
  • The 2014 proposed rule states that PQRS CGCAHPS participation would be voluntary for groups over 25 providers and could be selected as one of the areas calculating VM for practices over 100, regardless of how they submit PQRS data.
  • Also, the CGCAHPS instrument has been selected for evaluating the patient experience as part of both the Pioneer Accountable Care Organization (ACO) program and the Medicare Shared Savings Plan ACO program.

Q: IS CGCAHPS LINKED TO PAYMENT?

A: Health care reform legislation passed by Congress created a “Physician Compare” web site, which went live Jan. 1, 2011. Physician Compare will include clinical measures already collected through the Physician Quality Reporting System (PQRS) in 2013. The legislation also requires patient ratings be considered for inclusion on the web site. For Pioneer and MSSP ACOs, 25% of their quality results will be based on CGCAHPS and ultimately impact their ability to share in savings. For medical practices impacted by CGCAHPS, at least 16.7% of value-based dollars will be based on CGCAHPS as part of the value modifier (VM).

CMS will calculate how many standard deviations your score for each survey domain is away from the average. Then they will average the standard deviations across all of your survey domains. This average standard deviation represents your score for the Patient Experience Domain as part of the VM. The Patient Experience Domain will be equally weighted with the other quality domains for your practice.

Your final quality score which represents your average standard deviations from the national average will be used to place you into a category of high quality, average quality, or low quality.

Q: IF CGCAHPS IS NOT YET REQUIRED, WHY SHOULD WE START MEASURING NOW?

A: Listening to your patients can pay off in unexpected ways, such as helping you to prioritize service initiatives, recognize outstanding staff members and increase referrals. With the move toward value-based purchasing and tougher competition, now is the time to make sure that your organization is focused on the importance of patient satisfaction. When the HCAHPS survey was implemented by CMS, those hospitals that adopted our integrated survey in advance outperformed those that waited for mandated participation. Ask us for more information about how paying attention to the voice of your patients can improve your service performance and your bottom-line results.

Q: BEYOND CMS’ ACO CAHPS AND PQRS WHAT OTHER PROGRAMS UTILIZE CGCAHPS FOR PATIENT EXPERIENCE MEASUREMENT, BEYOND CMS?

A: Currently, medical practices working on their level, 1, 2 or 3 NCQA patient-centered medical home certification can gain one point towards certification by measuring CGCAHPS domains (plus additional questions on whole person and care coordination). For NCQA’s distinction in Patient Experience Reporting, they use a retrospective survey which includes CGCAHPS plus additional questions measuring: mental & emotional health, self-management support, shared decision making, and care coordination. We also anticipate the ABMS will use the 7 CGCAHPS questions related to Provider Communication as part of the MOC requirement, but we don’t have further information about timing, other than they’ve indicated a start in 2015. We will keep you posted as we get more information regarding each specialty.

Q: DOES PRESS GANEY HAVE CGCAHPS EXPERIENCE?

A: Press Ganey has been implementing the CGCAHPS visit-specific survey on behalf of clients since 2010. We currently have over 8,000 physician sites and more than 43,000 physicians utilizing this survey, often in combination with the Press Ganey Medical Practice survey.