Hospital Consumer Assessment of Health Care Providers and Systems
With bundled payments on the horizon and organizations being required to attain goal participation levels, gastroenterologists have a vested interest to understand HCAHPS (pronounced H-caps). Although most gastroenterologists do not have a primary inpatient gastroenterology service, but rather are consultants, a significant number of gastroenterologists do have such a service. In 2002, the Centers for Medicare and Medicaid Services (CMS), in partnership with the AHRQ, developed and tested what is now known as the Hospital CAHPS survey.4 In 2005, the HCAHPS survey was endorsed by the National Quality Forum and in December 2005 the Office of Management and Budget approved it for national implementation. CMS implemented the HCAHPS survey in 2006 and the first public reporting of HCAHPS results occurred in 2008. Hospitals were incentivized further to improve patient experience with the Patient Protection and Affordable Care Act of 2010 (Public Law 111-148), which specifically included HCAHPS performance in the calculation of the value-based incentive payment contained within the hospital value-based purchasing program, beginning with discharges in October 2012.
Dr. Ashish Atreja
HCAHPS is a 27-item survey instrument (available in official English, Spanish, Chinese, Russian, and Vietnamese versions) that is administered to a random sample of adult inpatients between 48 hours and 6 weeks after discharge via mail, telephone, mail with telephone follow-up evaluation, or voice recognition. Hospitals must achieve at least 300 completed surveys over four calendar quarters to be eligible for incentives. Ten HCAHPS measures (six summary measures, two individual items, and two global items) are reported publicly on the Hospital Compare website (www.hospitalcompare.hhs.gov). The six summary measures address how well nurses and doctors communicate with patients, how responsive hospital staff are to patients’ needs, how well hospital staff help patients manage pain, how well the staff communicates with patients about medicines, and whether key information is provided at discharge. The two individual items ask information about the cleanliness and quietness of patients’ rooms, and the two global items report patients’ overall rating of the hospital and whether they would recommend the hospital to family and friends.4
The Clinician and Group Consumer Assessment of Health Care Providers and Systems
The CG-CAHPS survey is a standardized tool, developed by the AHRQ, to measure patient perceptions of care provided by physicians in an office setting, and will be the survey that will impact gastroenterology practices the most. Similar to the CAHPS surveys for hospitals (HCAHPS) and home health agencies, it is anticipated that there will be national implementation of CG-CAHPS by CMS. CMS has included the CG-CAHPS survey as part of the required quality metrics within the Medicare Shared Savings Program, and it is anticipated that a CG-CAHPS instrument eventually will be required for full reimbursement for all medical practices, with results publicly reported at the Physician Compare website (http://www.medicare.gov/physiciancompare). Currently, participation is voluntary, although several states (Minnesota, Oregon, Vermont, and Maine) have mandated its use, and there is potential for group practices, including those with ambulatory surgical centers, participating in the Physician Quality Reporting System, to be required to participate in the near future (Figure 1). There are different versions of the survey including adult, child, visit specific, and 12-month visit versions. In addition, there are versions for accountable care organizations (with specialist questions built in) and patient-centered medical home. As of September 2012, there were 275 hospital and clinic clients participating in CG-CAHPS, although this is expected to grow. Many gastroenterology practices use surrogate outpatient surveys from a number of different vendors to assess outpatient experience, the most common being from Press-Ganey, which although similar, have distinct differences. The Press-Ganey survey is proprietary, is used mainly for internal use, and has no mandate for public reporting. Although both CG-CAHPS and Press-Ganey questionnaires have questions that focus on access, provider communication, provider rating, office staff, and recommendation of practice, Press-Ganey has additional questions regarding safety, cleanliness, and privacy. CG-CAHPS uses a four-point scale for the 12-month survey and a three-point scale for the visit survey, compared with Press-Ganey, which uses a five-point scale.
Potential limitations
Because patient experience survey scores increasingly are used to benchmark different institutions and provide reimbursement incentives, they also have received substantial criticism because of potential biases and pitfalls. To date, there are no convincing data that higher patient experience scores translate into better patient outcomes. In fact, there is a concern that catering solely to patient experience scores may be ill guided because it may implicitly encourage health care providers to honor requests for discretionary health care services. Such efforts may lead to overuse, higher costs, and worse outcomes. Some researchers argue that the surveys do not adequately take into account variables that can skew results against academic medical centers or hospitals in regions of the country that treat large numbers of patients with mental or other serious illnesses. Geographic, cultural, language, and ethnic differences can affect a patient's perspective about their medical or hospital experiences and it has been shown that none of the hospitals in the nation with 500 or more beds has scored in the 90th percentile for basic measures such as physician or nurse communication.2
