CAHPS for MIPS 101: What this patient experience survey means for healthcare clinicians and providers

Co-authored by Adam Higman, Payer Consulting

The Consumer Assessment of Healthcare Providers and Systems (CAHPS) for Merit-Based Incentive Payment Systems (MIPS) Survey—also known as MIPS CAHPS—was developed by the Centers for Medicare & Medicaid Services. This survey measures patient experience with clinicians participating in MIPS, one track of the Quality Payment Program (QPP) in which healthcare providers can receive performance-based Medicare payment adjustments. CAHPS for MIPS survey results are publicly reported on the Care Compare website.

If you’re a clinician or operate a healthcare practice, it’s important to understand the basics of this survey and how to get started.

What are CAHPS for MIPS surveys?

The CAHPS for MIPS Survey collects feedback from patients about their experience with their primary healthcare provider and visits to medical practices. Survey data serves to help patients compare care providers while incentivizing practices to improve care.

Is participation in the MIPS CAHPS Survey mandatory?

Only Accountable Care Organizations (ACOs) within the Medicare Shared Savings Program (MSSP) are required to use MIPS CAHPS. Outside of MSSP ACOs, CAHPS for MIPS is a voluntary measure for medical groups participating in the MIPS Program.

The MIPS CAHPS Survey is an optional quality measure survey that groups participating in traditional MIPS and some new MIPS Value Pathways (MVPs) can choose to administer through a CMS-approved vendor, like Press Ganey.

What types of questions does this patient experience survey ask?

The CAHPS for MIPS Survey asks patients 59 questions about their care over the past six months. The questions cover topics such as:

• Getting timely care, appointments, and information
• How well providers communicate
• Patient’s rating of provider
• Health promotion and education
• Shared decision making
• Courteous and helpful office staff
• Care coordination
• Stewardship of patient resources
• Access to specialists
• Health status and functional status

Who receives the CAHPS for MIPS Survey?

CMS selects a random sample of up to 860 fee-for-service Medicare beneficiaries (patients) who received primary care within the medical group or ACO. The sample is limited to patients age 18 or older who visited the group or ACO for primary care at least twice.

Those 18 and older who visited the group or ACO for primary care at least twice are eligible to take the survey. Sample size depends on the number of group/ACO clinicians and beneficiaries.

How do I administer the MIPS CAHPS Survey?

Groups that are using the MIPS CAHPS survey voluntarily as part of the MIPS Program must register to participate in CAHPS for MIPS through the CMS Registration System. ACOs in the MSSP don’t need to register, as they’re automatically registered to use the survey through their participation in MSSP. All ACOs and medical groups must contract with a CMS-approved survey vendor to conduct the survey.

The official CAHPS for MIPS Survey is conducted by CMS-approved survey vendors, like Press Ganey, once per year over a four-month period. Respondents are surveyed by mail with phone call follow-up.

Why is this patient experience survey important for healthcare clinicians and providers?

Survey feedback helps primary care providers receive performance-based Medicare payment adjustments and understand opportunities to improve care delivery. The provider’s score indicates whether they’re eligible for payment adjustments, with better scores indicating that high-quality care has been provided.

How do CAHPS for MIPS Surveys benefit patients?

MIPS CAHPS Surveys give patients the opportunity to provide feedback to their primary care physicians about various aspects of the patient experience. Since results from these surveys are publicly reported, patients can make informed decisions when selecting a physician. In turn, these insights help organizations better address patient needs.

How do CAHPS for MIPS Surveys improve healthcare delivery?

Collecting patient experience feedback gives primary care providers important insights. Key decision-makers can leverage this information to identify service recovery gaps and develop specific improvement strategies. Press Ganey offers benchmarks, patient experience consulting services, and more tools to ensure success.

How can my organization get started with CAHPS for MIPS surveys?

Healthcare organizations that choose to administer the CAHPs for MIPS Survey should consult a CMS-approved survey vendor, such as Press Ganey, to implement the survey and help leaders stay up to date on all associated requirements. Press Ganey also offers continuous patient experience insights through flexible outreach options, consulting solutions, industry-leading expertise, and compliance management to assist participating sites in adhering to survey requirements.

The MIPS CAHPS Survey is a valuable measurement tool for CMS and your organization to gauge the experiences of patients with primary care providers. To ensure your organization complies with CMS requirements, it’s critical to understand the basics of the survey program, how to implement the survey, and benefits of partnering with Press Ganey to administer the CAHPS for MIPS Survey.

Read more about CAHPS surveys and regulatory offerings or speak with an expert to learn how your organization can best measure patient experience.