CAHPS^® for Physician Quality Reporting System (PQRS) Survey

Note: 2021 was the last program year for CAHPS for PQRS. PQRS transitioned to the Merit-based Incentive Payment System (MIPS) under the Quality Payment Program. Please visit the CAHPS for MIPS webpage on CMS.gov for more information.  

Participation

How do I know if the CAHPS for PQRS Survey is an appropriate option for my group?

Medicare fee-for-service (FFS) beneficiaries are assigned to a group practice based on whether the group provided a wide variety of primary care services. The CAHPS for PQRS Survey is not an appropriate method for groups of physicians that do not provide primary care services (for example, a group of surgeons).

Who pays to administer the patient survey?

Group practices are responsible for the costs associated with the survey administration and must contract with an approved survey vendor. The list of 2021 approved survey vendors is available.

How do I authorize a vendor?

Group practices must select a vendor from the final list of approved CAHPS for PQRS survey vendors, and communicate their selection to CMS. In 2021 , the vendor authorization period ran from July 27 to September 20, 2021 .

I authorized my vendor last year. Do I still need to complete the Survey Vendor Authorization process, even if using the same vendor?   

Yes, Group Practices must authorize a survey vendor every year, even if using the same vendor. Group practices use a web-based tool to select and authorize a vendor from the approved list and are responsible for the
costs associated with administering the survey. 

What is the group practice’s responsibility in monitoring their survey vendor?

The group practice is responsible for assuring that the contracted vendor delivers the services according to the contract. The CAHPS for PQRS Survey Project Team reviews the vendor’s quality assurance plan and conducts site visits on behalf of CMS. These activities do not replace the group practice’s role in monitoring their vendor contract.

How will my practice know if we have enough beneficiaries to participate in CAHPS for PQRS Survey?

Some group practices might not have a sufficient number of beneficiaries to produce reliable data and it is recommended that these practices not choose the CAHPS for PQRS Survey option. Any group practice that does not meet the minimum sample requirements for the survey will be contacted by CMS after the June 30th close of registration.

Can an individual provider field and report CAHPS for PQRS?

The CAHPS for PQRS Survey can only be implemented for the group practice reporting (GPRO) option of the CMS PQRS program.

Where can I find a list of approved survey vendors?

You can find the final list of approved survey vendors on the Approved Vendor List page.

Sampling

Who identifies which patients are eligible to be used in the survey?

We will identify beneficiaries eligible for the survey from the pool of Medicare FFS beneficiaries assigned to the group practice.

How will CMS select a sample of patients seen by our group practice? Which of our group’s patients will be sampled?

CMS assigns Fee-for-service Medicare beneficiaries to a practice based on the plurality of the primary care claims during the first 2 quarters of performance year 2021 . CMS then randomly samples from those assigned beneficiaries to create the sample for the CAHPS for PQRS Survey. The sample will be limited to beneficiaries age 18 or older,  who are not known to be institutionalized or deceased, and who had two visits for care to the practice. The sample is drawn at the level of the group practice, not an individual provider. The survey names a specific provider, who delivered primary care to the beneficiary over multiple visits in the performance year to help orient the beneficiary to the care he or she received. The named provider can be a physician, specialist, nurse practitioner, physician assistant, or clinical nurse specialist.

How many patients seen by our group practice will be sampled?

The number of patients sampled may vary based on the size of the group practice.

• For large group practices of 100 or more eligible providers:
  • CMS will draw a sample of 860 beneficiaries
  • If the practice has fewer than 860 beneficiaries, but more than 415 beneficiaries, all eligible beneficiaries will be surveyed in 2021
  • If the practice has fewer than 416 beneficiaries, the survey cannot be conducted
• For group practices with 25 to 99 eligible providers:
  • CMS will draw a sample of 860 beneficiaries
  • If the practice has fewer than 860 beneficiaries, but more than 254 beneficiaries, all eligible beneficiaries will be surveyed in 2021
  • If the practice has fewer than 255 beneficiaries, the survey cannot be conducted
• For group practices with 2 to 24 eligible providers:
  • CMS will draw from a sample of 860 beneficiaries
  • If the practice has fewer than 860 beneficiaries, but more than 124 beneficiaries, all eligible beneficiaries will be surveyed in 2021
  • If the practice has fewer than 125 beneficiaries, the survey cannot be conducted

Can our group practice supplement the sample CMS selects to generate provider-level results?

No. Oversampling may be considered as an option in the future.

Survey Administration

When will the patient survey be conducted?

The survey is implemented on an annual basis. The 2021 Survey will be conducted November 2021 to February 2017. 

Survey Measures and Reporting

What topics does the patient survey include?

The CAHPS for PQRS survey measures twelve key domains of beneficiaries’ experiences of care that we refer to as summary survey measures (SSMs). A summary survey measure is a collection of survey items that assess the same patient experience domain of care.

1.         Getting Timely Care, Appointments and Information
2.         How Well Providers Communicate
3.         Patient’s Rating of Provider
4.         Access to Specialists
5.         Health Promotion and Education
6.         Shared Decision Making
7.         Health Status/Functional Status
8.         Courteous and Helpful Office Staff
9.         Care Coordination
10.       Between Visit Communication
11.       Helping You to Take Medication as Directed
12.       Stewardship of Patient Resources 

Where can I find the survey questions that correspond to each of the twelve key domains?

Table 1 lists the measures and corresponding questions included in the CAHPS for PQRS survey.

Will the survey provide provider-level results?

No. The survey will generate results and scores at the group practice level.

What format will the results be in?

You will get both narrative reports and an Excel file of scores based on the survey data. 

When will the results be posted on the Physician Compare website?

Results for the 2015 CAHPS for PQRS Survey were reported on Physician Compare in late 2021 . Of the 12 SSMs available for public reporting, 8 met the necessary public reporting standards for this year and are included on the website. Monitor our Physician Compare Initiative page for the latest information.