CAHPS, HOS and the Patient Experience: Taking the Next Step

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Matt Fillipps mfillipps@humana.com Humana Stars Quality Member Experience

CMS Official Surveys CAHPS and HOS overview

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CAHPS survey

Consumer Assessment of Healthcare Providers and Systems (CAHPS)

• Survey assesses consumers’ experiences with the quality of their health care and other plan services.

• Medicare Advantage and Prescription Drug Plan version of survey asks 95 questions.

• Annually, between 800 and 2,000 members are randomly selected from each plan to participate.

• Five attempts are made to survey the member: two paper, three telephonic.

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CAHPS survey question domains

Weight Measure Components

1.5 Getting care quickly • Scheduling an appointment • 15-minute wait time

1.5 Coordination of care • Review medications • Informed about specialist care

1.5 Getting needed care • Getting specialist appointment • Care, tests, treatments through the plan

1.5 Customer service • Customer service courteous and informative • Health plan forms

1.5 Getting needed prescription drugs • Ease of getting prescribed medications • Obtaining medications at retail or via mail

1 Annual flu vaccine • Obtaining flu vaccination during prior season

1.5 Rating health care quality • 0-10 rating of health care

1.5 Rating the health plan • 0-10 rating of health plan

1.5 Rating the drug plan • 0-10 rating of drug plan

Composite Single item Overall

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HOS survey

Health Outcomes Survey (HOS)

• This tool assesses the ability of a Medicare Advantage organization to maintain or improve its members’ physical and mental health.

• Survey asks 68 questions.

• Annually, between 800 and 2,000 members are randomly selected from each plan to participate.

• Members are selected to receive a baseline survey and a follow-up survey two years apart.

• Five attempts are made to survey the member: two paper, three telephonic.

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HOS survey measure domains

Weight Measure Components

3 Physical health • Self-assessment (past four weeks) • Accomplishing daily activities

3 Mental health • Self-assessment (past four weeks) • Daily mood, emotional state

* Bladder control • Issue (past six months) • Physician discussion • Treatment

1 Fall risk • Issue (past 12 months) • Physician discussion (past 12 months) • Treatment

1 Physical activity • Physician discussion (past 12 months) • Recommendation – start, increase, maintain

activity level (past 12 months)

Improvement Discussion

*Bladder control is a display measure only this year. It will be tracked, but not counted for “score.”

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Timeline: CAHPS & HOS official surveys

January

2016 February March April May June July

CAHPS survey 3/4 Prenotification letter

3/10 First paper questionnaire mails

4/4 Second paper questionnaire mails

4/21 Telephonic outreach begins

6/5 Follow-up calls end

6/5 Cutoff date for phone and mail surveys

6/18 Final data files due to CMS

HOS survey HOS baseline cohort survey

begins

HOS baseline cohort survey ends

5/6 Interim data files due to CMS

HOS follow-up cohort survey

begins

HOS follow-up cohort survey

ends

• Blackout period: Late February–June. The health plan is prohibited from asking members any CAHPS-related questions that could influence official survey responses. Physicians, however, may discuss CAHPS and HOS quality topics with patients during this period.

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Why are CAHPS & HOS important?

• At 28 percent, CAHPS and HOS make up a larger combined slice of the overall CMS Stars rating than any other focus area.

• At a 4-Star level or above, each plan is eligible for a bonus based on membership.

11%

17%

25% 8%

14%

12%

13%

Stars category weight

HOS

CAHPS

HEDIS

IRE

CMS

Patient safety

Improvement measures

HEDIS: Healthcare Effectiveness Data and Information Set; IRE: Independent Review Entity

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What are my clinical and business incentives?

Clinical case • Positive patient experiences correlate with:

o Adherence to medical advice1 (especially among patients with chronic conditions)

o Better health outcomes2

Business case • Providing a quality experience:

o Leads to patient retention3

o Keeps employees engaged and less likely to leave4

o May lower risk of malpractice suits5

Footnotes 1

DiMatteo MR, Sherbourne CD, Hays RD, et al. Physicians’ characteristics influence patients’ adherence to medical treatment: Results from the Medical Outcomes Study. Health Psychology. 1993; 12:93-102. 2

Rave N, Geyer M, Reeder B, Ernst J, Goldberg L, Barnard C. Radical systems change: Innovative strategies to improve patient satisfaction. Journal of Ambulatory Care Management. 2003; 26(2):159-174. 3 Safran DG, Montgomery JE, Chang H, Murphy J, Rogers WH. Switching doctors: Predictors of voluntary disenrollment from a primary physician’s practice. Journal of Family Practice. 2001; 50(2):130-136. 4

Rave N, Geyer M, Reeder B, Ernst J, Goldberg L, Barnard C. Radical systems change: Innovative strategies to improve patient satisfaction. Journal of Ambulatory Care Management. 2003; 26(2):159-174. 5

Fullam F, Garman AN, Johnson TJ, Hedberg EC. The use of patient satisfaction surveys and alternate coding procedures to predict malpractice risk. Medical Care. May 2009; 47(5):1-7.

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Financial impacts

Humana’s Star quality rating may impact rewards programs.

• For Risk and partial-risk providers − CMS Star ratings of Humana Medicare Advantage plans can impact

premium funding from CMS, which can in turn affect provider compensation depending on the contractual arrangement

• In 2016, patient experience rating is part of Humana’s Medicare Advantage rewards program for primary care physicians.

• For providers participating in Humana’s Medicare Advantage Model Practice or Medical Home Rewards Programs:

− The provider’s patient experience rating, as measured by results from a Humana-designed Patient Experience Survey, must be 80 percent or greater to earn a reward or care coordination fee, as applicable.

Measuring the Patient Experience Humana’s internal survey

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Patient experience overview

• Patient experience at physician’s office is key to CAHPS and HOS success.

• Humana measures patient experience using its own Patient Experience Survey (distinct from the official CMS surveys). • Voice-automated telephone survey • Survey season July to early February (return rate approximately 40 percent)

• Survey of patients who visited their PCP in the previous 60 days • Thirteen questions aligned with the following eight CAHPS & HOS measures:

- Getting needed care without delay (CAHPS) - Getting appointments and care quickly (CAHPS) - Getting needed prescription drugs (CAHPS) - Coordination of care (CAHPS) - Reducing the risk of falls (HOS) - Bladder control (HOS) - Physical activity (HOS) - Mental health (HOS)

• Goal: Look for best practices and areas of opportunity

Patient experience: Score calculation breakdown

• 11 questions on the Patient Experience Survey count toward the member experience score.

• Only questions 4 and 5 are excluded from the overall score because they are plan- and physician-driven measures.

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Q1

Q2

Q3

Q6

Q7

Q8

Q9

Q10

Q11

Q12

Q13

Member Experience Rating

(average of 3 categories)

Target = 80%

Coordination of Care Description

Access to Care Average of: Q1, Q2, Q3 scores

Coordination of Care Average of: Q6, Q7 scores

Patient Discussion

Average of:

Fall Risk Score (Q8, Q9 average),

Bladder Control Score (Q10, Q11 average),

Physical activity (Q12),

Mental health (Q13)

Patient experience: Cut points for the questions

Thresholds for Patient Experience Survey questions are based on industry cut points for the related CAHPS and HOS measures.

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1. Low threshold cut points are greater than or equal to the number shown. 2. High threshold cut points are less than, but not equal to, the number shown.

Question Low High Low High Low High Low High Low High

1 Difficulty Scheduling Appointment 0 70.99 71 72.99 73 76.99 77 78.99 79 100

2 Doctor Wait Time 0 70.99 71 72.99 73 76.99 77 78.99 79 100

3 Referral for Specialist 0 78.99 79 80.99 81 83.99 84 85.99 86 100

4 Insurance Covering Medications 0 86.99 87 88.99 89 90.99 91 91.99 92 100

5 Approval – Tests and Procedures 0 78.99 79 80.99 81 83.99 84 85.99 86 100

6 Doctor Review Medications 0 83.99 84 85.99 86 87.99 88 90.99 91 100

7 Doctor Informed – Specialist Care 0 83.99 84 85.99 86 87.99 88 90.99 91 100

8 Fall Risk – Discussion 0 52.99 53 59.99 60 66.99 67 72.99 73 100

9 Fall Risk – Treatment 0 52.99 53 59.99 60 66.99 67 72.99 73 100

10 Bladder Control – Discussion 0 30.99 31 35.99 36 59.99 60 70.99 71 100

11 Bladder Control – Treatment 0 30.99 31 35.99 36 59.99 60 70.99 71 100

12 Physical Activity 0 43.99 44 48.99 49 54.99 55 61.99 62 100

13 Mental Health 0 74.99 75 76.99 77 79.99 80 81.99 82 100

1-Star 2-Star 3-Star 4-Star 5-Star

Incorporating the Quality Experience

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Goals for “Incorporating the quality experience”

• Discuss each Patient Experience Survey topic

• Consider new tips to improve the process • Explore best practices and supporting

materials • Assess how each topic is incorporated into

your practice - Internal and external obstacles to

success?

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Topic: Difficulty scheduling appointment

Patient experience No. 1: Did you experience any difficulty setting up your appointment?

Remind patients to schedule their next visit well in advance if your practice is booking up quickly.

PCP Staff Advance scheduling

Dedicate staff members to patient scheduling, and book patients automatically for follow-up visits before they leave your office.

Pre-book follow-up

Use business card appointment reminders or tear off sheets so that the patient can have a date and time for their next visit to take with them.

Appointment reminder card

Call the patient a few days before a scheduled appointment and remind them (two to three attempts if patient does not answer).

Appointment reminder calls

Ensure that address, phone and email information is up-to-date before or following patient visit.

Records check

Reach out via phone and email to patients who have not been in for a visit in for six to 12 months and get them scheduled.

Annual wellness scheduling

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Topic: Difficulty scheduling appointment

Patient experience No. 1: Did you experience any difficulty setting up your appointment?

Utilize an online system as another source for appointment confirmation

PCP Staff

Patient Portal

Utilize an online system as another source for appointment confirmation

Patient Portal

Use business card appointment reminders or tear off sheets so that the patient can have a date and time for their next visit to take with them

Appointment Reminder Card

Call the patient a few days before their scheduled appointment and remind them (2-3 attempts if patient does not answer)

Appointment Reminder Calls

Ensure that address, phone, and email information is up-to-date before or following patient visit

Records Check

Reach out to patients via phone and email who have not been in for a visit in for 6-12 months and get them scheduled

Annual Wellness Scheduling

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Topic: 15-minute wait time

Patient experience No. 2: How long after your scheduled appointment time did you wait to see the person you came to see?

Remind patients that they need to arrive 15-30 minutes prior to their scheduled appointment time to complete necessary paperwork.

PCP Staff

Early arrival

Triage patients within 15 minutes of scheduled appointment time and take them back to exam room early.

Triaging and staging

Encourage patients to schedule appointments on days when your practice is less busy.

Off-peak scheduling

Schedule fewer patients whenever possible or factor in catch-up time. Fewer patients scheduled

Book similar tests and appointments on the same day whenever possible to keep appointment volume down.

Incorporate greeters or experience guides to welcome patients and help them through the appointment process.

Greeters

Similar appointments

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Topic: 15-minute wait time

Patient experience No. 2: How long after your scheduled appointment time did you wait to see the person you came to see?

Make fliers, pamphlets, posters and other health education items available to patients.

PCP Staff Educational materials

Hand out short surveys or assessments that could stimulate patient thinking on important health topics.

Surveys and assessments

Provide a clean, comfortable and visually appealing environment for patients to wait in.

Comfortable environment

Keep board games, decks of cards, dice, checkers, chess, magazines, a television and any other possible entertainment in the waiting room.

Provide entertainment

Place vending machines in the office or make healthy snacks, coffee and water available.

Give your staff tip sheets about how to manage patient wait-time expectations and how to improve patient perceptions.

Office tips sheet

Food and drink

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Topic: 15-minute wait time

Patient experience No. 2: How long after your scheduled appointment time did you wait to see the person you came to see?

Utilize an online system that allows patients to check in, communicates delays and gives patients other relevant information.

PCP Staff

Patient portal

Consider using a form or tear-off pad that enables patients to give feedback about their waiting room experience.

Patient feedback

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Topic: Specialist referral

Patient experience No. 3: Did you have any trouble getting a referral from your personal doctor to see a specialist ?

Schedule any necessary specialist follow-up on behalf of the patient before the patient leaves the office.

PCP Staff Pre-schedule specialist

Check to see if the specialist participates in the Humana network before scheduling, and make the patient aware.

Specialist network

Check to see if the recommended specialist appointment is covered by the patient’s plan and inform the patient of the copay.

Specialist coverage

Ensure patients understand that some specialty appointments are not urgent or emergent and that waiting a few weeks to be seen is OK.

Set expectations

Call to remind the patient of his/her specialist follow-up visit or to ensure the visit gets scheduled if the patient has not yet done so.

Consider using Humana’s specialist appointment reminder pads. Specialist pads

Appointment reminder call

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Topic: Specialist referral

Patient experience No. 3: Did you have any trouble getting a referral to see a specialist from your personal doctor?

Complete and send to the treatment center any physician referral forms and justifications, and ensure patient has referral before leaving.

PCP Staff Referral paperwork

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Topic: Difficulty obtaining prescribed medications

Patient experience No. 4: Did you have trouble with your prescription drug plan covering any medication your doctor prescribed?

Recommend mail order whenever possible to improve adherence, convenience and possibly reduce medication cost.

PCP Staff

Mail order

Ask if the patient has a convenient pharmacy that he or she already goes to. If the patient doesn’t, try to recommend one.

Pharmacy recommendation

Understand what is covered by the patient’s Humana Part D plan. Review formulary

If a prior authorization is required, call the pharmacy and do the leg work on the patient’s behalf.

Prior authorization

Check to see if there is a covered equivalent medication that could be prescribed if the proposed medication is not covered or is high tier.

Call on behalf of the patient to see how much he or she will be responsible for of the new prescription.

Copay

Generic or equivalent Rx

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Topic: Difficulty getting tests or treatments

Patient experience No. 5: Did you have any problem getting approval through your health plan for any test or procedure your doctor said you needed?

Check to see if recommended treatments, tests or procedures are covered under the patient’s plan.

PCP Staff

Coverage

Check on the patient cost share for any recommended test or treatment.

Copay

Help the patient identify where to receive any necessary follow-up treatment or tests.

Treatment location

Book follow-up appointment for tests or treatment for patients before they leave the office.

Schedule treatment

Complete and send any physician referral forms and justifications to the treatment center, and ensure patient has referral before leaving.

Ensure patients understand that some specialty appointments are not urgent or emergent and that waiting a few weeks to be seen is OK.

Set expectations

Referral paperwork

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Topic: Review medications

Patient experience No. 6: Did your personal doctor talk about all of the prescription medicines you were taking?

Encourage patients to write down and bring with them all of their prescriptions and directions about quantity and consumption frequency.

PCP Staff

Medication list

Consider having patients bring pill bottles of all prescriptions to their appointment, for a more thorough review with the physician.

Prescription bag

Look for duplicate medications and negative drug interactions; try to eliminate unnecessary prescriptions and switch to cheaper alternatives if medically appropriate.

Prescription analysis

Provide educational material to stress the importance of physician-patient conversations about reviewing prescription medications.

Educational postcard

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Topic: Physician informed about specialist care

Patient experience No. 7: Did your personal doctor seem informed and up to date about the care you got from specialists?

Follow up with the specialist’s office to ensure that any patient care results are sent to your practice.

PCP Staff Request records

Discuss with patients the results of specialist appointments, treatment or procedures, and recommend next steps.

Close discussion loop

Encourage patients to keep tear-offs to remind them of appointments leading up to the follow-up visit with the primary care physician (PCP).

Specialist pads as reminder

Provide educational material to stress the importance of PCP-patient conversations about specialist care results.

Educational postcard

Keep detailed records in patient charts about recommended specialist care and expected results, for review with patients.

Clearly convey to patients that you want them in for a follow-up (to discuss specialist care) within one month following the specialist visit.

Follow-up visit expectations

Patient chart notes

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Topic: Falls discussion

Patient experience No. 8: Did your doctor or other health care provider talk to you about falling or problems with balance or walking?

Assess severity of the issue through dialogue with the patient.

PCP Staff Problem assessment

Hand out questionnaires and materials to assist patients in evaluating the issue and its severity prior to seeing the physician.

Educational material

Advise patient to move or secure rugs, wires and other tripping hazards.

Tripping hazards

Advise patient to use a night light to avoid falls in the middle of the night.

Night light

Consider using visual media in the waiting room and computer screen savers in the exam room to help educate patients.

Provide reinforcement once the physician has addressed this as a topic of concern.

Reinforce discussion

Educational media

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Topic: Falls treatment

Patient experience No. 9: Did your doctor or other health care provider suggest any treatment, such as using a cane or walker, having your blood pressure checked or having regular vision

or hearing tests?

Check patient’s blood pressure in sitting and standing positions.

PCP Staff

Blood pressure

Evaluate patient’s vision or refer to a specialist who can assist further if necessary.

Vision test

Recommend physical therapy to rehabilitate weak muscles or bones that could make the patient prone to falling.

Physical therapy

Encourage patients in good health to strengthen bones and muscles through exercise.

Exercise

Help patients schedule any follow-up treatment required for this issue before they leave your office.

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Referral assistance

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Topic: Bladder control discussion

Patient experience No. 10: Have you ever talked with a doctor, nurse or other health care provider about leaking of urine?

Assess the severity of the issue through dialogue with the patient.

PCP Staff Problem level assessment

Hand out questionnaires and materials to help patients evaluate the issue and its severity prior to seeing the physician.

Educational material

Advise patients to hang a night light to avoid falls if they need to hurry to the bathroom in the middle of the night.

Night light

Consider using visual media displays in the waiting room and computer screen savers in the exam room to help educate patients.

Educational media

Provide reinforcement once the physician has addressed this as a topic of concern.

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Reinforce discussion

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Topic: Bladder control treatment

Patient experience No. 11: Did your doctor, nurse or other health care provider talk to you about ways to control or manage the leakage of urine?

Discuss bladder strengthening exercises with the patient if he or she has a minor issue.

PCP Staff Bladder exercises

Decide if medication is appropriate to treat the issue. Bladder medication

In more severe cases, bladder surgery may be recommended and referral assistance can be provided.

Bladder surgery

Help patients schedule any follow-up treatment required for this issue before they leave your office.

Referral assistance

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Topic: Physical activity

Patient experience No. 12: Did your doctor or other health care provider advise you to start, increase or maintain your level of exercise or physical activity?

Advise patient to take on an appropriate level of exercise.

PCP Staff Prescribe exercise

Write your recommendation on a tear-off pad and encourage patients to take the note with them.

Physical activity pads

Encourage patient to review any plan benefits that may allow him/her to join a gym, health club or other active group for a discount.

Gym or club membership

Post a calendar and include any fitness-related events offered at or near your office location.

Activities calendar

Send a newsletter to patients that mentions upcoming fitness or health events sponsored by your practice or the local community.

Provide reinforcement once the physician has addressed this as a topic of concern.

Reinforce discussion

Patient newsletter

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Topic: Mental health discussion

Patient experience No. 13: Did your doctor or other health care provider ask you about your mental or emotional health?

Remind yourself that many patients need help understanding that emotional health is a part of their primary care.

PCP Staff Educate the patient

Make use of physician educational material provided through Humana and any other organization with subject matter expertise.

Provider information

Encourage patients to take mental health preassessments while they wait, to assist the physician during discussion.

Mental health screens

Provide patients material that educates them on signs of depression or encourages them to be upbeat.

Educational material

Provide reinforcement once the physician has addressed this as a topic of concern.

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Reinforce discussion

Provider information Depression is a difficult thing to recognize in patients and talk about with them. Humana offers materials like this one-page flier and detailed presentation to support treatment

of patients who may be depressed.

Mental health screens

PHQ-2 and PHQ-9 mental health

screens can help assess the emotional health state of your

patients.

Educational material Humana provides this mental health

poster to encourage positive feelings and

emotional health among patients.

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Best practices and materials: Mental health discussion

Patient experience No. 13: Did your doctor or other health care provider ask you about your mental or emotional health?