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Federal Register / Vol. 86, No. 147 / Wednesday, August 4, 2021 / Rules and Regulations
which CMS publicly reports scores and star ratings. We note that hospices should be able to receive timely reports and data directly from their survey vendors. We encourage hospices who want to use CAHPS data for quality improvement to talk to their vendors about the reports and data that may be available shortly after data collection.
Comment: A commenter stated that the preview report timeframe is too short and that hospices should receive preview data at least 1 year prior to its publication in order to analyze performance and implement quality improvement.
Response: As stated previously, we recommend that hospices use data from their vendors for quality improvement, rather than wait for publicly-reported data. If we were to provide preview data a year in advance, the publicly reported data would be too old to be a meaningful reflection of the hospices performance. We believe additional delays in public reporting of data is not in the interest of the public using Care Compare.
Comment: Many commenters expressed concern about publicly reporting data that was collected and/or delivered during the COVID19 PHE.
They commented that these data could be skewed by the public health emergency.
Response: We will not include data from Q1 and Q2 2020 in Star Rating calculations, as hospices were exempted from submitting these quarters of data to CMS due to the COVID19 PHE.
Comment: Several commenters stated that the CAHPS Hospice Survey is unlike other CAHPS surveys in that the respondents are family members or friends of the deceasednot the patients themselves. They believe this is a key difference between the hospice survey and other CAHPS surveys and called for more information on the Care Compare site to make sure consumers are not misled.
Response: Although Care Compare already notes that for Hospice CAHPS
the user is comparing . . . hospices based on results from a national survey that asks a family member or friend of a hospice patient about their hospice care experience, we will consider whether there are additional ways to highlight this.
Comment: Some commenters objected to the comparative nature of the CAHPS
Hospice Survey star ratings, preferring instead, a rating based upon an external criteria rather than one that compares hospices to each other. As a few commenters noted, Each hospice is afforded the opportunity to achieve excellent ratings on the CAHPS Hospice
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Survey. Similarly, this same right should be afforded hospices under the Star Rating system through a clear portrayal Star Rating of performance to consumers and the public that reflects how most respondents scored the hospice, not how the hospice fares compared to all other hospices. One commenter also suggested that star ratings calculations be made available to hospices before they are publicly reported.
Response: Similar to other CMS
CAHPS star ratings, we propose that the cut-points used to determine CAHPS
Hospice Survey stars be constructed using statistical clustering procedures that minimize the score differences within a star category and maximize the differences across star categories. This ensures that star assignments clearly differentiate performance across groups of hospices. Such comparative star ratings, as proposed by CMS, help consumers identify high and low performing hospices. With respect to making calculations available before they are publicly reported, we do plan to provide star ratings calculations in preview reports prior to their display.
Comment: Several commenters noted that CMS is currently conducting a pilot test of a revised CAHPS Hospice Survey questionnaire and wondered whether the release of a new questionnaire would coincide with the introduction of star ratings. They also questioned whether CMS expected that use of a revised questionnaire would increase the number of hospices that achieve 75
completed questionnaires and would, therefore, be included in star ratings.
Response: We are currently conducting an experiment to test a new version of the survey, including the web mode of administration which may have an impact on response rates and the number of survey completes. Results of this experiment will help to inform changes to the survey in the future. We anticipate that star ratings will be released prior to a new version of the survey. Star ratings will continue to be calculated and released as we phase in the new survey version.
Comment: Many commenters questioned the weighting of the components of the star ratings, particularly the decision to weigh the two global questions Overall Rating and Willingness to Recommend at 50
percent of the weight for each composite measure.
Response: The Willingness to Recommend and Overall Rating measures are highly correlated with one another, as both provide global assessments of hospice care. Given this, weighting each of the two measures at
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100 percent would over-emphasize global assessments of care relative to the other aspects of care assessed by CAHPS
Hospice Survey measures. CMS
maintains its proposal to weight Willingness to Recommend and Overall Rating at 50 percent each for the purpose of calculating an overall CAHPS Hospice Survey star rating. This approach parallels the one used by CMS
for calculating star ratings for hospitals.
Comment: A few commenters questioned whether it is CMSs intent for the CAHPS to be the sole star rating vehicle for hospice care or whether there would be another star rating for HOPE measures when it is implemented?
Response: The FY 2022 proposal contemplated a CAHPS-only measure in the short-term. At this time, it is premature to determine whether the HOPE tool should be used to create star ratings, either separately from CAHPS or in combination with CAHPS. The HOPE
tool is now under development. We will consider other star ratings as applicable.
Comment: One commenter recommended that CMS award star ratings in FY 2022, but suppress public reporting in Care Compare until the August 2023 refresh when all the data will be after the COVID-exempted quarters.
Response: As mentioned previously, we plan to display stars no sooner than FY 2022. We will take into consideration the option of starting the stars display when all data will be after the COVID-exempted quarters.
Comment: One commenter strongly suggested that there should be a not applicable response option available for each question in the questionnaire.
Indeed, they noted that Questions such as How often did your family member get the help he or she needed for trouble breathing or How often did your family member get the help he or she needed for constipation are difficult for family members to answer if their loved one did not experience issues with those symptoms.
Response: On the questionnaire, the respondent is asked if their family member experienced the symptom. If they did not experience the symptom, the instructions say to skip to another question. Under these circumstances a not applicable is not needed.
Comment: A few commenters stated that the survey is too long. One commenter suggested that we should identify the key 1 or 2 questions in each survey domain and use them instead.
Response: We are currently conducting an experiment to test a shorter version of the CAHPS Hospice Survey. Results of this experiment will
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