June 13, 2019
Mr. Gopal Khanna
Agency for Healthcare Research and Quality
U.S. Department of Health and Human Services
RE: AHRQ Request for Information to Inform Potential Revisions to the Consumer Assessment of Healthcare Providers and Systems Health Plan Survey 5.0
Dear Mr. Khanna,
The Association for Community Affiliated Plans (ACAP) thanks you for the opportunity to comment on the Request for Information to inform potential revisions to the Consumer Assessment of Healthcare Providers and Systems Health Plan Survey 5.0.
ACAP is an association of 66 nonprofit and community-based Safety Net Health Plans located in 29 states. Collectively, ACAP health plans provide coverage to 20 million individuals enrolled in Medicaid, the Children’s Health Insurance Program (CHIP), Medicare Special Needs Plans for dually-eligible individuals, and Qualified Health Plans (QHPs) serving the health insurance Marketplaces. ACAP plans are members of their communities, partnering with states to improve the health and well-being of their members who rely upon Medicaid and CHIP as well as other publicly-supported programs.
See ACAP’s responses to the RFI’s questions below.
Question 1: How and why does the respondent’s organization use the Survey? For example, is it used for adults, children, or both? In what languages is it administered? What supplemental items, if any, are used (e.g., children with chronic conditions or others)?
ACAP plans believe that the survey is beneficial not only for accreditation purposes but also in tracking performance over time, creating analyses, identifying improvement opportunities, and gaining a better understanding of their beneficiaries and programs. Most ACAP plans report using both the adult and child surveys. A majority also reported administering the survey in two languages, namely English and Spanish. We presume they use these languages because the survey is already translated as such, allowing for easier dissemination. ACAP plans thought that having a choice of languages was useful as English is not the first language for a significant percentage of some plans’ populations. Although some ACAP plans mentioned fielding the survey in a variety of other languages depending on the demographics of their member population, they did not specifically state any hinderances or complications with translation.
About half of ACAP plans additionally reported using supplementary questions. Some mentioned using the Children with Chronic Conditions supplement, while others added other supplementary questions – usually regarding provider availability and network operations. ACAP plans believed that adding these measures allowed for a better understanding of their provider network’s access and efficiency. They appreciated having the opportunity to insert questions that they felt were informative regarding their specific plans.
Question 2: What is working well/what are the strengths of the Survey?
The majority of ACAP plans highlighted the ability of the survey to allow them to track changes in their plans over time as well as compare their plan to others, both regionally and nationally (Note: having a state-level benchmark was recommended by some plans). ACAP plans believed that this helped them in analyzing the effectiveness of various programs and allowed them to implement changes or new programs based on responses over time. Many plans also mentioned that the diversity of questions provides a useful overall picture and gave them valuable insights into their members’ experience and customer satisfaction. The comfort and care of beneficiaries is important to ACAP plans, and these items allowed for identification of areas of success as well as those that need improvement. It’s important to ensure that the survey focuses on aspects of the member experience that relate to the relationship between the health plan and its members.
Question 3: What content areas might be missing from the Survey?
Answers to this question varied widely between ACAP plans. A few mentioned that more open-ended questions and follow-up questions to specific survey items would be helpful and noted that some questions were too broad in their scope. ACAP plans thought that the ability to add custom questions or follow-up questions would allow for a better understanding of their members’ responses to certain items. They also believe that including these types of questions would help them to conduct deeper analyses and offer better feedback and more specific training to their networks and providers.
Additionally, some plans recommended consideration for including questions related to: their provider networks, such as provider and staff demographics; office wait times; coordination of care/care management; preferred method of communication with the health plan; follow-up on test results; rating of other staff (not just personal doctor/specialist); cultural congruence between provider and member; and additional services being offered by the plan. ACAP plans believe that these additional questions would further support them in conducting useful barrier analysis.
While there was interest in adding questions on certain issues, see below for comments about concern about adding to the current survey length.
Question 4: What content areas on the Survey are no longer relevant or useful and why?
The majority of ACAP plans stressed the need to shorten the survey, possibly via removing repetitive questions or those with low response rates/low reliability. It was suggested moving these questions to the supplemental question bank in case other groups still found them useful. ACAP plans believe that removing superfluous questions would potentially increase response rates, allowing for a more in-depth and accurate analysis of their programs. Additionally, many plans mentioned that some survey questions pertained to factors that were out of the plan’s control, were not relevant for their operations, and suggested modifying or removing them altogether.
Some plans mentioned that a few of the questions were vague and should be modified for clarity, especially those relating to Urgent Care or Emergency Department visits. ACAP plans feel that modifying these questions to make them more specific will allow for a better understanding of their members’ thoughts regarding using and receiving urgent or emergent care.
Additionally, as mentioned above in Question 3, including open-ended follow-up questions could provide better insight into the reasoning behind an answer (e.g., why did you rate a doctor good or bad?); the pure rating number is not actionable.
Finally, a few plans mentioned that items requiring respondent recall, such as the flu vaccine measure, were not particularly useful as they may not give an accurate measure. ACAP plans believe that the results of these questions could be skewed due to their nature, and suggest instead utilizing more questions that relate to relevant member experiences.
Question 5: Are there new topic areas the Survey should address?
ACAP plans recognize that social determinants of health play a major role in health outcomes and, if appropriate, would want to utilize this survey to gain a better understanding of the social and behavioral backgrounds of their beneficiaries and how they impact access to care and health outcomes. Some ACAP plans mentioned that more questions on social determinants of health should be added; however, it is unclear whether CAHPS is the best vehicle to collect this social determinant information. As such, we recommend that AHRQ convene a process to consider the development of appropriate questions that could capture a member’s experience with their plan with regard to those factors.
Other topics plans mentioned that would be valuable included: feedback on network adequacy; member engagement through portals and telehealth; continuity of care/care transitions programs; and communication and engagement with office staff as opposed to just personal doctor/specialists. ACAP plans believe that these types of questions would allow for a better realization of the circumstances surrounding their members’ health, and how they can better implement programs and initiatives to increase quality and access of care. Having questions to gain an understanding of the use/value of plan-sponsored wellness programs was also mentioned.
To re-iterate from Question 4, while adding questions in any of the areas may be valuable, the length of the survey should be maintained, if not shortened. That implies that some current questions should be deleted and/or any additional questions could be included in a supplemental set of measures.
Question 6: Should the Survey be revised, what implications or barriers would there be for the commenter’s organization to implement a new version of the Survey?
Most ACAP plans did not foresee any barriers to the actual implementation of a new version of the survey, as many mentioned they use a third-party vendor to administer the surveys. Almost all plans mentioned that creating a new survey would hinder their ability to follow trends, and that they would need a few years post-change to obtain accurate new trends. ACAP plans recognize the importance of tracking trends in order to understand whether interventions or program revisions are impacting/ improving the survey rates. A few plans also expressed concerns regarding how a new survey would impact the ability to give accurate NCQA ratings or if payment to plans is linked to CAHPS scores by state agencies. It was noted that state agencies may also need to approve any changes to the survey and would need to agree to a new baseline for a revised survey. ACAP plans are committed to providing quality care and understand the importance of creating accurate ratings.
Other than these concerns, our plans reiterated the need to remove old questions if new ones were added in order to not increase the length. Increasing the length could impact the administration, cost, response rates, and the validity of results. As mentioned above, old questions could be moved to a supplementary question bank for discretionary use. ACAP plans believe that maintaining a consistent and concise survey will allow for an accurate measurement and the creation of useful trends.
Question 7: What information/documentation would be helpful to the respondent’s organization in making a transition to a future version of the Survey?
Many ACAP plans stressed the need for pilot testing or the availability to comment on changes before they are implemented. ACAP plans feel that including their feedback in the creation of a new/revised survey is imperative to create useful and meaningful measures. They expressed the need for a clear summary of what the changes would be and that it would be helpful to know how to compare the new questions with old ones for analytic purposes. ACAP plans recognize that while updates to the survey would be beneficial, it is important to be able to continue and build upon their analyses from previous years.
Our plans also mentioned the need for ample advance notice of changes. ACAP plans feel as though they will need the opportunity to evaluate any survey modifications and request adequate time to implement said changes in a meaningful way. They noted that sufficient advance notice to any changes to the survey would be necessary to identify impacts to quality improvement initiatives, any impacts to state contracts, etc. They cited the need for training modules and sessions (including on-demand training) would be valuable in supporting the implementation of any changes.
In addition, several of our plans with higher dual eligible populations requested that the case mix methodology be revisited as they are negatively impacted after case mix is applied.
Finally, ACAP plans again expressed concern over the length of the survey and stressed that any addition of questions should be met with the removal of old or irrelevant questions.
Again, we thank you for this opportunity to comment on the Request for Information to inform potential revisions to the Consumer Assessment of Healthcare Providers and Systems Health Plan Survey 5.0. Please feel free to contact me (firstname.lastname@example.org, 202-204-7509) or Enrique Martinez-Vidal, Vice President for Quality and Operations (email@example.com, 202-204-7527), if you would like to discuss any of these issues in greater depth.
Margaret A. Murray
Chief Executive Officer