HCAHPS – Recent Program Updates

This blog post is taken from a recent Webinar featuring Karen Sorensen, Associate Vice President, National Initiatives, HealthStream.

As new CAHPS surveys continue to emerge, the HCAHPS survey continues to evolve. Let’s look at some recent and significant updates to the program.

The Pain Dimension – A Change of Plans

Perhaps the most controversial of the HCAHPS dimensions is the Pain Dimension. Physicians, Congress, and members of the public have questioned whether or not the current questions are contributing to the nation’s opioid abuse epidemic. As a result, beginning in fiscal year 2018, the Pain Dimension will be removed from the hospital Value-Based Purchasing calculations. In addition, the new questions regarding communication about pain will be added to the HCAHPS survey beginning in January of 2018. The new questions are:

  • During this hospital stay, did you have any pain?
  • During this hospital stay, how often did the hospital staff talk with you about how much pain you had?
  • During this hospital stay, how often did the hospital staff talk with you about how to treat your pain?
  • During this hospital stay, did you get medicine for pain?
  • Before giving you pain medicine, did hospital staff describe possible side effects in a way you could understand?

In addition, the dimension name will change from “Pain Management” to “Communication About Pain.”

If finalized, the new dimension will impact the fiscal year 2020 payment determination. Hospitals will need four consecutive quarters of data before results will be reported on the Hospital Compare website. Data will begin appearing on that website in October of 2019 if the new pain questions are added to the survey in January of 2018, which is the current working plan.

Don’t Be a Standout for the Wrong Reason

CMS is actively encouraging vendors to work with their customers to provide the most accurate patient lists possible. These lists are used to identify all patients who are eligible to take the survey. In addition, CMS uses the demographic data that is contained in these lists to do the data adjustments that impact the publicly-reported data and value-based purchasing calculations. Hospitals with a higher than average rate of missing data are being singled out by CMS and asked to provide corrected files. In addition, those hospitals may have their results on Hospital Compare footnoted.

HealthStream recommends regular audits of your patient files and the processes used to provide them to insure that the files meet the necessary standards for accuracy and completeness.

2017 Merit-Based Incentive Payment System (MIPS) Reporting – How HealthStream Can Help

CMS is currently in the process of notifying physician practices which of their clinicians (including physicians, physician’s assistants, nurse practitioners, clinical nurse specialists and certified registered nurse anesthetists) are required to participate in MIPS. Clinicians with more than $30,000.00 in Medicare billings providing care to 100 or more Medicare patients per year are required to participate.

The stakes are quite high for MIPS. Clinicians who do not participate at all in 2017 will automatically receive a 4% downward adjustment to their Medicare payments in 2019. (That amount increases to 9% in 2022.) Despite the relatively high stakes, research shows fairly high levels of unawareness of the new program, but it is not too late to identify which clinicians will need to participate and determine the optimal means by which they can meet the requirements.  

The good news is that 2017 is a transition year and clinicians have some options that can bring them into compliance relatively quickly. Submitting just a single quality measure or improvement activity will help avoid the initial 4% reduction. Talk to your HealthStream team to find out how CG Express, Regular CG CAHPS, PCMH CAHPS, partnering with the HealthStream Engagement Institute or using any of HealthStream’s improvement courseware for physician practices may help you earn credit on these measures.

HealthStream’s website is a rich source of information on all CAHPS topics. In addition, the QPP website ( is a great source of timely and accurate data on this topic.

Link to the full Webinar here.

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